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Huertas Nieto S, Velázquez Martín M, Sarnago Cebada F, Jiménez López-Guarch C, Maneiro Melón N, Flox Camacho Á, Segura de la Cal T, Cruz Utrilla A, Aguilar Colindres R, López Gude MJ, Quezada Loaiza CA, Revilla Ostolaza Y, Alonso Charterina S, Gómez Cuervo C, Arribas Ynsaurriaga F, Escribano Subías P. Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:158-166. [PMID: 37863183 DOI: 10.1016/j.rec.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/16/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION AND OBJECTIVES Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing. METHODS We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH. RESULTS We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049). CONCLUSIONS Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea.
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Affiliation(s)
- Sergio Huertas Nieto
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain.
| | - Maite Velázquez Martín
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Sarnago Cebada
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Carmen Jiménez López-Guarch
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Nicolás Maneiro Melón
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Ángela Flox Camacho
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Teresa Segura de la Cal
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Alejandro Cruz Utrilla
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | - María Jesús López Gude
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Andrés Quezada Loaiza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Yolanda Revilla Ostolaza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sergio Alonso Charterina
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Fernando Arribas Ynsaurriaga
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Pilar Escribano Subías
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Boon GJAM, van den Hout WB, Barco S, Bogaard HJ, Delcroix M, Huisman MV, Konstantinides SV, Meijboom LJ, Nossent EJ, Symersky P, Vonk Noordegraaf A, Klok FA. A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension. ERJ Open Res 2021; 7:00719-2020. [PMID: 34853780 PMCID: PMC8628742 DOI: 10.1183/23120541.00719-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH)
exceeds 1 year, contributing to higher mortality. Health economic
consequences of late CTEPH diagnosis are unknown. We aimed to develop a
model for quantifying the impact of diagnosing CTEPH earlier on survival,
quality-adjusted life-years (QALYs) and healthcare costs. Material and methods A Markov model was developed to estimate lifelong outcomes, depending on the
degree of delay. Data on survival and quality of life were obtained from
published literature. Hospital costs were assessed from patient records
(n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH
referral center. Medication costs were based on a mix of standard medication
regimens. Results For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH
(median age and delay of patients in the European CTEPH Registry), lifelong
healthcare costs were estimated at EUR 117 100 for a mix of treatment
options. In a hypothetical scenario of maximal reduction of current delay,
improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs.
The associated cost increase was EUR 44 654, of which 87% was
due to prolonged medication use. This accounts for an incremental
cost–utility ratio of EUR 21 900/QALY. Conclusion Our constructed model based on the Dutch healthcare setting demonstrates a
substantial health gain when CTEPH is diagnosed earlier. According to Dutch
health economic standards, additional costs remain below the deemed
acceptable limit of EUR 50 000/QALY for the particular disease
burden. This model can be used for evaluating cost-effectiveness of
diagnostic strategies aimed at reducing the diagnostic delay. This constructed model based on the Dutch healthcare setting can be used
for evaluating cost-effectiveness of diagnostic strategies aimed at reducing
the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3
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Affiliation(s)
- Gudula J A M Boon
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Dept of Biomedical Data Science - Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Xanthi, Greece
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Petr Symersky
- Dept of Cardiac Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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