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Dumitrescu D, Nagel C, Kovacs G, Bollmann T, Halank M, Winkler J, Hellmich M, Grünig E, Olschewski H, Ewert R, Rosenkranz S. Cardiopulmonary exercise testing for detecting pulmonary arterial hypertension in systemic sclerosis. Heart 2017; 103:774-782. [PMID: 28062514 DOI: 10.1136/heartjnl-2016-309981] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a devastating disease with limited survival and occurs as a frequent complication in patients with systemic sclerosis (SSc). A definite diagnosis of PAH is obtained by right heart catheterisation (RHC); however, the initial suspicion is raised by non-invasive methods. We assessed the diagnostic accuracy of key parameters derived from cardiopulmonary exercise testing (CPET) for detecting and ruling out SSc-associated PAH. METHODS In a multicentre setting, we prospectively evaluated 173 consecutive patients with SSc without known PAH, but with clinical suspicion of PAH. Each patient underwent CPET and RHC. RESULTS RHC identified PAH in 48 patients (27.8%), postcapillary pulmonary hypertension (PH) in 10 patients (5.8%) and ruled out PH in 115 patients (66.5%). CPET parameters correlated significantly with pulmonary haemodynamics. PeakVO2 and VE/VCO2 showed highest correlations with pulmonary arterial pressure, transpulmonary pressure gradient and pulmonary vascular resistance. Several parameters showed high sensitivity and specificity for PAH detection by receiver operating characteristic analysis. However, peakVO2 showed highest diagnostic accuracy (sensitivity 87.5%, specificity 74.8% at a threshold level of 13.8 mL/min/kg). A peakVO2 of >18.7 mL/kg/min was reached by 38/173 patients (22%) and excluded PAH in our cohort (negative predictive value 1.0). A nadir VE/VCO2 ratio of >45.5 showed a positive predictive value of 1.0. Diagnostic accuracy was highest in patients with low pulmonary arterial wedge pressure (<12 mm Hg). There were no study-related serious adverse events. CONCLUSIONS CPET is a safe and valuable method in the non-invasive detection of SSc-associated PAH. It may be particularly beneficial for reducing unnecessary RHC procedures.
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Affiliation(s)
- Daniel Dumitrescu
- Herzzentrum der Universität zu Köln, Klinik III für Innere Medizin, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Germany
| | - Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg, Heidelberg, Germany.,Lung Center, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Ludwig Boltzmann Institute for Lung Vascular Research, and Medical University of Graz, Graz, Austria
| | - Tom Bollmann
- Department of Internal Medicine B-Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Greifswald, Germany
| | - Michael Halank
- Department of Internal Medicine I, Carl Gustav Carus University Hospital, Technical University of Dresden, Dresden, Germany
| | - Jörg Winkler
- Klinik für Innere Medizin I, University of Leipzig, Leipzig, Germany
| | - Martin Hellmich
- Universitätsklinikum Köln, Institut für Medizinische Statistik, Cologne, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg, Heidelberg, Germany
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Ludwig Boltzmann Institute for Lung Vascular Research, and Medical University of Graz, Graz, Austria
| | - Ralf Ewert
- Department of Internal Medicine B-Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Greifswald, Germany
| | - Stephan Rosenkranz
- Herzzentrum der Universität zu Köln, Klinik III für Innere Medizin, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Germany
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Pulmonary Hypertension: Scientometric Analysis and Density-Equalizing Mapping. PLoS One 2017; 12:e0169238. [PMID: 28052133 PMCID: PMC5215006 DOI: 10.1371/journal.pone.0169238] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 12/12/2016] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by the increase of the mean pulmonary arterial pressure in the lung circulation. Despite the large number of experimental and clinical studies conducted on pulmonary hypertension, there is no comprehensive work that analyzed the global research activity on PH so far. We retrieved the bibliometric data of the publications on pulmonary hypertension for two periods from the Web of science database. Here, we set the first investigation period from 1900 to 2007 (t1) due to the cited half life of articles and the relating difficulties to interpret the citation parameters. The second evaluation period (t2) covers the time interval from 2008 onwards including the year 2015. The data were analyzed and processed to density-equalizing maps using the NewQIS platform. A total number of 18,986 publications were identified in t1 that come from 85 countries. The US published the highest number of publications (n = 7,290), followed by the UK, Germany, Japan and France. In t2 19,676 items could be found worked out by 130 countries. The raking started just the same with the USA as most publishing nation with 7,127 publications on PH, followed by the UK and Germany. Japan fell back on 6th place, whereas China came into view on the 5th position. Analyzing the average citation rate as a parameter for research quality, Mexico reached the highest value in t1 and Ireland in t2. While, the country specific h-index underlined the leading position of the US research in both evaluation periods again. The average number of international collaboration items was expanding from none in 1978 to 530 items in 2015 with the USA as the country with the highest number of collaboration articles. The present study is the first large scale density-equalizing mapping and scientometric analysis of global PH research activity. Our data draw a sketch of the global research architecture in this field, indicating a need for specific research programs in countries with a lower human development index.
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Held M, Kolb P, Grün M, Jany B, Hübner G, Grgic A, Holl R, Schaefers HJ, Wilkens H. Functional Characterization of Patients with Chronic Thromboembolic Disease. Respiration 2016; 91:503-9. [PMID: 27327769 DOI: 10.1159/000447247] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/25/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic thromboembolic pulmonary disease (CTED) have persistent pulmonary vascular obstruction and exercise intolerance without pulmonary hypertension at rest and may benefit from pulmonary endarterectomy. However, up to now, CTED has been poorly characterized. OBJECTIVES This study aimed to analyze the exercise capacity and limiting factors in CTED. METHODS We compared right heart catheterization and cardiopulmonary exercise test results of patients with CTED [mean pulmonary artery pressure (mPAP) at rest <25 mm Hg, n = 10], chronic thromboembolic pulmonary hypertension (CTEPH, n = 31) and a control group (n = 41) presenting with dyspnea but normal pulmonary vascular imaging and excluded pulmonary hypertension. RESULTS Subjects with CTED show a reduced oxygen uptake [median 76/interquartile range (IQR) 22% pred.] and work rate (median 76/IQR 21 W). The work rate was significantly lower compared to control subjects (p = 0.04) but not significantly different from CTEPH patients (p = 0.66). Oxygen pulse and breathing reserve were normal. CTED subjects showed decreased end-tidal CO2 at anaerobic threshold (28.4/4.3 mm Hg), an elevated VE/VCO2 slope (42.5/23.5), breathing equivalents (EQO2 32.0/8.7, EQCO2 39.5/8.8), alveolar-capillary oxygen gradient (34.7/15.5 mm Hg) and capillary end-tidal carbon dioxide gradient (8.8/5.7 mm Hg) compared to control subjects (p < 0.001). The degree of limitation was similar to that in CTEPH. CONCLUSIONS Despite an mPAP of <25 mm Hg, subjects with CTED show objective functional impairment and similar limitations to patients with CTEPH. Functional limitation is characterized by gas exchange disturbance and ineffective ventilation.
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Affiliation(s)
- Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital, Wx00FC;rzburg, Germany
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Milger K, Felix JF, Voswinckel R, Sommer N, Franco OH, Grimminger F, Reichenberger F, Seeger W, Ghofrani HA, Gall H. Sildenafil versus nitric oxide for acute vasodilator testing in pulmonary arterial hypertension. Pulm Circ 2015; 5:305-12. [PMID: 26064455 DOI: 10.1086/680355] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 10/11/2014] [Indexed: 11/03/2022] Open
Abstract
Vasoreactivity testing with inhaled NO is recommended for pulmonary arterial hypertension (PAH) because of its therapeutic and prognostic value. Sildenafil has acute pulmonary vasodilating properties, but its diagnostic and prognostic impact in PAH is unknown. Our objective was to compare acute vasodilating responses to sildenafil and those to NO during right heart catheterization and also their prognostic values in patients with PAH. Ninety-nine patients with idiopathic PAH and 99 with associated PAH underwent vasoreactivity testing with NO and sildenafil. Only mild adverse effects of sildenafil, in the form of hypotension, were observed, at a rate of 4.5%. The acute responder rate was 8.1% for NO and 11.6% for sildenafil. The NO-induced response in mean pulmonary arterial pressure and cardiac output correlated with the response to sildenafil. Thirteen patients were long-term responders to calcium channel blockers (CCBs), and 3 of them were correctly identified by acute vasoreactivity test with both drugs. The specificity of the vasoreactivity test for identifying long-term CCB responders was 88.9% for NO and 85.1% for sildenafil testing. A trend toward better survival was found in sildenafil and NO responders, compared with nonresponders. Use of sildenafil for vasoreactivity testing is safe. Sildenafil may be useful as alternative vasoreactivity-testing agent, identifying the same number of long-term CCB responders as NO. However, NO seems to be a more ideal testing drug because of its pharmacologic properties. Moreover, sildenafil vasoreactivity testing might contribute to an improved estimate of prognosis among patients with PAH.
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Affiliation(s)
- Katrin Milger
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL) ; Department of Internal Medicine V, University of Munich, Munich, Germany ; Comprehensive Pneumology Center, Munich, Germany, member of the German Center for Lung Research (DZL)
| | - Janine F Felix
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robert Voswinckel
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL) ; Department of Internal Medicine, Health Center Wetterau, Friedberg, Germany
| | - Natascha Sommer
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL)
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Friedrich Grimminger
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL)
| | - Frank Reichenberger
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL) ; Comprehensive Pneumology Center, Munich, Germany, member of the German Center for Lung Research (DZL) ; Asklepios Klinik Gauting, Gauting, Germany
| | - Werner Seeger
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL)
| | - Hossein A Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL)
| | - Henning Gall
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research (DZL) ; Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
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Bandorski D, Erkapic D, Stempfl J, Höltgen R, Grünig E, Schmitt J, Chasan R, Grimminger J, Neumann T, Hamm CW, Seeger W, Ghofrani HA, Gall H. Ventricular tachycardias in patients with pulmonary hypertension: an underestimated prevalence? A prospective clinical study. Herzschrittmacherther Elektrophysiol 2015; 26:155-162. [PMID: 26031512 DOI: 10.1007/s00399-015-0364-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/10/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Sudden cardiac death (SCD) accounts for approximately 30 % in patients with pulmonary arterial hypertension (PAH). The exact circumference for SCD in this patient population is still unclear. Malignant cardiac arrhythmias are reported to be rarely present. There are no systematic data concerning long-term electrocardiographic (ECG) recording in patients with PAH. OBJECTIVES We sought to investigate the rate of potentially relevant arrhythmias in patients with pulmonary hypertension (PH). METHODS Consecutive patients without diagnosis of known cardiac arrhythmias followed in our outpatient clinic for PH were enrolled in the study. All patients underwent a 72-h Holter ECG. Clinical data, 6-min walk distance, laboratory values, and echocardiography were collected/performed. RESULTS Ninety-two consecutive patients (New York Heart Association class (NYHA) III/IV: 65.2 %/5.4 %, PH Group 1: 35.9 %, Group 3: 10.9 %, Group 4: 28.3 %, Group 5: 2.2 %) were investigated. Relevant arrhythmias were newly detected in 17 patients: non-sustained ventricular tachycardia (n = 12), intermittent second-degree heart block (n = 1), intermittent third-degree heart block (n= 3), and atrial flutter (n = 1). Echocardiographic systolic pulmonary pressure and diameter of the right heart were elevated in patients with relevant arrhythmias. Right heart catheterization revealed higher pulmonary vascular resistance (672 vs. 542 dyn · s · cm(-5), p = 0.247) and lower cardiac index (2.46 vs. 2.82 l/min/m(2), p = 0.184). CONCLUSIONS Ventricular tachycardias occur more often in PH patients than previously reported. However, the prognostic relevance of non-sustained ventricular tachycardias in this cohort remains unclear. As a large number of PH patients die from SCD, closer monitoring, e.g., using implantable event recorders, might be useful to identify patients at high risk.
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Affiliation(s)
- Dirk Bandorski
- University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany,
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Pulmonale Hypertonie. Herz 2015; 40:457-68; quiz 469-70. [DOI: 10.1007/s00059-015-4230-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Left ventricular mass is preserved in patients with idiopathic pulmonary arterial hypertension and Eisenmenger's syndrome. Heart Lung Circ 2013; 23:454-61. [PMID: 24373913 DOI: 10.1016/j.hlc.2013.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 11/17/2013] [Accepted: 12/04/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Left ventricular (LV) atrophic remodelling was described for chronic thromboembolic pulmonary hypertension (PH) but not in other forms of PH. We aimed to assess LV morphometric changes in idiopathic pulmonary arterial hypertension (IPAH) and Eisenmenger's syndrome(ES). METHODS Fifteen patients with IPAH, 15 patients with ES and 15 healthy volunteers were included. Magnetic resonance was used to measure masses of LV, interventricular septum (IVS), LV free wall (LVFW), and LV end diastolic volume (LVEDV) indexed for body surface area. RESULTS Between patients with IPAH, ES and controls no differences in LVmassindex (54.4[45.2-63.3] vs 58.7[41.5-106.1] vs 52.8[46.5-59.3], p=0.50), IVSmassindex (21.6[18.2-21.9)] vs 27.4[18.0-32.9] vs 20.7[18.2-23.2], p=0.18), and LVFWmassindex ([32.4[27.1-40.0] vs 36.7[30.9-62.1] vs 32.5[26.9-36.1], p=0.29) were found. LVEDVindex was lower in IPAH patients than in controls and in ES patients (54.9[46.9-58.5] vs 75.2[62.4-88.9] vs 73.5[62.1-77.5], p<0.001). In IPAH LVEDV but not LV mass correlated with pulmonary vascular resistance (r=-0.56, p=0.03) and cardiac output (r=0.59, p=0.02). CONCLUSIONS LV mass is not reduced in patients with IPAH and with ES and is not affected by haemodynamic severity of PH. LVEDV is reduced in IPAH patients in proportion to reduced pulmonary flow but preserved in patients with ES, where reduced pulmonary flow to LV is compensated by right-to left shunt.
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Inconsistencies in the development of the ESC Clinical Practice Guidelines for Heart Failure. Int J Cardiol 2013; 168:1724-7. [DOI: 10.1016/j.ijcard.2013.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 05/04/2013] [Indexed: 11/18/2022]
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Zafrir B, Adir Y, Shehadeh W, Shteinberg M, Salman N, Amir O. The association between obesity, mortality and filling pressures in pulmonary hypertension patients; the “obesity paradox”. Respir Med 2013. [DOI: 10.1016/j.rmed.2012.10.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Myöhänen H, Vaheri A. Regulation and interactions in the activation of cell-associated plasminogen. Cell Mol Life Sci 2004; 61:2840-58. [PMID: 15558213 DOI: 10.1007/s00018-004-4230-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The main components in plasminogen activation include plasminogen, tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), urokinase plasminogen activator receptor (uPAR), and plasminogen activator inhibitors-1 and -2 (PAI-1, PAI-2). These components are subject to extensive regulation and interactions with for example, pericellular adhesion molecules. Although uPA and tPA are quite similar in structure and have common inhibitors and physiological substrates, their physiological roles are distinct. Traditionally, the role of tPA has been in fibrinolysis and that of uPA in cell migration, especially in cancer cells. Recently several targets for tPA/plasmin have been found in neuronal tissues. The functional role of the PAIs is no longer simply to inhibit overexpressed plasminogen activators, and PAI-2 has an unidentified role in the regulation of cell death.
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Affiliation(s)
- H Myöhänen
- Haartman Institute, University of Helsinki, P.O. Box 21, 00014, Helsinki, Finland
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