1
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Toma M, Savonitto G, Lombardi CM, Airò E, Driussi M, Gentile P, Howard L, Moschella M, Di Poi E, Pagnesi M, Monti S, Collini V, D'Angelo L, Vecchiato V, Giannoni A, Adamo M, Barbisan D, Bauleo C, Garascia A, Metra M, Sinagra G, Giudice FL, Stolfo D, Ameri P. Frequency, characteristics and risk assessment of pulmonary arterial hypertension with a left heart disease phenotype. Clin Res Cardiol 2024:10.1007/s00392-024-02448-9. [PMID: 38619580 DOI: 10.1007/s00392-024-02448-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
AIM To obtain real-world evidence about the features and risk stratification of pulmonary arterial hypertension (PAH) with a left heart disease (LHD) phenotype (PAH-LHD). METHODS AND RESULTS By reviewing the records of consecutive incident PAH patients at 7 tertiary centers from 2001 to 2021, we selected 286 subjects with all parameters needed to determine risk of death at baseline and at first follow-up with COMPERA and COMPERA 2.0 scores. Fifty seven (20%) had PAH-LHD according to the AMBITION definition. Compared with no-LHD ones, they were older, had higher BMI, more cardiovascular comorbidities, higher E/e' ratio and left atrial area, but lower BNP concentrations and better right ventricular function and pulmonary hemodynamics. Survival was comparable between PAH-LHD and no-LHD patients, although the former were less commonly treated with dual PAH therapy. Both COMPERA and COMPERA 2.0 discriminated all-cause mortality risk of PAH-LHD at follow-up, but not at baseline. Risk profile significantly improved during follow-up only when assessed by COMPERA 2.0. At multivariable analysis with low-risk status as reference, intermediate-high and high-risk, but not LHD phenotype, were associated with higher hazard of all-cause mortality. Results were comparable in secondary analyses including patients in the last 10 years and atrial fibrillation and echocardiographic abnormalities as additional criteria for PAH-LHD. CONCLUSIONS In real life, PAH-LHD patients are frequent, have less severe disease and are less likely treated with PAH drug combinations than no-LHD. The COMPERA 2.0 model may be more appropriate to evaluate their mortality risk during follow-up and how it is modulated by therapy.
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Affiliation(s)
- Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Giulio Savonitto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Carlo Maria Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Edoardo Airò
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Mauro Driussi
- Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Piero Gentile
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Luke Howard
- Faculty of Medicine, Imperial College London, National Heart & Lung Institute, London, UK
- Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Martina Moschella
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Emma Di Poi
- Department of Medicine, Rheumatology Clinic, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Matteo Pagnesi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Simonetta Monti
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Valentino Collini
- Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | | | - Veronica Vecchiato
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Alberto Giannoni
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Davide Barbisan
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Carolina Bauleo
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | | | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Francesco Lo Giudice
- Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy.
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy.
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2
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Kearney K, Brown K, Celermajer DS, Collins N, Cordina R, Corrigan C, Dwyer N, Feenstra J, Keating D, Keogh A, Kotlyar E, Lavender M, McWilliams T, Williams T, Whitford H, Weintraub R, Wrobel J, Ellender C, Anderson J, Lau EM. Impact of Left Heart Disease Risk Factors on Outcomes in Pulmonary Arterial Hypertension Therapy. Chest 2024; 165:967-977. [PMID: 37951349 DOI: 10.1016/j.chest.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 10/04/2023] [Accepted: 10/07/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Current guidelines recommend initial monotherapy for pulmonary arterial hypertension (PAH) with cardiopulmonary comorbidities, despite limited available evidence to guide management. RESEARCH QUESTION Do left heart disease (LHD) risk factors have an impact on treatment response and influence applicability of risk assessment in a real-world cohort of patients with PAH? STUDY DESIGN AND METHODS The Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial criteria was used to define the phenotype of patients with PAH with risk factors for LHD. Treatment strategy, functional outcome, long-term survival, and risk discrimination were compared with a reference PAH cohort using the Pulmonary Hypertension Society of Australia and New Zealand Registry. RESULTS A total of 487 incident patients with PAH diagnosed between 2011 and 2020 were included. Of these, 103 (21.1%) fulfilled the definition of PAH with LHD risk factors, with 384 (78.9%) remaining as the reference group. Patients in the PAH with LHD risk factors group were older (66 ± 13 vs 58 ± 19 years; P < .001), had lower pulmonary vascular resistance (393 ± 266 vs 708 ± 391 dyn.s/cm5; P = .031), and had worse 6-min walk distance (286 ± 130 vs 327 ± 136 m; P = .005) at diagnosis. The PAH with LHD risk factors group was less likely to receive initial combination therapy (27% vs 44%; P = .02). Changes in 6-min walk distance at 12 months were similar in both groups (43 ± 77 m in the PAH with LHD risk factors group and 50 ± 90 m in the reference group; P = .50), including when stratified by initial treatment strategy (PAH with LHD risk factors group vs reference PAH group: monotherapy: 40 ± 81 vs 38 ± 95 m, P = .87; combination therapy: 53 ± 78 vs 64 ± 106 m, P = .511). Functional class improvements were also similar in both groups. REVEAL Registry 2.0 risk score effectively discriminated risk in both populations (C statistic = 0.756 for the PAH with LHD risk factors group and C statistic = 0.750 for the reference PAH group). There was no difference in survival between the two groups (log-rank test, P = .29). INTERPRETATION In a real-world cohort, patients with PAH with LHD risk factors were less likely to be exposed to initial combination therapy. Nevertheless, selected patients with PAH with LHD risk factors who were treated with initial combination therapy derived similar functional response compared with the reference group. Further studies are needed to phenotype patients with PAH with cardiopulmonary comorbidities who may benefit from initial combination therapy.
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Affiliation(s)
- Katherine Kearney
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Karen Brown
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Rachael Cordina
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Carolyn Corrigan
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - Nathan Dwyer
- Department of Cardiology, Royal Hobart Hospital, Hobart, TAS, Australia
| | - John Feenstra
- Queensland Lung Transplant Service, Prince Charles Hospital, Chermside, QLD, Australia; Wesley Pulmonary Hypertension Service, Wesley Hospital, Auchenflower, QLD, Australia
| | - Dominic Keating
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Anne Keogh
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Eugene Kotlyar
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Tanya McWilliams
- Greenlane Clinical Centre, Auckland City Hospital, Auckland, New Zealand
| | - Trevor Williams
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helen Whitford
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Robert Weintraub
- Department of Cardiology, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute and Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Claire Ellender
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - James Anderson
- Department of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Edmund M Lau
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Scagliola R, Brunelli C, Balbi M. Pulmonary Arterial Hypertension in the Elderly: Peculiar Features and Challenges for a Proper Phenotyping Approach. J Cardiovasc Dev Dis 2023; 10:401. [PMID: 37754830 PMCID: PMC10531962 DOI: 10.3390/jcdd10090401] [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: 08/16/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
(1) Introduction. Although pulmonary arterial hypertension (PAH) usually affects young people with a low cardiovascular risk profile, progressive epidemiologic changes have been providing a codified phenotype of elderly subjects with PAH and increased risk predictors for left heart disease. We therefore conducted a systematic review to describe the current knowledge and characteristics of elderly individuals with PAH and further insights concerning their prognostic outcomes and therapeutic response. (2) Methods. A search was conducted in PubMed, Embase, and Cochrane Library for publications evaluating the epidemiology, diagnostic work-up, and treatment of PAH in elderly subjects. (3) Among the 74 publications initially retrieved, 16 full-text articles were selected for the present systematic review. Compared to their younger counterparts, elderly individuals with PAH showed greater clinical deterioration, reduced exercise capacity, and worse prognostic outcomes, as well as less response to PAH-targeted therapy and higher rates of PAH drug discontinuation. (4) Conclusions. Demographic changes over time contributed to define a peculiar PAH phenotype in elderly patients, with an increased burden of cardiovascular comorbidities and distinctive features compared to young patients. Further investigations are needed in order to better clarify the nosologic criteria, and management in this subset population.
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Affiliation(s)
- Riccardo Scagliola
- Cardiology Division, Department of Emergency, Cardinal G. Massaia Hospital, 14100 Asti, Italy
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
| | - Claudio Brunelli
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
| | - Manrico Balbi
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
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4
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Omura J, Kitahara K, Takano M, Idehara K, Kim S. Real-world clinical practice of pulmonary arterial hypertension in Japan: Insights from a large administrative database. Pulm Circ 2023; 13:e12275. [PMID: 37649808 PMCID: PMC10462924 DOI: 10.1002/pul2.12275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a fatal disease that often occurs at an early age. In recent years, aggressive treatment with multiple drugs from the early-stage diagnosis is expected to improve the prognosis. Indeed, a high rate of initial combination therapy and excellent treatment outcomes have been reported from specialized centers for PAH in Japan. However, information on PAH epidemiology, including non-PAH specialized centers in Japan, is unclear. To address the above, we conducted a retrospective observational cohort study from April 2008 to September 2020 using real-world evidence from a large-scale administrative database (Medical Data Vision) to examine baseline characteristics, comorbidities, and treatment profiles of Japanese patients with PAH. Five hundred and eighteen patients with PAH (treatment-naive PAH, age 67.2 ± 15.9) were identified through our comprehensive approach which combined PAH disease codes, medications, and diagnostic procedures. Moreover, we showed that a larger proportion of patients received monotherapy in their initial treatment (66%) compared to those receiving combination therapy (34%). During the 1-year follow-up after PAH diagnosis, 13% of patients increased their PAH medications while other patients either decreased their PAH medications (6%) or discontinued PAH treatment (27%). The 3- and 5-year event-free survival rates of all-cause death were 72% and 64%, respectively. This is the first large-scale administrative database study that provides insights into real-world PAH management in Japan. This study highlighted a different PAH clinical landscape which included a larger portion of the elderly population, higher initial monotherapy treatment, and lower survival rates than previous studies.
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Affiliation(s)
- Junichi Omura
- Medical AffairsJanssen Pharmaceutical K. K.TokyoJapan
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5
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Stencel J, Rajapreyar I, Samson R, Le Jemtel T. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 2022; 19:364-374. [PMID: 36045314 DOI: 10.1007/s11897-022-00573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE REVIEW Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.
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Affiliation(s)
- Jason Stencel
- Tulane University School of Medicine, New Orleans, LA, USA.
| | | | - Rohan Samson
- Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA
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Kianzad A, van Wezenbeek J, Celant LR, Oosterveer FP, Noordegraaf AV, Meijboom LJ, de Man FS, Bogaard HJ, Handoko ML. Idiopathic pulmonary arterial hypertension patients with a high H2FPEF-score: insights from the Amsterdam UMC PAH-cohort. J Heart Lung Transplant 2022; 41:1075-1085. [DOI: 10.1016/j.healun.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022] Open
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7
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Scagliola R, Brunelli C, Balbi M. Treatment with neurohormonal inhibitors and prognostic outcome in pulmonary arterial hypertension with risk factors for left heart disease. World J Crit Care Med 2022; 11:85-91. [PMID: 35433314 PMCID: PMC8968482 DOI: 10.5492/wjccm.v11.i2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/04/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite major advances in pharmacologic treatment, patients with pulmonary arterial hypertension (PAH) still have a considerably reduced life expectancy. In this context, chronic hyperactivity of the neurohormonal axis has been shown to be detrimental in PAH, thus providing novel insights on the role of neurohormonal blockade as a potential therapeutic target.
AIM To evaluate the application and prognostic effect of neurohormonal inhibitors (NEUi) in a single-center sample of patients with idiopathic PAH and risk factors for left heart disease.
METHODS We analyzed data retrospectively collected from our register of right heart catheterizations performed consecutively from January 1, 2005 to October 31, 2018. Patients on beta-blocker, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker or mineralocorticoid receptor antagonist at the time of right heart catheterization were classified as NEUi users and compared to NEUi non-recipients.
RESULTS Complete data were available for 57 PAH subjects: 27 of those (47.4%) were taking at least one NEUi at the time of right heart catheterization and were compared with the remaining 36 NEUi non-recipients. NEUi users were older and had a higher cardiovascular risk profile compared to non-recipients. Additionally, NEUi non-users had a higher probability of dying during the course of follow-up than NEUi recipients (56.7% vs 25.9%, log-rank P = 0.020).
CONCLUSION The above data highlighted a subgroup of patients with PAH and comorbidities for left heart disease in which NEUi use has shown to be associated with improved survival. Future prospective studies are needed to identify the most appropriate therapeutic strategies in this subset population.
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Affiliation(s)
- Riccardo Scagliola
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova 16132, Genova, Italy
| | - Claudio Brunelli
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova 16132, Genova, Italy
| | - Manrico Balbi
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova 16132, Genova, Italy
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8
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Wilkins MR. Personalized Medicine for Pulmonary Hypertension:: The Future Management of Pulmonary Hypertension Requires a New Taxonomy. Clin Chest Med 2021; 42:207-216. [PMID: 33541614 DOI: 10.1016/j.ccm.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension is a convergent phenotype that presents late in the natural history of the condition. The current clinical classification of patients lacks granularity, and this impacts on the development and deployment of treatment. Deep molecular phenotyping using platform 'omic' technologies is beginning to reveal the genetic and molecular architecture that underlies the phenotype, promising better targeting of patients with new treatments. The future treatment of pulmonary hypertension depends on the integration of clinical and molecular information to create a new taxonomy that defines patient groups coupled to druggable targets.
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Affiliation(s)
- Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
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9
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Church C, Gin-Sing W, Grady D, Johnson M, Kiely DG, Lordan J, Turner N, Wort SJ, Condliffe R. Establishing expert consensus for the optimal approach to holistic risk-management in pulmonary arterial hypertension: a Delphi process and narrative review. Expert Rev Respir Med 2021; 15:1493-1503. [PMID: 34018901 DOI: 10.1080/17476348.2021.1931129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Pulmonary arterial hypertension (PAH) is associated with significant morbidity and reduced life expectancy. Various medical therapies, together with non-medical therapies such as exercise training, have been shown to improve outcomes for patients. We performed a Delphi consensus process to establish optimal approaches to optimizing patient care.Methods: A steering group of PAH experts formulated 38 statements grouped into 6 themes: burden of PAH, risk-stratification, the role of clinical phenotyping in the management of PAH, assessing clinical response to treatment, maximizing the medical treatment pathway and the role of other management options. An online survey was sent to PAH health-care professionals throughout the UK to assess consensus with these statements. Consensus was defined as high if ≥70% and very high if ≥90% of the respondents agreed with a statement. A narrative review for each theme was then performedResults: Consensus was very high in 27 (71%) statements, high in 7 (18%) statements and was not achieved in 4 (11%) statements.Conclusions: Based on the consensus scores, the steering group derived 13 recommendations which, if implemented, should result in improved holistic care of patients with PAH.
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Affiliation(s)
- Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Wendy Gin-Sing
- Pulmonary Hypertension Service, Hammersmith Hospital, London, United Kingdom
| | - Duncan Grady
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Trust, Cambridge, United Kingdom
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Jim Lordan
- Pulmonary Vascular Unit, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Nadine Turner
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - S John Wort
- Pulmonary Hypertension Service, Royal Brompton Hospital, London, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
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How Closely Do Clinical Trial Participants Resemble "Real-World" Patients with Groups 2 and 3 Pulmonary Hypertension? A Structured Review. Ann Am Thorac Soc 2021; 17:779-783. [PMID: 32150687 DOI: 10.1513/annalsats.202001-003rl] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Historically, pulmonary arterial hypertension (PAH) has been considered a disease of young adults, but over the last three decades, the average age at diagnosis has increased, presenting clinicians with some unique challenges. Clinical symptoms of PAH, including shortness of breath and reduced functional capacity, are not specific for the disease and may be present in older patients because of their age or as a result of comorbid conditions. Eliminating other causes for these symptoms can delay PAH diagnosis and initiation of PAH-specific treatment compared with younger patients. Currently, there are no specific guidelines relating to PAH in older patients and existing guidelines for identifying patients at potential risk of PAH may not be appropriate for patients aged over 65 years. Even though older patients tend to be diagnosed with more advanced symptoms, and evidence suggests that they are less responsive to PAH-specific therapies, treatment is often less aggressive than in younger patients. Even after adjusting for age, survival rates remain disproportionately lower in the older vs. younger PAH populations. Specific guidelines for diagnosis and treatment of older patients with PAH are needed to improve care and outcomes in this growing population. This review aims to assess the challenges associated with diagnosing and managing PAH in older patients, based on literature searches, authors' experiences, and expert opinions.
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Affiliation(s)
- Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris-Sud, Paris, France
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, W12 0HS, UK
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Venkateshvaran A, Manouras A, Kjellström B, Lund LH. The additive value of echocardiographic pulmonary to left atrial global strain ratio in the diagnosis of pulmonary hypertension. Int J Cardiol 2019; 292:205-210. [PMID: 31176524 DOI: 10.1016/j.ijcard.2019.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/10/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The distinction between pre-capillary and post-capillary pulmonary hypertension (PH) is central to accurate diagnosis and appropriate therapy. We aimed to investigate the ability of the novel echocardiographic pulmonary to left atrial global strain ratio (ePLAGS) to distinguish pre-capillary from post-capillary PH and compare its discriminatory strength with the echocardiographic pulmonary to left atrial ratio (ePLAR). METHODS Consecutive subjects with unexplained dyspnea or heart failure underwent echocardiography immediately followed by right heart catheterization. Subjects who did not satisfy the ESC/ERS criteria for PH, in atrial fibrillation or under pacemaker therapy, or with significant concomitant valvular disease were excluded. ePLAGS was calculated as peak tricuspid regurgitation velocity divided by left atrial global reservoir strain. RESULTS One hundred and thirty PH subjects, as defined by right heart catheterization, were included in the analysis (pre-capillary: n = 64, post-capillary: n = 66). ePLAGS was lower in pre-capillary compared with post-capillary PH (0.19 ± 0.14 vs. 0.45 ± 0.58 m/s/%; p = 0.02) and significantly different between combined post- and pre-capillary PH (Cpc-PH) and isolated post-capillary PH (Ipc-PH) (0.62 ± 0.85 vs. 0.32 ± 0.19 m/s/%; p = 0.04). ePLAR was higher in pre-capillary as compared with post-capillary PH (0.37 ± 0.16 vs. 0.20 ± 0.08; p < 0.001) but did not differ between Ipc-PH and Cpc-PH. ePLAGS demonstrated stronger discriminating power than ePLAR to distinguish pre-capillary from post-capillary PH (AUC = 0.80 vs. 0.70). In the setting of post capillary PH, ePLAGS showed reasonable ability to distinguish Ipc-PH from Cpc-PH (AUC = 0.65). ePLAR, however, did not differentiate these two groups (AUC = 0.49; p > 0.05). CONCLUSIONS ePLAGS accurately differentiates pre-capillary from post-capillary PH and demonstrates higher diagnostic ability than ePLAR.
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Affiliation(s)
- Ashwin Venkateshvaran
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Aristomenis Manouras
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Barbro Kjellström
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Rothbard N, Agrawal A, Fischer C, Talwar A, Sahni S. Pulmonary arterial hypertension in the elderly: Clinical perspectives. Cardiol J 2018; 27:184-193. [PMID: 30155860 DOI: 10.5603/cj.a2018.0096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 08/24/2018] [Accepted: 07/11/2018] [Indexed: 01/25/2023] Open
Abstract
Pulmonary hypertension (PH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventric-ular failure and death. Pulmonary arterial hypertension (PAH) (World Health Organization Group I), a subset of PH, and may be idiopathic in nature or associated with other systemic conditions and is thought to most commonly effect women, the majority of whom are of childbearing age. However, PAH in the elderly population is being increasingly diagnosed creating clinical considerations that had once not been considered. Often in an elderly population the diagnosis of PAH may be delayed due to chronic comorbid conditions such as coronary artery disease or other dyspneic conditions. Though survival and clinical outcomes have improved, the elderly population continues to have disproportionately lower survival rates. High clinical suspicion of PAH warrants a complete diagnostic workup with right heart catheterization. Upon diagnosis, PAH specific therapy should be initiated with possible drug interactions in mind. Adjuvant pulmonary rehabilitation should be considered as a conservative measure with definitive results. Finally, psychosomatic aspects of the disease should also be considered in elderly populations.
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Affiliation(s)
- Nicholas Rothbard
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States
| | - Abhinav Agrawal
- Department of Pulmonary, Northwell Health System, Critical Care and Sleep Medicine, 410 Lakeville Rd., Suite 107, 11040 New Hyde Park, United States
| | - Conrad Fischer
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States.,Department of Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY, United States
| | - Arunabh Talwar
- Department of Pulmonary, Northwell Health System, Critical Care and Sleep Medicine, 410 Lakeville Rd., Suite 107, 11040 New Hyde Park, United States
| | - Sonu Sahni
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States. .,Department of Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY, United States.
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Charalampopoulos A, Lewis R, Hickey P, Durrington C, Elliot C, Condliffe R, Sabroe I, Kiely DG. Pathophysiology and Diagnosis of Pulmonary Hypertension Due to Left Heart Disease. Front Med (Lausanne) 2018; 5:174. [PMID: 29928642 PMCID: PMC5997828 DOI: 10.3389/fmed.2018.00174] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension due to left heart disease (PH-LHD) is the most common type of pulmonary hypertension, although an accurate prevalence is challenging. PH-LHD includes PH due to systolic or diastolic left ventricular dysfunction, mitral or aortic valve disease and congenital left heart disease. In recent years a new and distinct phenotype of “combined post-capillary and pre-capillary PH,” based on diastolic pulmonary gradient and pulmonary vascular resistance, has been recognized. The roles of right ventricular dysfunction and pulmonary vascular compliance in PH-LHD have also been elucidated recently and they appear to have significant clinical implications. Echocardiography continues to play a seminal role in diagnosis of PH-LHD and heart failure with preserved LV ejection fraction, as it can identify valve disease and help to distinguish PH-LHD from pre-capillary PH. Right, and occasionally left heart catheterization, remains the gold-standard for diagnosis and phenotyping of PH-LHD, although Cardiac Magnetic Resonance Imaging is emerging as a useful alternative tool in non-invasive diagnostic and prognostic assessment of PH-LHD. In this review, the latest evidence for more recent advances will be discussed, including the role of fluid challenge and exercise during cardiac catheterization to unravel occult post-capillary and the role of vasoreactivity testing. The use of many or all of these diagnostic techniques will undoubtedly provide key information about sub-groups of patients with PH-LHD that might benefit from medical therapy previously considered to be only suitable for pulmonary arterial hypertension.
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Affiliation(s)
- Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Peter Hickey
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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RP5063, a novel, multimodal, serotonin receptor modulator, prevents Sugen 5416-hypoxia–induced pulmonary arterial hypertension in rats. Eur J Pharmacol 2017; 810:83-91. [DOI: 10.1016/j.ejphar.2017.05.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/24/2017] [Accepted: 05/29/2017] [Indexed: 11/20/2022]
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16
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Lau EMT, Giannoulatou E, Celermajer DS, Humbert M. Epidemiology and treatment of pulmonary arterial hypertension. Nat Rev Cardiol 2017; 14:603-614. [DOI: 10.1038/nrcardio.2017.84] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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17
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Parikh KS, Rao Y, Ahmad T, Shen K, Felker GM, Rajagopal S. Novel approach to classifying patients with pulmonary arterial hypertension using cluster analysis. Pulm Circ 2017; 7:486-493. [PMID: 28597780 PMCID: PMC5467940 DOI: 10.1177/2045893217705891] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/30/2017] [Indexed: 11/15/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) patients have distinct disease courses and responses to treatment, but current diagnostic and treatment schemes provide limited insight. We aimed to see if cluster analysis could distinguish clinical phenotypes in PAH. An unbiased cluster analysis was performed on 17 baseline clinical variables of PAH patients from the FREEDOM-M, FREEDOM-C, and FREEDOM-C2 randomized trials of oral treprostinil versus placebo. Participants were either treatment-naïve (FREEDOM-M) or on background therapy (FREEDOM-C, FREEDOM-C2). We tested for association of clusters with outcomes and interaction with respect to treatment. Primary outcome was 6-minute walking distance (6MWD) change. We included 966 participants with 12-week (FREEDOM-M) or 16-week (FREEDOM-C and FREEDOM-C2) follow-up. Four patient clusters were identified. Compared with Clusters 1 (n = 131) and 2 (n = 496), Clusters 3 (n = 246) and 4 (n = 93) patients were older, heavier, had worse baseline functional class, 6MWD, Borg Dyspnea Index, and fewer years since PAH diagnosis. Clusters also differed by PAH etiology and background therapies, but not gender or race. Mean treatment effect of oral treprostinil differed across Clusters 1-4 increased in a monotonic fashion (Cluster 1: 10.9 m; Cluster 2: 13.0 m; Cluster 3: 25.0 m; Cluster 4: 50.9 m; interaction P value = 0.048). We identified four distinct clusters of PAH patients based on common patient characteristics. Patients who were older, diagnosed with PAH for a shorter period, and had worse baseline symptoms and exercise capacity had the greatest response to oral treprostinil treatment.
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Affiliation(s)
- Kishan S. Parikh
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Youlan Rao
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kai Shen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - G. Michael Felker
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Opitz CF, Hoeper MM, Gibbs JSR, Kaemmerer H, Pepke-Zaba J, Coghlan JG, Scelsi L, D’Alto M, Olsson KM, Ulrich S, Scholtz W, Schulz U, Grünig E, Vizza CD, Staehler G, Bruch L, Huscher D, Pittrow D, Rosenkranz S. Pre-Capillary, Combined, and Post-Capillary Pulmonary Hypertension. J Am Coll Cardiol 2016; 68:368-78. [DOI: 10.1016/j.jacc.2016.05.047] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 04/28/2016] [Accepted: 05/03/2016] [Indexed: 01/02/2023]
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19
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Hussain N, Charalampopoulos A, Ramjug S, Condliffe R, Elliot CA, O'Toole L, Swift A, Kiely DG. Pulmonary hypertension in patients with heart failure and preserved ejection fraction: differential diagnosis and management. Pulm Circ 2016; 6:3-14. [PMID: 27162611 PMCID: PMC4860544 DOI: 10.1086/685021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most common cause of pulmonary hypertension (PH) due to left heart disease (LHD) was previously rheumatic mitral valve disease. However, with the disappearance of rheumatic fever and an aging population, nonvalvular LHD is now the most common cause of group 2 PH in the developed world. In this review, we examine the challenge of investigating patients who have PH and heart failure with preserved ejection fraction (HF-pEF), where differentiating between pulmonary arterial hypertension (PAH) and PH-LHD can be difficult, and also discuss the entity of combined precapillary and postcapillary PH. Given the proven efficacy of targeted therapy for the treatment of PAH, there is increasing interest in whether these treatments may benefit selected patients with PH associated with HF-pEF, and we review current trial data.
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Affiliation(s)
- Nehal Hussain
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Sheila Ramjug
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Laurence O'Toole
- Department of Cardiology, Northern General Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Andrew Swift
- Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
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