1
|
Distler O, Ofner C, Huscher D, Jordan S, Ulrich S, Stähler G, Grünig E, Held M, Ghofrani HA, Claussen M, Lange TJ, Klose H, Rosenkranz S, Vonk-Noordegraaf A, Vizza CD, Delcroix M, Opitz C, Pausch C, Scelsi L, Neurohr C, Olsson KM, Coghlan JG, Halank M, Skowasch D, Behr J, Milger K, Remppis BA, Skride A, Jureviciene E, Gumbiene L, Miliauskas S, Löffler-Ragg J, Wilkens H, Pittrow D, Hoeper MM, Ewert R. Treatment strategies and survival of patients with connective tissue disease and pulmonary arterial hypertension: a COMPERA analysis. Rheumatology (Oxford) 2024; 63:1139-1146. [PMID: 37462520 PMCID: PMC10986797 DOI: 10.1093/rheumatology/kead360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/27/2023] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) occurs in various connective tissue diseases (CTDs). We sought to assess contemporary treatment patterns and survival of patients with various forms of CTD-PAH. METHODS We analysed data from COMPERA, a European pulmonary hypertension registry, to describe treatment strategies and survival in patients with newly diagnosed PAH associated with SSc, SLE, MCTD, UCTD and other types of CTD. All-cause mortality was analysed according to the underlying CTD. For patients with SSc-PAH, we also assessed survival according to initial therapy with endothelin receptor antagonists (ERAs), phosphodiesterase type 5 inhibitors (PDE5is) or a combination of these two drug classes. RESULTS This analysis included 607 patients with CTD-PAH. Survival estimates at 1, 3 and 5 years for SSc-PAH (n = 390) were 85%, 59% and 42%; for SLE-PAH (n = 34) they were 97%, 77% and 61%; for MCTD-PAH (n = 33) they were 97%, 70% and 59%; for UCTD-PAH (n = 60) they were 88%, 67% and 52%; and for other CTD-PAH (n = 90) they were 92%, 69% and 55%, respectively. After multivariable adjustment, the survival of patients with SSc-PAH was significantly worse compared with the other conditions (P = 0.001). In these patients, the survival estimates were significantly better with initial ERA-PDE5i combination therapy than with initial ERA or PDE5i monotherapy (P = 0.016 and P = 0.012, respectively). CONCLUSIONS Mortality remains high in patients with CTD-PAH, especially for patients with SSc-PAH. However, for patients with SSc-PAH, our results suggest that long-term survival may be improved with initial ERA-PDE5i combination therapy compared with initial monotherapy.
Collapse
Affiliation(s)
- Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christian Ofner
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology, and Berlin Institute of Health, Charité-Universitätsmedizin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Suzana Jordan
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerd Stähler
- Klinik für Pneumologie, Klinik Fachklinik Löwenstein, Löwenstein, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - H Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | - Martin Claussen
- Fachabteilung Pneumologie, LungenClinic Großhansdorf, Großhansdorf, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans Klose
- Department of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine and the Cologne Cardiovascular Research Center, University of Cologne, Cologne, Germany
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - C Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven–University of Leuven, Leuven, Belgium
| | - Christian Opitz
- Department of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - Christine Pausch
- GWT-TUD GmbH, Innovation Center Real World Evidence, Dresden, Germany
| | - Laura Scelsi
- Fondazione IRCSS S. Matteo Pavia, Division of Cardiology Stolfo Davide, Azienda Sanitaria Universitaria Giuliano Isontina, Pavia, Italy
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Robert-Bosch-Krankenhaus Stuttgart, Stuttgart, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center of Lung Research, Gießen, Germany
| | | | - Michael Halank
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany
| | - Dirk Skowasch
- Innere Medizin–Kardiologie/Pneumologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Jürgen Behr
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research, Munich, Germany
| | - Katrin Milger
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research, Munich, Germany
| | | | - Andris Skride
- VSIA Pauls Stradins Clinical University Hospital, Riga, Lativa
| | - Elena Jureviciene
- Faculty of Medicine of Vilnius University, Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Lina Gumbiene
- Faculty of Medicine of Vilnius University, Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Skaidrius Miliauskas
- Department of Pulmonology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Judith Löffler-Ragg
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Heinrike Wilkens
- Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - David Pittrow
- GWT-TUD GmbH, Innovation Center Real World Evidence, Dresden, Germany
- Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center of Lung Research, Gießen, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Department of Respiratory Medicine, Universitätsmedizin Greifswald, Germany
| |
Collapse
|
2
|
Cirulis MM, Emerson LL, Bull DA, Hatton N, Nativi-Nicolai J, Hildebrandt GC, Ryan JJ. Pulmonary arterial hypertension in primary amyloidosis. Pulm Circ 2016; 6:244-8. [PMID: 27252852 DOI: 10.1086/686172] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Amyloidosis involves extravascular deposition of fibrillar proteins within tissues and organs. Primary light chain amyloidosis represents the most common form of systemic amyloidosis involving deposition of monoclonal immunoglobulin light chains. Although pulmonary amyloid deposition is common in primary amyloidosis, clinically significant pulmonary amyloidosis is uncommon, and elevated pulmonary artery pressures are rarely observed in the absence of other underlying etiologies for pulmonary hypertension, such as elevated filling pressures secondary to cardiac amyloid. In this case report, we present a patient with primary light chain amyloidosis and pulmonary arterial hypertension in the setting of pulmonary vascular and right ventricular myocardial amyloid deposition.
Collapse
Affiliation(s)
- Meghan M Cirulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA; Internal Medicine-Pediatrics Residency Program, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lyska L Emerson
- Division of Anatomic Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - David A Bull
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Nathan Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jose Nativi-Nicolai
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Gerhard C Hildebrandt
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
3
|
Wang H, Liu T, Cai YY, Luo L, Wang M, Yang M, Cai L. Pulmonary hypertension in polymyositis. Clin Rheumatol 2015; 34:2105-12. [PMID: 26468158 DOI: 10.1007/s10067-015-3095-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 07/16/2015] [Accepted: 10/08/2015] [Indexed: 01/25/2023]
Abstract
Pulmonary hypertension (PH) is relatively common in connective tissue diseases. However, few studies have focused on the pulmonary hypertension (PH) associated with polymyositis (PM). Our aim is to investigate the prevalence of PH and determine the associated factors for PH in patients with PM. Multicenter study of 61 patients with PM underwent evaluation including general information, physical examination, laboratory indictors, thoracic high-resolution CT (HRCT) imaging, and transthoracic echocardiography (TTE). TTE was performed to estimate the pulmonary arterial pressure. PH was defined as resting systolic pulmonary artery pressure (sPAP) ≥40 mmHg. PH was identified in ten patients (16.39 %) who had few cardiopulmonary symptoms. PM patients with PH had higher prevalence of interstitial lung disease (ILD) and pericardial effusion (PE) compared with patients without PH (18 vs. 11.5 %, p = 0.005; 11.5 vs. 9.8 %, p = 0.004; respectively). After controlling for age, gender, and potential factors, ILD and PE were independently associated with PH in patients with PM in multivariate analysis (OR = 8.193, 95 % CI 1.241-54.084, p = 0.029; OR = 8.265, 95 % CI 1.298-52.084, p = 0.025; respectively). Depending on TTE, the possible prevalence of PH was 16.39 % in patients with PM. Both ILD and PE may contribute to the development of PH in PM.
Collapse
Affiliation(s)
- Han Wang
- Cardiovascular Disease Research Institute, The Third People's Hospital of Chengdu, 82 Qinlong St, Chengdu, Sichuan, 610031, People's Republic of China
| | - Tao Liu
- Department of Neurology, People's Hospital of Hainan Province, 19 Xiuhua Road, Haikou, Hainan, 570311, People's Republic of China
| | - Ying-ying Cai
- Department of Geriatric, The First Affiliated Hospital of Chengdu Medical College, 278 Baoguang St, Chengdu, Sichuan, 610083, People's Republic of China
| | - Lian Luo
- Cardiovascular Disease Research Institute, The Third People's Hospital of Chengdu, 82 Qinlong St, Chengdu, Sichuan, 610031, People's Republic of China
| | - Meng Wang
- Department of Neurology, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang St, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Mengmeng Yang
- Cardiovascular Disease Research Institute, The Third People's Hospital of Chengdu, 82 Qinlong St, Chengdu, Sichuan, 610031, People's Republic of China
| | - Lin Cai
- Cardiovascular Disease Research Institute, The Third People's Hospital of Chengdu, 82 Qinlong St, Chengdu, Sichuan, 610031, People's Republic of China.
| |
Collapse
|
4
|
|
5
|
Clinical and laboratory profiles of 136 systemic sclerosis patients with and without echocardiographically detected pulmonary hypertension. Z Rheumatol 2014; 74:67-71. [DOI: 10.1007/s00393-014-1391-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
6
|
Ahmed S, Palevsky HI. Pulmonary Arterial Hypertension Related to Connective Tissue Disease. Rheum Dis Clin North Am 2014; 40:103-24. [DOI: 10.1016/j.rdc.2013.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
7
|
Chow SL, Chandran V, Fazelzad R, Johnson SR. Prognostic factors for survival in systemic lupus erythematosus associated pulmonary hypertension. Lupus 2011; 21:353-64. [DOI: 10.1177/0961203311429815] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Pulmonary hypertension (PH) is a rare but severe manifestation of systemic lupus erythematosus (SLE) that can ultimately result in death. The identification of factors that prognosticate survival in SLE-PH is necessary for appropriate monitoring, timing of therapeutics and lung transplantation. The primary objective of this study was to identify prognostic factors for survival in SLE-PH through review of the literature. The methodological quality of the prognostic studies was also evaluated .Methods: A systematic review of the literature was performed to identify studies evaluating prognostic factors for survival in SLE-PH. Medline, EMBASE, CINAHL, and Cochrane Central Registry of Controlled Trials (inception – week 2 2010) were searched. A standardized abstraction form was used by two independent reviewers to extract prognostic factors. Methodological quality was evaluated using a validated quality index. Results: Twenty-three observational studies from 375 citations were evaluated. Elevated mean pulmonary artery pressure, Raynaud’s phenomenon, thrombocytopenia, plexiform lesion, infection, thrombosis, pregnancy, pulmonary vasculitis and anticardiolipin antibodies were associated with decreased survival. Lupus disease activity, nephritis and central nervous system disease were not associated with survival. The sample sizes were small and methodological quality of the studies was variable. Conclusion: This study summarizes factors that may be associated with decreased survival in SLE-PH. The small sample sizes and variable methodological quality preclude definitive conclusions. This study provides the groundwork for further research using large cohorts.
Collapse
Affiliation(s)
- SL Chow
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - V Chandran
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - R Fazelzad
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - SR Johnson
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| |
Collapse
|
8
|
Huang J, Wolk JH, Gewitz MH, Mathew R. Progressive endothelial cell damage in an inflammatory model of pulmonary hypertension. Exp Lung Res 2010; 36:57-66. [PMID: 20128682 DOI: 10.3109/01902140903104793] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Monocrotaline (MCT)-induces progressive disruption of endothelial cell membrane and caveolin-1 leading to pulmonary arterial hypertension (PAH). Treatment instituted early rescues caveolin-1 and attenuates PAH. To test the hypothesis that the poor response to therapy in established PAH is due to progressive deregulation of multiple signaling pathways, the authors investigated time-dependent changes in the expression of caveolin-1, gp130, PY-STAT3, Bcl-xL, and the molecules involved in NO signaling pathway (endothelial nitric oxide synthase [eNOS], heat sock protein 90 [HSP90], Akt, soluble guanylate cyclase [sGC] alpha1 and beta1 subunits). PAH and right ventricular hypertrophy (RVH) were observed at 2 and 3 weeks. Progressive loss of endothelial caveolin-1 and sGC (alpha1, beta1), PY-STAT3 activation, and Bcl-xL expression were observed at 1 to 3 weeks post-MCT. The expression of gp130 increased at 48 hours and 1 week, with a subsequent loss at 2 and 3 weeks. The expression of eNOS increased at 48 hours and 1 week post-MCT, with a significant loss at 3 weeks. The expression of HSP90 and Akt decreased at 2 and 3 weeks post-MCT concomitant with PAH. Thus, MCT induces progressive loss of membrane and cytosolic proteins, resulting in the activation of proliferative and antiapoptotic factors, and deregulation of NO signaling leading to PAH. An attractive therapeutic approach to treat PAH may be an attempt to rescue endothelial cell membrane integrity.
Collapse
Affiliation(s)
- Jing Huang
- Section of Pediatric Cardiology, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York 10595, USA
| | | | | | | |
Collapse
|
9
|
|
10
|
Ruiz-Cano MJ, Escribano P, Alonso R, Delgado J, Carreira P, Velazquez T, Sanchez MAG, Sáenz de la Calzada C. Comparison of baseline characteristics and survival between patients with idiopathic and connective tissue disease-related pulmonary arterial hypertension. J Heart Lung Transplant 2009; 28:621-7. [PMID: 19481024 DOI: 10.1016/j.healun.2009.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 11/26/2008] [Accepted: 02/08/2009] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Both idiopathic pulmonary arterial hypertension (IPAH) and pulmonary arterial hypertension (PAH) related to connective tissue diseases (CPAH) are classified in the group of PAH disorders. However, CPAH has a particularly worse prognosis than IPAH. Few studies have compared the clinical, functional and hemodynamic profiles of IPAH and CPAH. METHODS We performed a retrospective cohort study of patients with IPAH or CPAH. Demographic characteristics, functional status (FE), pulmonary function test and hemodynamic values at the time of diagnosis were compared between the two etiologies. Global cumulative survival rates free from transplantation (SFT) and survival according to date of diagnosis were analyzed. RESULTS Despite similar PAH severity, patients with CPAH showed a more severe baseline impairment of 6-minute walking test (6MWT) (307 +/- 116 m vs 378 +/- 101 m) and diffusion capacity of the lung for carbon monoxide (DLCO) (57 +/- 25% vs 75 +/- 30% of predicted) than IPAH (p < 0.01). Survival rates at 1, 3 and 5 years of follow-up were 87%, 71% and 63% for IPAH, and 70%, 53% and 42% for CPAH, respectively (p < 0.05). IPAH showed better survival when treatment was started after Year 2000 (p = 0.01). However, CPAH showed a poorer prognosis than IPAH in the more recent era (p < 0.05). CPAH (hazard ratio [HR] = 2.03), DLCO <80% (HR = 1.98) and treatment before Year 2000 (HR = 2.27) were associated with an independent increased risk of death or transplantation. CONCLUSIONS Despite similar functional and hemodynamic severity, patients with CPAH showed a more severe baseline impairment of 6MWT and DLCO and worse overall prognosis than IPAH. Both IPAH and CPAH survival improved in the current era. Nevertheless, CPAH still showed a poorer prognosis than IPAH.
Collapse
Affiliation(s)
- Maria J Ruiz-Cano
- Pulmonary Hypertension, Heart Failure and Heart Transplantation Unit, Cardiology Department, 12 de Octubre University Hospital, Avenida Andalucia Km 5.4, Madrid, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Cardiovascular consequences of pulmonary hypertension. Nurs Clin North Am 2008; 43:17-36; v. [PMID: 18249223 DOI: 10.1016/j.cnur.2007.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension occurs when pulmonary vascular pressures are elevated. Pulmonary arterial hypertension is associated with occlusion of the pulmonary arterial tree, while pulmonary venous hypertension is seen when pulmonary vein outflow is impeded. Cardiovascular consequences are common with pulmonary hypertension, regardless of the underlying pathogenesis and whether management is complex. However, there are a number of interventions that may improve quality of life and survival of pulmonary hypertension. This article discusses current recommendations for diagnosis and management.
Collapse
|
12
|
Ulrich S, Nicolls MR, Taraseviciene L, Speich R, Voelkel N. Increased regulatory and decreased CD8+ cytotoxic T cells in the blood of patients with idiopathic pulmonary arterial hypertension. Respiration 2007; 75:272-80. [PMID: 18025812 PMCID: PMC3030245 DOI: 10.1159/000111548] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 09/10/2007] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND An association between pulmonary arterial hypertension (PAH) and various immune disorders is well established. Recently, the role of an intact immune system in protecting against pulmonary angioproliferation was shown in an animal model. OBJECTIVE To elucidate the role of T cells in human PAH, we comparatively studied T cell subclasses with emphasis on regulatory T cells (T(reg)) in the peripheral blood of patients with idiopathic pulmonary arterial hypertension (IPAH) and healthy controls. METHODS Isolated peripheral blood mononuclear cells from 36 patients diagnosed with IPAH and 33 healthy controls were stained with fluorescently labeled monoclonal antibodies against superficial T cell markers (CD3, CD4, CD8, CD25) and FoxP3, the intracellular marker of T(reg) cells. The relative cell distribution was analyzed by flow cytometry. The functionality of patient and control T(reg) cells was assessed by coculture of T(reg) with nonregulatory T cells from the same individual. RESULTS Significantly less CD8+ T cells (p = 0.02) and more CD25hi+ and FoxP3+CD4+ T cells were found in the peripheral blood of patients compared with controls (p = 0.009 and p < 0.001, respectively). The percentage of FoxP3+ cells within the CD25hi+CD4+ T(reg) cells was similar. T(reg) cell functionality was equal in patients and controls. CONCLUSION Our findings of decreased CD8+ T cells and increased T(reg) cells in the peripheral blood of patients with IPAH are novel and may have implications for directing future research in the field to elucidate the differential role of T cells and the immune system in IPAH.
Collapse
Affiliation(s)
- Silvia Ulrich
- University of Colorado Health Science Center, Denver, Colo., USA
- Department of Internal Medicine and Pulmonology, University Hospital Zürich, Zürich, Switzerland
| | - Mark R. Nicolls
- University of Colorado Health Science Center, Denver, Colo., USA
| | | | - Rudolf Speich
- Department of Internal Medicine and Pulmonology, University Hospital Zürich, Zürich, Switzerland
| | - Norbert Voelkel
- University of Colorado Health Science Center, Denver, Colo., USA
| |
Collapse
|
13
|
Oudiz RJ, Schilz RJ, Barst RJ, Galié N, Rich S, Rubin LJ, Simonneau G. Treprostinil, a prostacyclin analogue, in pulmonary arterial hypertension associated with connective tissue disease. Chest 2004; 126:420-7. [PMID: 15302727 DOI: 10.1378/chest.126.2.420] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To assess the efficacy and safety of continuous subcutaneous infusion of treprostinil, a stable prostacyclin analogue, for treating pulmonary arterial hypertension (PAH) in patients with connective tissue disease (CTD). DESIGN Two multicenter, randomized, double-blind, placebo-controlled, prospective trials of treprostinil vs placebo in 470 patients with PAH. PATIENTS A subset of 90 patients with PAH and CTD, including systemic lupus erythematosus, diffuse scleroderma, limited scleroderma, and mixed CTD/overlap syndrome. INTERVENTIONS Patients received either treprostinil (initiated at 1.25 ng/kg/min, and titrated upward) or placebo via continuous subcutaneous infusion. The maximum dose of treprostinil allowed was 22.5 ng/kg/min. MEASUREMENTS Six-minute walk (6MW) distance and dyspnea-fatigue scores were determined at baseline, and at 6 weeks and 12 weeks. Hemodynamic measures were obtained at baseline and at 12 weeks. RESULTS At baseline, most patients had New York Heart Association class III symptoms. The mean baseline 6MW distance was 289 m (range, 60 to 448 m). The mean dose of treprostinil at week 12 was 8.4 ng/kg/min (range, 1.25 to 17.5 ng/kg/min). After 12 weeks, the change in cardiac index from baseline was + 0.2 +/- 0.08 L/min/m(2) in the treprostinil group and - 0.07 +/- 0.07 L/min/m(2) in the placebo group (p = 0.007). The pulmonary vascular resistance index decreased by 4 +/- 2 U x m(2) in the treprostinil group and increased by 1 +/- 1 U x m(2) in the placebo group (p = 0.006). The placebo-corrected median improvement from baseline in 6MW distance was 25 m in treprostinil-treated patients (p = 0.055); this improvement appeared to be dose related. Dyspnea fatigue scores also improved in the treprostinil group compared with the placebo group (p = 0.014). Adverse events included infusion site pain and typical side effects related to prostaglandins, and were tolerated by most patients. CONCLUSIONS Continuous subcutaneous infusion of treprostinil in patients with PAH associated with CTD improved exercise capacity, symptoms of PAH, and hemodynamics.
Collapse
Affiliation(s)
- Ronald J Oudiz
- Research and Education Institute, Harbor-UCLA Medical Center, Torrance, CA 90502, USA.
| | | | | | | | | | | | | |
Collapse
|
14
|
|
15
|
Nauser TD, Stites SW. Pulmonary hypertension: new perspectives. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2003; 9:155-62. [PMID: 12826774 DOI: 10.1111/j.1527-5299.2002.01050.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The World Health Organization symposium offers a new treatment-oriented classification of pulmonary hypertension based on an improved understanding of its pathophysiology. Regardless of the etiology, severe or unrelieved pulmonary hypertension leads to right heart failure. Symptoms and signs of pulmonary hypertension are often subtle and nonspecific. As a result, a significant delay between the onset of symptoms and the diagnosis of pulmonary hypertension is common. Echocardiography with Doppler flow is the most useful study to evaluate patients suspected of having pulmonary hypertension. The suspected diagnosis of pulmonary hypertension should then be confirmed by right heart catheterization. If present, further evaluation may include oxygen assessment, pulmonary function testing, high resolution computed tomography of the chest, and ventilation-perfusion lung scanning. Treatment of pulmonary hypertension requires uncommon expertise. General measures include correction of the underlying cause, reversal of hypoxemia and judicious use of diuretics. Advances in vasodilator therapy have increased treatment options beyond calcium channel blockers and intravenous epoprostenol. Lung transplantation remains an option for select patients with pulmonary hypertension not responding to medical management.
Collapse
Affiliation(s)
- Trenton D Nauser
- Division of Pulmonary and Critical Care Medicine, Department of Veterans Affairs Medical Center, Kansas City, MO 64128-2295, USA.
| | | |
Collapse
|
16
|
Kawut SM, Taichman DB, Archer-Chicko CL, Palevsky HI, Kimmel SE. Hemodynamics and survival in patients with pulmonary arterial hypertension related to systemic sclerosis. Chest 2003; 123:344-50. [PMID: 12576350 DOI: 10.1378/chest.123.2.344] [Citation(s) in RCA: 249] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
STUDY OBJECTIVES The goal of this study was to determine whether the survival of patients with pulmonary hypertension related to systemic sclerosis (SScPH) was different from that of patients with other forms of pulmonary arterial hypertension. DESIGN Retrospective cohort study. SETTING Tertiary care medical center. PATIENTS Our cohort was composed of 33 patients with pulmonary hypertension that is sporadic, familial, or related to anorexigen use (PPH) and 22 patients with SScPH who underwent initial pulmonary artery catheterization and vasodilator study at our center between January 1997 and June 2001. MEASUREMENTS AND RESULTS Patients with SScPH had somewhat lower percentage of predicted lung volumes than patients with PPH (total lung capacity, 80% vs 92%; p = 0.06) and had lower percentage of predicted diffusion capacity of the lung for carbon monoxide (42% vs 68%; p = 0.0002). Right atrial pressure, pulmonary artery pressure, and cardiac index were similar between the groups. Patients with SScPH and PPH were treated with usual medical therapies, such as digoxin, warfarin, and continuous IV epoprostenol. Despite these similarities, the risk of death in patients with SScPH was higher than in patients with PPH (unadjusted hazard ratio, 2.9; 95% confidence interval, 1.1 to 7.8; p = 0.03). This increased risk appeared to persist after adjustment for a variety of demographic, hemodynamic, or treatment variables. CONCLUSIONS Despite having similar hemodynamics, patients with SScPH have a higher risk of death than patients with PPH. Future studies of the mechanism and therapy of pulmonary arterial hypertension should focus on the distinctions between the different forms of this disease.
Collapse
Affiliation(s)
- Steven M Kawut
- Pulmonary, Allergy, and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, USA.
| | | | | | | | | |
Collapse
|
17
|
Abstract
Pulmonary arterial hypertension is a life threatening complication of several connective tissue diseases including scleroderma (both diffuse and limited scleroderma, or the CREST syndrome--calcinosis cutis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangectasia), systemic lupus erythomatosis (SLE), mixed connective tissue disease (MCTD), and less commonly, rheumatoid arthritis (RA) and dermatomyositis/polymyositis. This report reviews the occurrence of this complication, potential etiologies, clinical presentation, and treatment options.
Collapse
Affiliation(s)
- Karen A Fagan
- Pulmonary Hypertension Center, University of Colorado Health Sciences Center, Denver, CO, USA
| | | |
Collapse
|
18
|
Chu JW, Kao PN, Faul JL, Doyle RL. High prevalence of autoimmune thyroid disease in pulmonary arterial hypertension. Chest 2002; 122:1668-73. [PMID: 12426269 DOI: 10.1378/chest.122.5.1668] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES An association between thyroid disease and pulmonary arterial hypertension (PAH) has been reported, yet the pathogenetic relationship between these conditions remains unclear. Because immune system dysfunction may underlie this association, we sought to determine the prevalence of autoimmune thyroid disease (AITD) in patients with PAH. DESIGN AND SETTING Prospective observational study at a single academic institution. PATIENTS Sixty-three consecutive adults with PAH (ie, sustained pulmonary artery systolic pressure, > 25 mm Hg) were evaluated for clinical, biochemical, and serologic features of AITD. MEASUREMENTS Thyroid gland dysfunction was determined by clinical examination for goiter, and by biochemical measurements of thyrotropin and free thyroxine. Immune system dysfunction was determined by serologic measurements of antibodies to thyroglobulin and thyroid peroxidase. First-degree family history of AITD also was ascertained in order to investigate for genetic clustering of autoimmunity. RESULTS Thirty-one patients (49%; 95% confidence interval [CI], 37 to 62%) received diagnoses of AITD. Eighteen patients were newly diagnosed, and 9 patients required the initiation of pharmacologic treatment. There was no chronologic relationship between the diagnosis or treatment of PAH and that of AITD. Sixteen patients (25%; 95% CI, 15 to 36%) had 24 first-degree family members with AITD. CONCLUSIONS Approximately half of the patients with PAH have concomitant AITD. These two conditions may be linked by a common immunogenetic susceptibility, and the elucidation of this association may advance the understanding of the pathophysiology and treatment of PAH. Systematic surveillance for occult thyroid dysfunction in patients with PAH may prevent the hemodynamic exacerbation of right heart failure.
Collapse
Affiliation(s)
- James W Chu
- Divisions of Endocrinology and Metabolism, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5236, USA
| | | | | | | |
Collapse
|
19
|
Hopkins N, McLoughlin P. The structural basis of pulmonary hypertension in chronic lung disease: remodelling, rarefaction or angiogenesis? J Anat 2002; 201:335-48. [PMID: 12430958 PMCID: PMC1570922 DOI: 10.1046/j.1469-7580.2002.00096.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic lung disease in humans is frequently complicated by the development of secondary pulmonary hypertension, which is associated with increased morbidity and mortality. Hypoxia, inflammation and increased shear stress are the primary stimuli although the exact pathways through which these initiating events lead to pulmonary hypertension remain to be completely elucidated. The increase in pulmonary vascular resistance is attributed, in part, to remodelling of the walls of resistance vessels. This consists of intimal, medial and adventitial hypertrophy, which can lead to encroachment into and reduction of the vascular lumen. In addition, it has been reported that there is a reduction in the number of blood vessels in the hypertensive lung, which could also contribute to increased vascular resistance. The pulmonary endothelium plays a key role in mediating and modulating these changes. These structural alterations in the pulmonary vasculature contrast sharply with the responses of the systemic vasculature to the same stimuli. In systemic organs, both hypoxia and inflammation cause angiogenesis. Furthermore, remodelling of the walls of resistance vessels is not observed in these conditions. Thus it has been generally stated that, in the adult pulmonary circulation, angiogenesis does not occur. Prompted by previous observations that chronic airway inflammation can lead to pulmonary vascular remodelling without hypertension, we have recently shown, using quantitative stereological techniques, that angiogenesis can occur in the adult pulmonary circulation. Pulmonary angiogenesis has also been reported in some other conditions including post-pneumonectomy lung growth, metastatic disease of the lung and in biliary cirrhosis. Such angiogenesis may serve to prevent or attenuate increased vascular resistance in lung disease. In view of these more recent data, the role of structural alterations in the pulmonary vasculature in the development of pulmonary hypertension should be carefully reconsidered.
Collapse
Affiliation(s)
- Natalie Hopkins
- Department of Human Anatomy and Physiology, Conway Institute of Biomolecular and Biomedical Research, Dublin, Ireland
| | | |
Collapse
|
20
|
Abstract
Adverse pulmonary outcomes that follow anesthesia and surgery are often attributed to anesthesia care. PPCs are a significant concern for anesthesia caregivers because they use drugs and techniques that temporarily decrease lung volume, impair airway reflexes, limit immune function, and depress secretion mobilization. A significant component of perioperative risk derives from the surgical site, postoperative pain, and effects of pharmacologic pain management. Rapidly evolving surgical and anesthesia techniques and the introduction of newer pharmaceutical agents make it difficult to identify best practice from retrospective experience reported in the perioperative literature. Prospective studies that deal with specific patient populations, incomparable patient groups or techniques, and unique practice bias have limited validity of claims regarding several promising approaches to perioperative risk reduction. In the absence of clear scientific principles, a perioperative pulmonary risk management strategy for the early part of this century is based on the consensus practice of informed clinicians (Box 4).
Collapse
Affiliation(s)
- Charles B Watson
- Department of Anesthesia, Bridgeport Hospital, Perry 3, Box 5000, 267 Grant Street, Bridgeport, CT 06610, USA.
| |
Collapse
|
21
|
McMillan E, Martin WL, Waugh J, Rushton I, Lewis M, Clutton-Brock T, Townend JN, Kilby MD, Gordon C. Management of pregnancy in women with pulmonary hypertension secondary to SLE and anti-phospholipid syndrome. Lupus 2002; 11:392-8. [PMID: 12139379 DOI: 10.1191/0961203302lu216xx] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary hypertension is found in about 10% of patients with systemic lupus erythematosis (SLE). Pulmonary hypertension may be present at the time of diagnosis or may develop after the diagnosis of SLE or anti-phospholipid syndrome (APS). It often presents in the reproductive years and has a significant impact on pregnancy outcome, being a significant cause of indirect maternal deaths. In our observational case series of three patients there were two deaths (66%). In cases 1 and 2 the pulmonary hypertension developed during pregnancy and deteriorated rapidly with markedly abnormal mean pulmonary artery pressures of 80 and 70 mmHg respectively prior to death. Both patients died within 48 hours of delivery. In case 3 the pulmonary hypertension was milder and was diagnosed very early in pregnancy. The patient received multidisciplinary care from the first trimester and the management of the pregnancy, delivery and the early puerperium was planned. Careful epidural anaesthesia was used and the patient had invasive monitoring on the intensive therapy unit (ITU) for 72 hours. Women with pulmonary hypertension need to be aware of the high risk of maternal mortality associated with pregnancy but we believe that an improvement in outcome can be achieved by careful assessment and the use of a multidisciplinary approach from early in pregnancy.
Collapse
Affiliation(s)
- E McMillan
- Department of Fetal Medicine, Birmingham Women's Hospital, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Nishimura T, Faul JL, Berry GJ, Veve I, Pearl RG, Kao PN. 40-O-(2-hydroxyethyl)-rapamycin attenuates pulmonary arterial hypertension and neointimal formation in rats. Am J Respir Crit Care Med 2001; 163:498-502. [PMID: 11179130 DOI: 10.1164/ajrccm.163.2.2006093] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pneumonectomized rats develop pulmonary hypertension (PH) and pulmonary vascular neointimal formation 4 wk after monocrotaline (MCT) administration. Male Sprague-Dawley rats were injected with MCT (60 mg/kg) on Day 7 after left pneumonectomy. Three groups (n = 5) received 40-O-(2-hydroxyethyl)-rapamycin (RAD, 2.5 mg/kg/d, by gavage): Group PMR(5-35) from Day 5 to Day 35, Group PMR5-14 from Day 5 to Day 14, and Group PMR15-35 from Day 15 to Day 35. By Day 35, rats that received vehicle had higher mean pulmonary arterial pressures (Ppa = 41 +/- 3 mm Hg) (p < 0.001), right ventricular systolic pressures (Prv,s = 45 +/- 2 mm Hg) (p < 0.01), and right ventricle/(left ventricle plus septum) (0.55 +/- 0.05) (p = 0.028) than rats in Groups PMR5-35 (Ppa = 25 +/- 3 mm Hg, Prv,s = 32 +/- 7 mm Hg, RV/LV&S = 0.42 +/- 0.06) and PMR5-14 (Ppa = 29 +/- 4 mm Hg, Prv,s = 30 +/- 5 mm Hg, RV/LV&S = 0.43 +/- 0.07). Pulmonary arterial neointimal formation (quantified by a vascular occlusion score) was more severe in vehicle-treated rats (1.93 +/- 0.03) than in Groups PMR5-14 (1.56 +/- 0.27) and PMR(5-35) (1.57 +/- 0.1) (p < 0.01). RAD attenuates the development of MCT-induced pulmonary arterial hypertension in the pneumonectomized rat.
Collapse
Affiliation(s)
- T Nishimura
- Division of Pulmonary and Critical Care Medicine, Department of Pathology, Stanford University Medical Center, Stanford, California 94305-5236, USA
| | | | | | | | | | | |
Collapse
|
23
|
Faul JL, Nishimura T, Berry GJ, Benson GV, Pearl RG, Kao PN. Triptolide attenuates pulmonary arterial hypertension and neointimal formation in rats. Am J Respir Crit Care Med 2000; 162:2252-8. [PMID: 11112148 DOI: 10.1164/ajrccm.162.6.2002018] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This paper reports the effect of triptolide (a diterpenoid triepoxide) on the development of monocrotaline (MCT)-induced pulmonary hypertension in pneumonectomized rats. Male Sprague- Dawley rats were injected with MCT (60 mg/kg) on Day 7 after left pneumonectomy. Rats received therapy from Day 5 to 35 with triptolide (0.25 mg/kg intraperitoneally, every other day, n = 10), or vehicle (0.1 ml of ethanol/cremophor intraperitoneally, every other day, n = 10). By Day 35, triptolide-treated rats demonstrated lower mean pulmonary arterial pressure (mPAP) than vehicle-treated rats (mPAP 21 +/- 3 versus 42 +/- 5 mm Hg, p < 0.001). Triptolide-treated rats also had significantly less right ventricular hypertrophy (RVH) and pulmonary arterial neointimal formation. In a rescue experiment, rats initiated therapy on Day 21. At Day 35, vehicle-treated rats (n = 4) had higher mPAP (40 +/- 9 mm Hg), greater RVH, and more severe pulmonary arterial neointimal formation than rats that received triptolide (0.25 mg/kg every other day, n = 7, mPAP 30 +/- 4 mm Hg) and rats that received triptolide (0.2 mg/kg daily, n = 7, mPAP 25 +/- 5 mm Hg, p < 0.01). In pneumonectomized rats that receive MCT, triptolide attenuates the development of pulmonary hypertension and RVH, and promotes regression of pulmonary arterial neointimal formation.
Collapse
MESH Headings
- Analysis of Variance
- Animals
- Disease Models, Animal
- Diterpenes/therapeutic use
- Drug Evaluation, Preclinical
- Epoxy Compounds
- Hemodynamics/drug effects
- Hypertension, Pulmonary/chemically induced
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/pathology
- Hypertension, Pulmonary/physiopathology
- Immunosuppressive Agents/therapeutic use
- Male
- Monocrotaline
- Neovascularization, Pathologic/chemically induced
- Neovascularization, Pathologic/drug therapy
- Neovascularization, Pathologic/pathology
- Neovascularization, Pathologic/physiopathology
- Phenanthrenes
- Pneumonectomy
- Rats
- Rats, Sprague-Dawley
- Specific Pathogen-Free Organisms
- Time Factors
- Tunica Intima/drug effects
- Tunica Intima/pathology
Collapse
Affiliation(s)
- J L Faul
- The Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, California 94305-5236, USA
| | | | | | | | | | | |
Collapse
|
24
|
Yi ES, Kim H, Ahn H, Strother J, Morris T, Masliah E, Hansen LA, Park K, Friedman PJ. Distribution of obstructive intimal lesions and their cellular phenotypes in chronic pulmonary hypertension. A morphometric and immunohistochemical study. Am J Respir Crit Care Med 2000; 162:1577-86. [PMID: 11029379 DOI: 10.1164/ajrccm.162.4.9912131] [Citation(s) in RCA: 210] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We investigated the distribution of pulmonary arteriopathy in chronic pulmonary hypertension (PH) in a quantitative histopathologic study, using computer-assisted image analysis. We also examined the histologic manifestations and cellular phenotypes of various obstructive intimal lesions in PH with an immunohistochemical method. A total of 53 lungs removed at autopsy or explantation were obtained for the study from 51 documented cases of moderate to severe PH (15 cases of primary pulmonary hypertension [PPH], eight cases of Eisenmenger's syndrome [EISEN], 22 cases of chronic major-vessel thromboembolic disease [CTED], and three cases of PH associated with other known causes), and two unused donor lungs served as normal controls. Intimal thickening in PPH was most prominent in small pulmonary arteries and arterioles less than 200 micrometer in diameter. Plexiform lesions in PPH were associated with significantly smaller arteries than in EISEN. Arteries larger than 400 micrometer showed a significant intimal thickening only in CTED. Obstructive intimal lesions in PH comprised a morphologic spectrum with frequent intermediate forms between plexiform and thrombotic lesions. Most cells within various intimal lesions showed an immunoprofile of myofibroblasts that were positive for vimentin and alpha-smooth muscle actin, but negative for desmin and endothelial markers including Factor VIII, clonal designator (CD)31, and CD34. Endothelial markers were positive only in the single layer of cells lining slitlike lumens, when the latter were present. In conclusion, major types of PH had characteristic distribution patterns of obstructive intimal lesions, showing mainly a myofibroblastic phenotype and variable endothelial/vascular differentiation.
Collapse
Affiliation(s)
- E S Yi
- Departments of Pathology, Medicine, and Radiology, University of California San Diego School of Medicine, San Diego, California, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
|
26
|
Curnock AL, Dweik RA, Higgins BH, Saadi HF, Arroliga AC. High prevalence of hypothyroidism in patients with primary pulmonary hypertension. Am J Med Sci 1999; 318:289-92. [PMID: 10555089 DOI: 10.1097/00000441-199911000-00001] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To characterize the prevalence of hypothyroidism in a population with primary pulmonary hypertension (PPH). METHODS Retrospective record review of 41 patients with PPH seen between 1991 and 1997 at a tertiary care center. Data abstracted included: history of previous thyroid disease, intake of thyroid supplement, and thyroid function tests. Hypothyroidism was defined as a serum thyroid stimulating hormone (TSH) level higher than 5.5 U/L, intake of thyroid supplement, or low serum thyroxine level. RESULTS Of the 40 patients with PPH included in the study (11 men and 29 women), ages ranged from 11 to 76 years (mean 43.5 years). The mean pulmonary artery pressure was 58.7 mm Hg. Thirty-three patients had normal serum TSH levels (3 of whom were on levothyroxine supplement); 1 had low TSH; 5 had high TSH (range, 6.8-9.9 U/L, mean 8.4 U/L), and 1 had low thyroxine (T4 < 1.0 microg/dL). Nine of 40 patients (22.5%) had evidence of hypothyroidism, which is much more than expected in the general population of similar age range (2.8% in men, 7.5% in women) (p = 0.002). CONCLUSIONS The prevalence of hypothyroidism in patients with PPH is high (22.5%). Patients with PPH should be investigated for the possibility of coexisting hypothyroidism.
Collapse
Affiliation(s)
- A L Curnock
- Department of General Internal Medicine, The Cleveland Clinic Foundation, Ohio 44195, USA
| | | | | | | | | |
Collapse
|