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Inada Y, Suematsu Y, Matsuda T, Yano Y, Morita K, Bando K, Teshima R, Fukuda H, Fujimi K, Miura SI. Effect of Left Ventricular Diastolic Dysfunction on the Cardiopulmonary Exercise Test in Patients With Cardiovascular Disease. Am J Cardiol 2024; 222:157-164. [PMID: 38703885 DOI: 10.1016/j.amjcard.2024.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
Left ventricular diastolic dysfunction exists in patients with heart failure with reduced ejection fraction and causes activity restriction and a poor prognosis, but there have been few reports about exercise tolerance in patients with diastolic dysfunction, regardless of left ventricular ejection fraction (LVEF). In this study, 294 cardiovascular disease patients who performed a cardiopulmonary exercise test (CPX) with an adequate examination by echocardiography at Fukuoka University Hospital from 2011 to 2020 were investigated. Patients were divided into groups with grade I and grade II or III diastolic dysfunction according to diagnostic criteria, regardless of LVEF, by echocardiography. After adjusting for age, gender, body mass index, smoking, and LVEF by propensity score matching, we compared the results of CPX between the grade I and grade II/III groups. There were no significant differences in hemodynamic parameters, or in the respiratory exchange ratio, oxygen uptake per body weight, oxygen uptake per heart rate, or parameters of ventilatory volume. Ventilatory equivalents per oxygen uptake and per carbon dioxide output were significantly worse in the grade II/III group from the rest to peak periods during CPX. In conclusion, left ventricular diastolic dysfunction worsens ventilatory efficacy during CPX. This effect potentially contributes to a poor prognosis in left ventricular diastolic dysfunction.
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Affiliation(s)
- Yuki Inada
- Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | | | - Takuro Matsuda
- Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | - Yuiko Yano
- Division of Internal Medicine, Miyase Clinic, Fukuoka, Japan
| | - Kai Morita
- Division of Internal Medicine, Hinoki Clinic, Fukuoka, Japan
| | - Kakeru Bando
- Department of Cardiology, Hakujyuji Hospital, Fukuoka, Japan
| | - Reiko Teshima
- Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | | | - Kanta Fujimi
- Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan; Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Shin-Ichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan; Department of Cardiology, Fukuoka University Nishijin Hospital, Fukuoka, Japan.
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Echocardiographic Ventricular Septal Motion Abnormalities are Associated With Pre-Capillary Pulmonary Hypertension in Patients With Preserved Left Ventricular Function. Heart Lung Circ 2021; 31:119-127. [PMID: 34088629 DOI: 10.1016/j.hlc.2021.04.015] [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: 02/08/2019] [Revised: 02/02/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ventricular septal motion abnormalities (VSMA) are common echocardiographic finding in patients with pulmonary hypertension (PHTN). This study sought to evaluate the relationship between echocardiographic findings and the classification of PHTN. METHODS This study retrospectively studied 146 consecutive patients referred for right heart catheterisation for clinically suspected PHTN. VSMA were defined as any echocardiographic description of leftward abnormal septal motion or position. RESULTS VSMA were present in 42 patients (29%). Patients with VSMA were younger and more likely to have prior pulmonary embolism. They also had less obstructive sleep apnoea, hypertension and dyslipidaemia. By echocardiography, patients with VSMA had lower left ventricular mass, left atrial size and lateral wall E/e' ratio. At cardiac catheterisation, PHTN was confirmed in all (100%) patients with VSMA (compared with 75% in patients without VSMA); 98% with VSMA had elevated pulmonary vascular resistance (compared with 55% without VSMA; p<0.005 for all). VSMA were found to have 91% sensitivity and 51% specificity for the diagnosis of pre-capillary PHTN. On multivariate analysis, VSMA were found to be strong independent predictors for the diagnosis of pre-capillary PHTN (HR, 9.15; 95% CI, 3.0-28.2; p<0.001). Left atrial enlargement was also a strong negative predictor for pre-capillary PHTN (HR, 0.14; 95% CI, 0.05-0.36; p<0.001). CONCLUSION Ventricular septal motion abnormalities were strongly associated with pre-capillary PHTN in patients with suspected PHTN. The findings suggest that patients with VSMA should be further evaluated by right heart catheterisation.
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Ruocco G, Gavazzi A, Gonnelli S, Palazzuoli A. Pulmonary arterial hypertension and heart failure with preserved ejection fraction: are they so discordant? Cardiovasc Diagn Ther 2020; 10:534-545. [PMID: 32695633 DOI: 10.21037/cdt-19-405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) and pulmonary arterial hypertension (PAH) are two emerging diseases focusing the attention of numerous researchers. In the last PAH guideline, there is a crossroad between the two diseases and pulmonary hypertension (PH) due to heart failure (HF) is categorized as subtype 2. In order to assess the correct diagnosis and management, it should be better understood the points of convergence and divergence of two diseases. Although, risk factors, demographic characteristics and haemodynamics are different, we report several similarities regarding vascular alterations, some aspects of cardiac remodelling, and clinical presentation. This model suggests HFpEF and PAH as two comparable conditions, with different cardiac adaptation and trajectories, linked to the intrinsic properties of either right and left ventricles. In both diseases the early pathophysiological mechanisms appear to begin from peripheral vasculature and to be backward transmitted to the larger arterial vascular district, and eventually to the myocardial structure. In this paper we would propose a simple approach to recognize the concordances and, all at once, distinguish the peculiarities of the two diseases.
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Affiliation(s)
- Gaetano Ruocco
- Cardiology Unit, Regina Montis Regalis Hospital, ASLCN1, Mondovì (Cuneo), Italy
| | - Antonello Gavazzi
- FROM Research Foundation of the Bergamo Hospital, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefano Gonnelli
- Cardiovascular Diseases Unit, Department of Internal Medicine, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, Le Scotte Hospital, University of Siena, Siena, Italy
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Adir Y, Guazzi M, Offer A, Temporelli PL, Cannito A, Ghio S. Pulmonary hemodynamics in heart failure patients with reduced or preserved ejection fraction and pulmonary hypertension: Similarities and disparities. Am Heart J 2017; 192:120-127. [PMID: 28938958 DOI: 10.1016/j.ahj.2017.06.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The current understanding of pulmonary hypertension (PH) due to left ventricular diseases does not distinguish heart failure (HF) with reduced ejection fraction (HFrEF) from HF and preserved ejection fraction (HFpEF), in terms of pulmonary hemodynamics. The value of pulmonary vascular compliance (PCa) and diastolic pulmonary gradient (DPG) as predictors of survival in either HF syndrome is controversial. The aims of our study were to compare the pulmonary hemodynamics in the two HF phenotypes, given similar values of pulmonary artery wedge pressure (PAWP), and to evaluate the impact of PCa and DPG on survival. METHODS We retrospectively reviewed the charts of 168 PH-HFrEF and 86 PH-HFpEF patients. The independent association of PCa and DPG with prognosis was assessed by means of a Cox proportional hazard model. All cause survival was analyzed over an average follow-up period of 50 months. RESULTS PH-HFpEF patients had a significantly higher DPG than PH-HFrEF patients (6.1±7.1 vs 1.8±4.5 mmHg, adjusted P=.025). PCa was similar in PH-HFpEF and PH-HFrEF. PCa was a significant predictor of survival, according to previously described preset cutoffs (2.15 mL/mmHg in HFrEF and 1.1 mL/mmHg in HFpEF) and based on a continuous scale; whereas DPG had no impact on survival in both patients groups. CONCLUSION Our findings suggest that for similar levels of PAWP, pulmonary circulation may be stiffer in patients with HFpEF-PH than patients with HFrEF-PH, leading to higher DPGs. Nonetheless, PCa rather than DPG emerged as the stronger predictor of survival in both left-sided PH phenotypes.
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Berthelot E, Montani D, Algalarrondo V, Dreyfuss C, Rifai R, Benmalek A, Jais X, Bouchachi A, Savale L, Simonneau G, Chemla D, Humbert M, Sitbon O, Assayag P. A Clinical and Echocardiographic Score to Identify Pulmonary Hypertension Due to HFpEF. J Card Fail 2016; 23:29-35. [PMID: 27742455 DOI: 10.1016/j.cardfail.2016.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 09/05/2016] [Accepted: 10/06/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a frequent cause of pulmonary hypertension (PH) that is not easy to differentiate from precapillary PH. We aimed to determine whether the characteristic features of the patients may help differentiate between HFpEF and precapillary PH. METHODS AND RESULTS Clinical and echocardiographic parameters were analyzed in 156 patients referred to our PH referral center. Right heart catheterization identified 78 PH-HFpEF patients and 78 with precapillary PH. Compared with precapillary PH, PH-HFpEF patients were older, with a smaller proportion of women, a higher proportion of hypertension, diabetes mellitus, atrial fibrillation and sleep apnea syndrome, and a higher body mass index. On echocardiography, PH-HFpEF patients had higher left ventricular mass index, higher left atrial area, and smaller right ventricular end-diastolic area. Following multivariate analysis, a model predicting the probability of PH-HFpEF was built with history of diabetes mellitus, presence of atrial fibrillation, left atrial area, right ventricular end-diastolic area, and left ventricular mass index. The score was internally validated using bootstrap method (area under the curve 0.93 [95% confidence interval 0.918-0.938]). A score <5 ruled out PH-HFpEF. CONCLUSION A score including clinical and echocardiographic criteria may help physicians to identify PH-HFpEF from precapillary PH.
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Affiliation(s)
| | - David Montani
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Vincent Algalarrondo
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Cardiologie, Hôpital Béclère, Clamart, France
| | - Céline Dreyfuss
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Raed Rifai
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anouar Benmalek
- Faculté de Pharmacie, Châtenay-Malabry Cedex, and INSERM UMR_S 1180, Chatenay-Malabry, France
| | - Xavier Jais
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Amir Bouchachi
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Gerald Simonneau
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Denis Chemla
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; AP-HP, Service de Physiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Univ. Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, LabEx LERMIT, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Patrick Assayag
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Le Kremlin-Bicêtre, France
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Assad TR, Brittain EL, Wells QS, Farber-Eger EH, Halliday SJ, Doss LN, Xu M, Wang L, Harrell FE, Yu C, Robbins IM, Newman JH, Hemnes AR. Hemodynamic evidence of vascular remodeling in combined post- and precapillary pulmonary hypertension. Pulm Circ 2016; 6:313-21. [PMID: 27683608 PMCID: PMC5019084 DOI: 10.1086/688516] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/28/2016] [Indexed: 01/06/2023] Open
Abstract
Although commonly encountered, patients with combined postcapillary and precapillary pulmonary hypertension (Cpc-PH) have poorly understood pulmonary vascular properties. The product of pulmonary vascular resistance and compliance, resistance-compliance (RC) time, is a measure of pulmonary vascular physiology. While RC time is lower in postcapillary PH than in precapillary PH, the RC time in Cpc-PH and the effect of pulmonary wedge pressure (PWP) on RC time are unknown. We tested the hypothesis that Cpc-PH has an RC time that resembles that in pulmonary arterial hypertension (PAH) more than that in isolated postcapillary PH (Ipc-PH). We analyzed the hemodynamics of 282 consecutive patients with PH referred for right heart catheterization (RHC) with a fluid challenge from 2004 to 2013 (cohort A) and 4,382 patients who underwent RHC between 1998 and 2014 for validation (cohort B). Baseline RC time in Cpc-PH was higher than that in Ipc-PH and lower than that in PAH in both cohorts (P < 0.001). In cohort A, RC time decreased after fluid challenge in patients with Ipc-PH but not in those with PAH or Cpc-PH (P < 0.001). In cohort B, the inverse relationship of pulmonary vascular compliance and resistance, as well as that of RC time and PWP, in Cpc-PH was similar to that in PAH and distinct from that in Ipc-PH. Our findings demonstrate that patients with Cpc-PH have pulmonary vascular physiology that resembles that of patients with PAH more than that of Ipc-PH patients. Further study is warranted to identify determinants of vascular remodeling and assess therapeutic response in this subset of PH.
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Affiliation(s)
- Tufik R. Assad
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Evan L. Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Quinn S. Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Eric H. Farber-Eger
- Center for Human Genetics Research, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen J. Halliday
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Laura N. Doss
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Ivan M. Robbins
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - John H. Newman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Gabriel L, Delavenne X, Bedouch P, Khouatra C, Bouvaist H, Cordier JF, Mornex JF, Pison C, Cottin V, Bertoletti L. Risk of Direct Oral Anticoagulant Bioaccumulation in Patients with Pulmonary Hypertension. Respiration 2016; 91:307-15. [DOI: 10.1159/000445122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/01/2016] [Indexed: 11/19/2022] Open
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Berra G, Noble S, Soccal PM, Beghetti M, Lador F. Pulmonary hypertension in the elderly: a different disease? Breathe (Sheff) 2016; 12:43-9. [PMID: 27066136 PMCID: PMC4818237 DOI: 10.1183/20734735.003416] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Pulmonary hypertension (PH) is a haemodynamic syndrome defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg determined by right heart catheterisation (RHC) [1, 2]. A lot of diseases fulfil this definition, but they differ widely between each other in respect to their pathophysiology, their haemodynamic characteristics, their clinical presentation, their natural prognosis and their potential therapeutic strategies. The current guidelines on PH diagnosis and management make the distinction between five groups of more than 200 causes of PH [2], but these diseases are very different from one another. In the current classification, the first group (group 1) represents a progressive vasculopathy leading to pre-capillary PH called pulmonary arterial hypertension (PAH), characterised by a characteristic small-calibre pulmonary artery remodelling, as a result of proliferation of endothelial and smooth muscle cells as well as medial hypertrophy. So, if we compare PAH (for example idiopathic PAH) from PH due to valvular disease like mitral insufficiency (group 2.3) it is easy to understand that apart from the fact that mean pulmonary arterial pressure (mPAP) exceeds 25 mmHg in both cases, these two entities have very different pathophysiological pathways. In the first case, there is a true pulmonary vasculopathy. In the second, PH is mainly related to the consequences of an increased hydrostatic pressure in the left atrium transmitted to the venous compartment of the pulmonary circulation and then back through the capillary bed. If the pathophysiology of these entities is different, the targets of their treatments are too. The main goal of PAH treatment consists in reducing pulmonary vascular resistance (PVR) with specific medication and, when appropriate, with specific treatment of the underlying disease as it is the case for associated-PAH (group 1.4). Alternatively, the management of PH related to a mitral regurgitation would be to improve the ventricular preload, diminish the ventricular afterload and, if necessary, to correct the anatomical anomaly. The distinction between PH in the elderly and normal ageing might make diagnosis difficulthttp://ow.ly/YYF1Q
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Affiliation(s)
- Grégory Berra
- Service de Pneumologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Stéphane Noble
- Programme Hypertension Pulmonaire, Hôpitaux Universitaires de Genève, Geneva, -Switzerland; Service de Cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Paola M Soccal
- Service de Pneumologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland; Programme Hypertension Pulmonaire, Hôpitaux Universitaires de Genève, Geneva, -Switzerland
| | - Maurice Beghetti
- Programme Hypertension Pulmonaire, Hôpitaux Universitaires de Genève, Geneva, -Switzerland; Unité de Cardiologie Pédiatrique, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Frédéric Lador
- Service de Pneumologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland; Programme Hypertension Pulmonaire, Hôpitaux Universitaires de Genève, Geneva, -Switzerland
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Richter SE, Roberts KE, Preston IR, Hill NS. A Simple Derived Prediction Score for the Identification of an Elevated Pulmonary Artery Wedge Pressure Using Precatheterization Clinical Data in Patients Referred to a Pulmonary Hypertension Center. Chest 2016; 149:1261-8. [PMID: 26501213 DOI: 10.1378/chest.15-0819] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 09/13/2015] [Accepted: 10/05/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND One of the foremost diagnostic challenges in clinical pulmonary hypertension is discriminating between pulmonary arterial hypertension (group 1) and heart failure with preserved ejection fraction (group 2.2). Group 2.2 is defined as a normal left ventricular ejection fraction (> 50%) and a pulmonary arterial wedge pressure (PAWP) > 15 mm Hg. We aimed to determine whether patient history, demographics, and noninvasive measures could predict PAWP before to right heart catheterization. METHODS Data were prospectively collected on 350 consecutive patients at a single tertiary care medical center; of these patients, 151 met criteria for entry into our study (88 in group 1 and 63 in group 2.2). Data included historical features, demographics, and results of a transthoracic echocardiogram. A multivariate regression model was developed to predict PAWP > 15 mm Hg. RESULTS Univariate predictors of PAWP > 15 mm Hg included older age, higher BMI and weight, systemic systolic BP and pulse pressure, more features of the metabolic syndrome, presence of hypertension and left atrial enlargement, absence of right ventricular enlargement, and lower glomerular filtration rate and 6-min walk distance. The optimal model for predicting PAWP > 15 mm Hg was composed of age (> 68 years), BMI (> 30 kg/m(2)), absence of right ventricular enlargement, and presence of left atrial enlargement (area under the curve, 0.779). CONCLUSIONS Clinical characteristics obtained before diagnostic right heart catheterization accurately predict the probability of elevation of PAWP > 15 mm Hg in patients with preserved ejection fraction. These combined clinical characteristics can be used a priori to predict the likelihood of group 2.2 pulmonary hypertension.
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Affiliation(s)
- Stefan E Richter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Kari E Roberts
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Ioana R Preston
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
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Trammell AW, Pugh ME, Newman JH, Hemnes AR, Robbins IM. Use of pulmonary arterial hypertension-approved therapy in the treatment of non-group 1 pulmonary hypertension at US referral centers. Pulm Circ 2015; 5:356-63. [PMID: 26064462 DOI: 10.1086/681264] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/24/2014] [Indexed: 11/03/2022] Open
Abstract
Pulmonary hypertension (PH) is a frequent complication of left heart disease and parenchymal lung disease, and it portends increased mortality. A growing number of medications are approved for the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH). However, they are not well studied in PH of other etiologies (WHO groups 2-5). We sought to assess treatment approaches used by PAH referral centers in this diverse group of patients. We developed a semiquantitative online survey designed to evaluate the use of PAH-approved therapy by pulmonary vascular disease centers in the United States for management of non-group 1 PH. Thirty of 50 centers completed the survey. Almost all centers (93%) reported using PAH therapy for patients with non-group 1 PH, including 77% with group 2 PH and 80% with group 3 PH. Elevated transpulmonary gradient or pulmonary vascular resistance and the presence of right ventricular (RV) dysfunction were commonly cited as supporting use of PAH therapy in patients with PH secondary to left heart disease. For patients with PH and concomitant parenchymal lung disease, degree of pulmonary function impairment and RV dysfunction were most important in influencing use of PAH therapy. In conclusion, pulmonary vascular disease treatment centers use PAH-approved therapy for patients with WHO group 2-5 PH, mostly relying on hemodynamics and assessment of RV function to identify candidates for therapy. Clinical trials designed to test the efficacy of PAH therapy in PH due to left heart and lung disease are needed, as clinical practice has extended beyond the evidence for these etiologies of PH.
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Affiliation(s)
- Aaron W Trammell
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meredith E Pugh
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John H Newman
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anna R Hemnes
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ivan M Robbins
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Tampakakis E, Leary PJ, Selby VN, De Marco T, Cappola TP, Felker GM, Russell SD, Kasper EK, Tedford RJ. The diastolic pulmonary gradient does not predict survival in patients with pulmonary hypertension due to left heart disease. JACC-HEART FAILURE 2014; 3:9-16. [PMID: 25453535 DOI: 10.1016/j.jchf.2014.07.010] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/08/2014] [Accepted: 07/28/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study sought to evaluate if diastolic pulmonary gradient (DPG) can predict survival in patients with pulmonary hypertension due to left heart disease (PH-LHD). BACKGROUND Patients with combined post- and pre-capillary PH-LHD have worse prognosis than those with passive pulmonary hypertension. The transpulmonary gradient (TPG) and pulmonary vascular resistance (PVR) have commonly been used to identify high-risk patients. However, these parameters have significant shortcomings and do not always correlate with pulmonary vasculature remodeling. Recently, it has been suggested that DPG may be better a marker, yet its prognostic ability in patients with cardiomyopathy has not been fully assessed. METHODS A retrospective cohort of 1,236 patients evaluated for unexplained cardiomyopathy at Johns Hopkins Hospital was studied. All patients underwent right heart catheterization and were followed until death, cardiac transplantation, or the end of the study period (mean time 4.4 years). The relationships between DPG, TPG, or PVR and survival in subjects with PH-LHD (n = 469) were evaluated with Cox proportional hazards regression and Kaplan-Meier analyses. RESULTS DPG was not significantly associated with mortality (hazard ratio [HR]: 1.02, p = 0.10) in PH-LHD whereas elevated TPG and PVR predicted death (HR: 1.02, p = 0.046; and HR: 1.11, p = 0.002, respectively). Similarly, DPG did not differentiate survivors from non-survivors at any selected cut points including a DPG of 7 mm Hg. CONCLUSIONS In this retrospective study of patients with cardiomyopathy and PH-LHD, an elevated DPG was not associated with worse survival.
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Affiliation(s)
- Emmanouil Tampakakis
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Peter J Leary
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington
| | - Van N Selby
- Division of Cardiology, University of California-San Francisco, San Francisco, California
| | - Teresa De Marco
- Division of Cardiology, University of California-San Francisco, San Francisco, California
| | - Thomas P Cappola
- Penn Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Edward K Kasper
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Guazzi M, Gomberg-Maitland M, Arena R. Pulmonary hypertension in heart failure with preserved ejection fraction. J Heart Lung Transplant 2014; 34:273-81. [PMID: 25577563 DOI: 10.1016/j.healun.2014.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/18/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022] Open
Abstract
In heart failure with preserved ejection fraction (HFpEF), an entity that remains challenging and difficult to treat, the development of pulmonary hypertension (PH), via an increase in left atrial pressure, is the direct consequence of reduced relaxation and enhanced stiffness of the left ventricle and is now viewed as an important contributor to clinical worsening and increased mortality. PH becomes a relevant clinical phenotype in approximately 50% of patients with HFpEF and represents a true challenge in the clinical follow-up and management of these patients. Along with these epidemiologic insights, there has been increasing recognition of the pathophysiology of PH and its consequences on the right ventricle in patients with HFpEF. Novel and effective therapeutic interventions aimed at preventing and reversing PH are highly relevant in the attempt to modify the poor clinical trajectory and growing health care burden of HFpEF. Many theoretical rationales as well as progressively accumulating evidence support the usefulness of nitric oxide pathway-potentiating compounds in targeting the lung vasculature through phosphodiesterase 5 inhibitors or guanylate cyclase stimulators to produce vasodilation and potentially a biologic effect. These pharmacologic strategies may be clinically effective options for the treatment of PH in patients with HFpEF; however, large controlled trials are necessary to address definitively the safety, tolerability, and potential impact on morbidity and mortality. This review details the pathophysiologic process, prevalence, and consequences of HFpEF-associated PH and discusses current and emerging treatment strategies to prevent or treat this deleterious sequela when present.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, Cardiology, I.R.C.C.S., Policlinico San Donato University Hospital, Milan, Italy.
| | | | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago, Chicago, Illinois
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Pugh ME, Sivarajan L, Wang L, Robbins IM, Newman JH, Hemnes AR. Causes of pulmonary hypertension in the elderly. Chest 2014; 146:159-166. [PMID: 24480915 DOI: 10.1378/chest.13-1900] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is common in elderly patients, but a detailed analysis of the causes of PH in the elderly has not been performed. We hypothesized that pulmonary arterial hypertension (PAH) is rare in elderly patients and sought to describe the characteristics of these patients at a large referral center. METHODS Clinical and hemodynamic data were collected on consecutive patients ≥ 65 years of age referred for evaluation of PH. The subtype of PH was determined after standard evaluation using the World Health Organization (WHO) classification. Patients with PH not meeting criteria for PAH with "out-of-proportion" PH related to group 2 or group 3 disease were classified as "other/mixed PH." A model using age, presence of connective tissue disease, and left atrial size was developed to predict the probability of PAH diagnosis. RESULTS Two hundred forty-six elderly patients were evaluated (mean age, 72.9 ± 5.5 years, 78% women); 36 had PAH (15%). Idiopathic PAH was rare (four patients, 1.6%). WHO group 2 PH was the most frequent diagnosis (n = 70, 28% of cohort); mixed/other PH (n = 43, 17%) and WHO group 3 PH (n = 34, 14%) were also common diagnoses. Connective tissue disease strongly predicted PAH diagnosis (OR, 27.2; 95% CI, 9.5-77.6). CONCLUSIONS PAH is an uncommon cause of PH in elderly patients, most frequently associated with connective tissue disease. WHO group 2 PH and mixed disease are common, highlighting a need for careful phenotyping of elderly patients with PH prior to initiating PAH therapy.
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Affiliation(s)
- Meredith E Pugh
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | | | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John H Newman
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Guazzi M. Pulmonary hypertension in heart failure preserved ejection fraction: prevalence, pathophysiology, and clinical perspectives. Circ Heart Fail 2014; 7:367-77. [PMID: 24643889 DOI: 10.1161/circheartfailure.113.000823] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, Cardiology, IRCCS, Policlinico San Donato University Hospital, Milan, Italy
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