1
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Patel B, D'Souza S, Sahni T, Yehya A. Pulmonary hypertension secondary to valvular heart disease: a state-of-the-art review. Heart Fail Rev 2024; 29:277-286. [PMID: 38017225 DOI: 10.1007/s10741-023-10372-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
Pulmonary hypertension (PH) is a common disease affecting up to 1% of the population and at least 50% of patients diagnosed with heart failure (HF) (Hoeper et al. in Lancet Respir Med 4(4):306-322, 2016). It is estimated that PH is present in 15% to 60% of patients with valvular heart disease (VHD) which can result from an increase in pulmonary blood flow and subsequently in pulmonary venous congestion and pulmonary vascular resistance (PVR). It is important to identify the severity of PH in patients with VHD to appropriately risk stratify and manage these patients (Magne et al. in JACC Cardiovasc Imaging 8(1):83-99, 2015). In this review, we examine the diagnostic criteria for PH and its pathophysiology. We also focus on the growing evidence supporting the presence of PH secondary to VHD and describe the contemporary surgical and medical therapeutic interventions in this patient population (Fig. 1).
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Affiliation(s)
- Bansi Patel
- Virginia Hospital Center, Arlington, VA, USA
| | | | - Tamanna Sahni
- Kaiser Permanente Internal Medicine Residency, Gaithersburg, MD, USA
| | - Amin Yehya
- Sentara Advanced Heart Failure Center, Norfolk, VA, USA.
- Eastern Virginia Medical School, Norfolk, VA, USA.
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2
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Naing P, Kangaharan N, Scalia GM, Strange G, Playford D. Pulmonary hypertension in remote and disadvantaged population: overcoming unique challenges for improved outcomes. Intern Med J 2023; 53:12-20. [PMID: 35762199 PMCID: PMC10087585 DOI: 10.1111/imj.15860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/21/2022] [Indexed: 01/27/2023]
Abstract
Pulmonary hypertension (PH) is a common and debilitating medical condition with high mortality. PH research has traditionally focused on pulmonary arterial hypertension and its management in expert PH centres. Other forms of PH such as PH associated with cardiac or respiratory disease are more common, less well-understood and associated with higher mortality. Epidemiology of PH in disadvantaged, remote and rural regions, remains largely undocumented. In this review, we discuss the unique challenges in identifying PH in rural and disadvantaged populations using the Top End region of the Northern Territory of Australia as an example. We propose a simple diagnostic approach, ideally suited to regions where resource allocation is scarce, using clinical skills, echocardiography, and an escalation algorithm. The brief history, epidemiology and current literature on PH are summarised to inform the busy clinicians. We highlight two case examples from the Top End to illustrate the challenges and potential solutions.
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Affiliation(s)
- Pyi Naing
- University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Flinders University, Adelaide, South Australia, Australia.,The Prince Charles Hospital, Brisbane, Queensland, Australia.,Royal Darwin Hospital, Top End Health Service, Darwin, Northern Territory, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Nadarajah Kangaharan
- Flinders University, Adelaide, South Australia, Australia.,Royal Darwin Hospital, Top End Health Service, Darwin, Northern Territory, Australia.,Northern Territory (NT) Cardiac Service, Darwin, Northern Territory, Australia
| | - Gregory M Scalia
- The Prince Charles Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Geoff Strange
- University of Notre Dame Australia, Fremantle, Western Australia, Australia.,University of Sydney, Sydney, New South Wales, Australia.,Heart Research Institute, Sydney, New South Wales, Australia
| | - David Playford
- University of Notre Dame Australia, Fremantle, Western Australia, Australia
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3
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Moghaddam N, Swiston JR, Tsang MYC, Levy R, Lee L, Brunner NW. Impact of targeted pulmonary arterial hypertension therapy in patients with combined post- and precapillary pulmonary hypertension. Am Heart J 2021; 235:74-81. [PMID: 33422519 DOI: 10.1016/j.ahj.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/05/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Combined post- and precapillary pulmonary hypertension (CpcPH) portends poor outcomes in pulmonary hypertension related to left heart disease (PH-LHD). While recent evidence does not support the use of targeted pulmonary arterial hypertension (PAH) therapy in PH-LHD, there is a lack of clinical data on their use in CpcPH. We evaluated the outcomes in patients with CpcPH treated with PAH therapies. METHODS Retrospectively, 50 patients meeting hemodynamic criteria of CpcPH and started on PAH-targeted drugs were identified. Fifty age- and gender-matched PAH patients were chosen as controls. We evaluated the change in 6-minute walk distance, World Health Organization functional class (FC), tricuspid annular plane systolic excursion, BNP or NT-proBNP, and pulmonary artery systolic pressure at 3, 6, 12, and 24 months of follow-up. RESULTS After adjusting for age and gender, there was no improvement in World Health Organization FC in CpcPH over 2 years (odds ratio of change to FC I/II 1.01, 95% CI: 0.98-1.04). There was no significant improvement in 6-minute walk distance (β coefficient 0.21, 95% CI: -0.98 to 1.4), reduction in BNP/NT-proBNP (β coefficient -12.16, 95% CI: -30.68 to 6.37), increase in tricuspid annular plane systolic excursion (β coefficient 0.074, 95% CI: 0.010-0.139), or decrease in pulmonary artery systolic pressure (0.996, 95% CI: 0.991-1.011) in CpcPH with therapy. There was higher mortality in CpcPH compared to PAH on treatment (24% vs 4%, P = .003). CONCLUSIONS There were no improvements in symptoms, exercise capacity, or echocardiographic parameters with PAH-targeted therapy in CpcPH. Further studies into potential treatments benefiting this population are needed.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John R Swiston
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Michael Y C Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Levy
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Lisa Lee
- Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Nathan W Brunner
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada.
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4
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Yin H, Favreau-Lessard AJ, deKay JT, Herrmann YR, Robich MP, Koza RA, Prudovsky I, Sawyer DB, Ryzhov S. Protective role of ErbB3 signaling in myeloid cells during adaptation to cardiac pressure overload. J Mol Cell Cardiol 2020; 152:1-16. [PMID: 33259856 DOI: 10.1016/j.yjmcc.2020.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Myeloid cells play an important role in a wide variety of cardiovascular disorders, including both ischemic and non-ischemic cardiomyopathies. Neuregulin-1 (NRG-1)/ErbB signaling has recently emerged as an important factor contributing to the control of inflammatory activation of myeloid cells after an ischemic injury. However, the role of ErbB signaling in myeloid cells in non-ischemic cardiomyopathy is not fully understood. This study investigated the role of ErbB3 receptors in the regulation of early adaptive response using a mouse model of transverse aortic constriction (TAC) for non-ischemic cardiomyopathy. METHODS AND RESULTS TAC surgery was performed in groups of age- and sex-matched myeloid cell-specific ErbB3-deficient mice (ErbB3MyeKO) and control animals (ErbB3MyeWT). The number of cardiac CD45 immune cells, CD11b myeloid cells, Ly6G neutrophils, and Ly6C monocytes was determined using flow cytometric analysis. Five days after TAC, survival was dramatically reduced in male but not female ErbB3MyeKO mice or control animals. The examination of lung weight to body weight ratio suggested that acute pulmonary edema was present in ErbB3MyeKO male mice after TAC. To determine the cellular and molecular mechanisms involved in the increased mortality in ErbB3MyeKO male mice, cardiac cell populations were examined at day 3 post-TAC using flow cytometry. Myeloid cells accumulated in control but not in ErbB3MyeKO male mouse hearts. This was accompanied by increased proliferation of Sca-1 positive non-immune cells (endothelial cells and fibroblasts) in control but not ErbB3MyeKO male mice. No significant differences in intramyocardial accumulation of myeloid cells or proliferation of Sca-1 cells were found between the groups of ErbB3MyeKO and ErbB3MyeWT female mice. An antibody-based protein array analysis revealed that IGF-1 expression was significantly downregulated only in ErbB3MyeKO mice hearts compared to control animals after TAC. CONCLUSION Our data demonstrate the crucial role of myeloid cell-specific ErbB3 signaling in the cardiac accumulation of myeloid cells, which contributes to the activation of cardiac endothelial cells and fibroblasts and development of an early adaptive response to cardiac pressure overload in male mice.
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Affiliation(s)
- Haifeng Yin
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | | | - Joanne T deKay
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | - Yodit R Herrmann
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | - Michael P Robich
- Maine Medical Center Research Institute, Scarborough, ME, United States of America; Maine Medical Center, Cardiovascular Institute, Portland, ME, United States of America
| | - Robert A Koza
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | - Igor Prudovsky
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | - Douglas B Sawyer
- Maine Medical Center Research Institute, Scarborough, ME, United States of America; Maine Medical Center, Cardiovascular Institute, Portland, ME, United States of America
| | - Sergey Ryzhov
- Maine Medical Center Research Institute, Scarborough, ME, United States of America.
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5
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Sharma K, Mok Y, Kwak L, Agarwal SK, Chang PP, Deswal A, Shah AM, Kitzman DW, Wruck LM, Loehr LR, Heiss G, Coresh J, Rosamond WD, Solomon SD, Matsushita K, Russell SD. Predictors of Mortality by Sex and Race in Heart Failure With Preserved Ejection Fraction: ARIC Community Surveillance Study. J Am Heart Assoc 2020; 9:e014669. [PMID: 32924735 PMCID: PMC7792380 DOI: 10.1161/jaha.119.014669] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) accounts for half of heart failure hospitalizations, with limited data on predictors of mortality by sex and race. We evaluated for differences in predictors of all‐cause mortality by sex and race among hospitalized patients with HFpEF in the ARIC (Atherosclerosis Risk in Communities) Community Surveillance Study. Methods and Results Adjudicated HFpEF hospitalization events from 2005 to 2013 were analyzed from the ARIC Community Surveillance Study, comprising 4 US communities. Comparisons between clinical characteristics and mortality at 1 year were made by sex and race. Of 4335 adjudicated acute decompensated heart failure cases, 1892 cases (weighted n=8987) were categorized as HFpEF. Men had an increased risk of 1‐year mortality compared with women in adjusted analysis (hazard ratio [HR], 1.27; 95% CI, 1.06–1.52 [P=0.01]). Black participants had lower mortality compared with White participants in unadjusted and adjusted analyses (HR, 0.79; 95% CI, 0.64–0.97 [P=0.02]). Age, heart rate, worsening renal function, and low hemoglobin were associated with increased mortality in all subgroups. Higher body mass index was associated with improved survival in men, with borderline interaction by sex. Higher blood pressure was associated with improved survival among all groups, with significant interaction by race. Conclusions In a diverse HFpEF population, men had worse survival compared with women, and Black participants had improved survival compared with White participants. Age, heart rate, and worsening renal function were associated with increased mortality across all subgroups; high blood pressure was associated with decreased mortality with interaction by race. These insights into sex‐ and race‐based differences in predictors of mortality may help strategize targeted management of HFpEF.
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Affiliation(s)
- Kavita Sharma
- Division of Cardiology The Johns Hopkins Hospital Baltimore MD
| | - Yejin Mok
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Lucia Kwak
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Patricia P Chang
- Department of Medicine University of North Carolina Chapel Hill NC
| | - Anita Deswal
- Section of Cardiology Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston TX
| | - Amil M Shah
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Dalane W Kitzman
- Cardiology and Geriatrics Sections Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Lisa M Wruck
- Duke Clinical Research InstituteCenter for Predictive Medicine Durham NC
| | - Laura R Loehr
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Gerardo Heiss
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Josef Coresh
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Wayne D Rosamond
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Scott D Solomon
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Kunihiro Matsushita
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
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6
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Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, Lang IM, Brittain EL. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther 2020; 10:1659-1674. [PMID: 33224779 PMCID: PMC7666956 DOI: 10.21037/cdt-20-348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Irene Marthe Lang
- Division of Cardiology, Department of Medicine, Medical University of Vienna, Vienna
| | - Evan L. Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
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7
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Dasgupta A, Wu D, Tian L, Xiong PY, Dunham-Snary KJ, Chen KH, Alizadeh E, Motamed M, Potus F, Hindmarch CCT, Archer SL. Mitochondria in the Pulmonary Vasculature in Health and Disease: Oxygen-Sensing, Metabolism, and Dynamics. Compr Physiol 2020; 10:713-765. [PMID: 32163206 DOI: 10.1002/cphy.c190027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In lung vascular cells, mitochondria serve a canonical metabolic role, governing energy homeostasis. In addition, mitochondria exist in dynamic networks, which serve noncanonical functions, including regulation of redox signaling, cell cycle, apoptosis, and mitochondrial quality control. Mitochondria in pulmonary artery smooth muscle cells (PASMC) are oxygen sensors and initiate hypoxic pulmonary vasoconstriction. Acquired dysfunction of mitochondrial metabolism and dynamics contribute to a cancer-like phenotype in pulmonary arterial hypertension (PAH). Acquired mitochondrial abnormalities, such as increased pyruvate dehydrogenase kinase (PDK) and pyruvate kinase muscle isoform 2 (PKM2) expression, which increase uncoupled glycolysis (the Warburg phenomenon), are implicated in PAH. Warburg metabolism sustains energy homeostasis by the inhibition of oxidative metabolism that reduces mitochondrial apoptosis, allowing unchecked cell accumulation. Warburg metabolism is initiated by the induction of a pseudohypoxic state, in which DNA methyltransferase (DNMT)-mediated changes in redox signaling cause normoxic activation of HIF-1α and increase PDK expression. Furthermore, mitochondrial division is coordinated with nuclear division through a process called mitotic fission. Increased mitotic fission in PAH, driven by increased fission and reduced fusion favors rapid cell cycle progression and apoptosis resistance. Downregulation of the mitochondrial calcium uniporter complex (MCUC) occurs in PAH and is one potential unifying mechanism linking Warburg metabolism and mitochondrial fission. Mitochondrial metabolic and dynamic disorders combine to promote the hyperproliferative, apoptosis-resistant, phenotype in PAH PASMC, endothelial cells, and fibroblasts. Understanding the molecular mechanism regulating mitochondrial metabolism and dynamics has permitted identification of new biomarkers, nuclear and CT imaging modalities, and new therapeutic targets for PAH. © 2020 American Physiological Society. Compr Physiol 10:713-765, 2020.
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Affiliation(s)
- Asish Dasgupta
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Danchen Wu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ping Yu Xiong
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Kuang-Hueih Chen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elahe Alizadeh
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Mehras Motamed
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - François Potus
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Charles C T Hindmarch
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Providence Care Hospital, Kingston, Ontario, Canada
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8
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Vanderpool RR, Saul M, Nouraie M, Gladwin MT, Simon MA. Association Between Hemodynamic Markers of Pulmonary Hypertension and Outcomes in Heart Failure With Preserved Ejection Fraction. JAMA Cardiol 2019. [PMID: 29541759 DOI: 10.1001/jamacardio.2018.0128] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance Heart failure with preserved ejection fraction (HFpEF) is highly prevalent, yet there are no specific therapies, possibly due to phenotypic heterogeneity. The development of pulmonary hypertension (PH) in patients with HFpEF is considered a high-risk phenotype in need of targeted therapies, but there have been limited hemodynamic and outcomes data. Objective To identify the hemodynamic characteristics and outcomes of PH-HFpEF. Design, Setting, and Participants Cohort study of participants who had a right heart catheterization from January 2005 to September 2012 (median [interquartile range] follow-up time, 1578 [554-2513] days) were analyzed. Hemodynamic catheterization data was linked to the clinical data repository of all inpatient and outpatient encounters across a health system. Single tertiary referral center for heart failure and PH within a large health care network using a common clinical data repository was studied. There were 19 262 procedures in 10 023 participants. Exposures Participants were classified as having no PH, precapillary PH, or PH in the setting of left heart disease (reduced or preserved ejection fraction). Pulmonary hypertension associated with HFpEF was defined as mean pulmonary artery pressure of 25 mm Hg or more, pulmonary artery wedge pressure of 15 mm Hg or more, and left ventricular ejection fraction of 45% or more. Pulmonary hypertension severity was quantified by the hemodynamic parameters transpulmonary gradient, pulmonary vascular resistance, and diastolic pulmonary gradient. Main Outcomes and Measures The primary outcome was time to all-cause mortality. Secondary outcomes were time to acute hospitalization and cardiovascular hospitalization. Results The mean (SD) of all study individuals was 65 (38) years. Of 10 023 individuals, 2587 (25.8%) had PH-HFpEF. Mortality was 23.6% at 1 year and 48.2% at 5 years. Cardiac hospitalizations occurred in 28.1% at 1 year and 47.4% at 5 years. The frequency of precapillary PH using clinically defined cut-offs for transpulmonary gradient (>12 mm Hg), pulmonary vascular resistance (3 Woods units), and diastolic pulmonary gradient (≥7 mm Hg) were 12.6%, 8.8%, and 3.5%, respectively. Transpulmonary gradient, pulmonary vascular resistance, and diastolic pressure gradient were predictive of mortality and cardiac hospitalizations. Conclusions and Relevance In a large cohort referred for invasive hemodynamic assessment, PH-HFpEF was common. Transpulmonary gradient, pulmonary vascular resistance, and diastolic pulmonary gradient are all associated with mortality and cardiac hospitalizations.
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Affiliation(s)
- Rebecca R Vanderpool
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa Saul
- Analytics Center, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marc A Simon
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
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9
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Simon MA, Maron BA. Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction. Where to Draw the Line. Am J Respir Crit Care Med 2019; 200:278-279. [PMID: 31038986 PMCID: PMC6680312 DOI: 10.1164/rccm.201903-0689ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marc A Simon
- 1Department of Medicine
- 2Pittsburgh Heart, Lung, Blood and Vascular Medicine InstituteUniversity of PittsburghPittsburgh, Pennsylvania
- 3UPMCPittsburgh, Pennsylvania
| | - Bradley A Maron
- 4Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusettsand
- 5Department of CardiologyBoston Veterans Affairs Healthcare SystemBoston, Massachusetts
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10
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Zelt JG, Chaudhary KR, Cadete VJ, Mielniczuk LM, Stewart DJ. Medical Therapy for Heart Failure Associated With Pulmonary Hypertension. Circ Res 2019; 124:1551-1567. [DOI: 10.1161/circresaha.118.313650] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jason G.E. Zelt
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
| | - Ketul R. Chaudhary
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
| | - Virgilio J. Cadete
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
| | - Lisa M. Mielniczuk
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
| | - Duncan J. Stewart
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
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11
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Zhao M, Liu M, Leal JP, Tsui BMW, Wong DF, Pomper MG, Zhou Y. Association of PET-measured myocardial flow reserve with echocardiography-estimated pulmonary artery systolic pressure in patients with hypertrophic cardiomyopathy. PLoS One 2019; 14:e0212573. [PMID: 30893304 PMCID: PMC6426216 DOI: 10.1371/journal.pone.0212573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 02/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a known complication of HCM and is a strong predictor of mortality. We aim to investigate the relationship between microvascular dysfunction measured by quantitative PET and PH in HCM patients. METHODS Eighty-nine symptomatic HCM patients were included in the study. Each patient underwent two 20-min 13N-NH3 dynamic PET scans for rest and stress conditions, respectively. A 2-tissue irreversible compartmental model was used to fit the segments time activity curves for estimating segmental and global myocardial blood flow (MBF) and myocardial flow reserve (MFR). Echocardiographic derived PASP was utilized to estimate PH. RESULTS Patients were categorized into two groups across PASP: PH (PASP > 36 mmHg) and no-PH (PASP ≤ 36 mmHg). patients with PH had larger left atrium, ratio of higher inflow early diastole (E) and atrial contraction (A) waves, E/A, and ratio of inflow and peak early diastolic waves, E/e', significantly reduced global stress MBF (1.85 ± 0.52 vs. 2.13 ± 0.56 ml/min/g; p = 0.024) and MFR (2.21 ± 0.57 vs. 2.62 ± 0.75; p = 0.005), while the MBFs at rest between the two groups were similar. There were significant negative correlations between global stress MBF/MFR and PASP (stress MBF: r = -0.23, p = 0.03; MFR: r = -0.32, p = 0.002); for regional MBF and MFR measurements, the highest linear correlation coefficients were observed in the septal wall (stress MBF: r = -0.27, p = 0.01; MFR: r = -0.31, p = 0.003). Global MFR was identified to be independent predictor for PH in multivariate regression analysis. CONCLUSION Echocardiography-derived PASP is negatively correlated with global MFR measured by 13N-NH3 dynamic PET. Global MFR is suggested to be an index of PH in HCM patients.
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Affiliation(s)
- Min Zhao
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Min Liu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jeffrey P. Leal
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Benjamin M. W. Tsui
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Dean F. Wong
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Martin G. Pomper
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Yun Zhou
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
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12
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Soni M, Birati EY. Recognition, Diagnosis, and Management of Heart Failure with Preserved Ejection Fraction. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:21:1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The clinical syndrome of heart failure with preserved ejection fraction (HFpEF) is unique in terms of etiologies, diagnostic criteria, costs, and treatment modalities when compared to heart failure with reduced ejection fraction. There is an emerging paradigm shift that recognizes the clinical syndrome of HFpEF and its various phenotypes. Understanding these HFpEF phenotypes is crucial to understanding the pathophysiology of HFpEF, which in turn can further guide our management strategies. This review outlines the diagnostic criteria, introduces the common clinical phenotypes, and discusses treatments currently utilized in practice for the management of HFpEF.
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Musumeci MB, Mastromarino V, Casenghi M, Tini G, Francia P, Maruotti A, Romaniello A, Magrì D, Lillo R, Adduci C, Volpe M, Autore C. Pulmonary hypertension and clinical correlates in hypertrophic cardiomyopathy. Int J Cardiol 2017; 248:326-332. [DOI: 10.1016/j.ijcard.2017.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/12/2017] [Indexed: 12/20/2022]
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Finch KT, Stratton EA, Farber HW. Ranolazine for the treatment of pulmonary hypertension associated with heart failure with preserved ejection fraction: A pilot study. J Heart Lung Transplant 2016; 35:1370-1373. [DOI: 10.1016/j.healun.2016.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 07/12/2016] [Accepted: 07/24/2016] [Indexed: 12/30/2022] Open
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Huis In 't Veld AE, Van Vliet AG, Spruijt OA, Handoko ML, Marcus JT, Vonk Noordegraaf A, Bogaard HJ. CTA-derived left to right atrial size ratio distinguishes between pulmonary hypertension due to heart failure and idiopathic pulmonary arterial hypertension. Int J Cardiol 2016; 223:723-728. [PMID: 27573596 DOI: 10.1016/j.ijcard.2016.08.314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/17/2016] [Accepted: 08/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND/OBJECTIVES Assessing atrial sizes by routine non-gated CT-angiography (CTA) could be of value in discriminating between pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF) and idiopathic pulmonary arterial hypertension (IPAH). We aimed to determine how left (LA) and right atrial (RA) sizes on non-gated CTA can help discriminate between these patients. METHODS AND RESULTS In an initial study, CMR was used in 15 IPAH and 15 PH-HFpEF patients to determine LA- and RA size throughout the cardiac cycle. While significant variations were noted in LA size over the cardiac cycle, the calculated ratio of left over right atrial size (LA/RA ratio) remained stable in both groups and discriminated between PH-HFpEF and IPAH. In a second study, routine non-gated CTA was used to validate the diagnostic use of a LA/RA ratio in 95 consecutive treatment-naive patients with a final diagnosis of either IPAH (n=64) or PH-HFpEF (n=31). ROC analyses were conducted to determine the discriminative properties of atrial size parameters. On a transversal view, LA size was 19cm2 (±5) in the IPAH group versus 27cm2 (±6) in the PH-HFpEF group (p<0.001). CTA derived LA/RA ratio was significantly higher in PH-HFpEF patients compared to IPAH patients and had good discriminative abilities (AUC=0.833). CONCLUSIONS Assessing LA/RA size ratio by non-gated CTA allows for accurate discrimination between PH-HFpEF and IPAH patients. Because CTA is often available in the early diagnostic work-up, a LA/RA size ratio may guide clinical and diagnostic decision-making, even before invasive hemodynamic measurements.
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Affiliation(s)
- Anna E Huis In 't Veld
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - Alexander G Van Vliet
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - Onno A Spruijt
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, VU University Medical Center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - J Tim Marcus
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, VU University Medical center, Institute for Cardiovascular Research, De Boelelaan 1117, Postbus 7057, 1007, MB, Amsterdam, The Netherlands.
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17
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Samson R, Jaiswal A, Ennezat PV, Cassidy M, Le Jemtel TH. Clinical Phenotypes in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2016; 5:e002477. [PMID: 26811159 PMCID: PMC4859363 DOI: 10.1161/jaha.115.002477] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Rohan Samson
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Abhishek Jaiswal
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Pierre V. Ennezat
- Department of CardiologyCentre Hospitalier Universitaire de GrenobleGrenoble Cedex 09France
| | - Mark Cassidy
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Thierry H. Le Jemtel
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
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Arena R, Lavie CJ, Borghi-Silva A, Daugherty J, Bond S, Phillips SA, Guazzi M. Exercise Training in Group 2 Pulmonary Hypertension: Which Intensity and What Modality. Prog Cardiovasc Dis 2015; 59:87-94. [PMID: 26569571 DOI: 10.1016/j.pcad.2015.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 12/29/2022]
Abstract
Pulmonary hypertension (PH) due to left-sided heart disease (LSHD) is a common and disconcerting occurrence. For example, both heart failure (HF) with preserved and reduced ejection fraction (HFpEF and HFrEF) often lead to PH as a consequence of a chronic elevation in left atrial filling pressure. A wealth of literature demonstrates the value of exercise training (ET) in patients with LSHD, which is particularly robust in patients with HFrEF and growing in patients with HFpEF. While the effects of ET have not been specifically explored in the LSHD-PH phenotype (i.e., composite pathophysiologic characteristics of patients in this advanced disease state), the overall body of evidence supports clinical application in this subgroup. Moderate intensity aerobic ET significantly improves peak oxygen consumption, quality of life and prognosis in patients with HF. Resistance ET significantly improves muscle strength and endurance in patients with HF, which further enhance functional capacity. When warranted, inspiratory muscle training and neuromuscular electrical stimulation are becoming recognized as important components of a comprehensive rehabilitation program. This review will provide a detailed account of ET programing considerations in patients with LSHD with a particular focus on those concomitantly diagnosed with PH.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA.
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Paulo, Brazil
| | - John Daugherty
- Department of Biomedical and Health Information Sciences, College of Applied Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Samantha Bond
- Department of Biomedical and Health Information Sciences, College of Applied Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Shane A Phillips
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Marco Guazzi
- Cardiology, I.R.C.C.S. Policlinico San Donato, University of Milano, San Donato Milanese, Milano, Italy
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