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Tuttle M, Sarnak MJ, Navaneethan SD. Therapeutic approaches for pulmonary hypertension in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2024; 33:494-502. [PMID: 38899951 PMCID: PMC11290985 DOI: 10.1097/mnh.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a common comorbidity in patients with chronic kidney disease (CKD), but therapeutic options are limited. We discuss the epidemiology of pulmonary hypertension in patients with CKD and review therapies for pulmonary hypertension with a focus on emerging treatments for pulmonary arterial hypertension (PAH). RECENT FINDINGS The definition of pulmonary hypertension has been updated to a lower threshold of mean pulmonary artery pressures of more than 20 mmHg, potentially leading to more patients with CKD to qualify for the diagnosis of pulmonary hypertension. Endothelin receptor antagonists, a class of medications, which demonstrated efficacy in patients with PAH, have been shown to slow progression of CKD, but their efficacy in lowering pulmonary artery pressures and their effects on reducing cardiovascular mortality in this population remains unproven. Sotatercept, a novel activin signaling inhibitor, which was previously studied in dialysis patients has been shown to increase exercise capacity in patients with PAH. These studies may lead to new specific therapies for pulmonary hypertension in patients with CKD. SUMMARY Pulmonary hypertension is common in patients with CKD. Although our understanding of factors leading to pulmonary hypertension in this population have evolved, evidence supporting disease-specific therapy in CKD is limited arguing for larger, long-term studies.
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MESH Headings
- Humans
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/drug therapy
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Antihypertensive Agents/therapeutic use
- Endothelin Receptor Antagonists/therapeutic use
- Animals
- Treatment Outcome
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Affiliation(s)
- Marcelle Tuttle
- Tufts Medical Center, Nephrology Division, Department of Medicine, Boston, MA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Mark J. Sarnak
- Tufts Medical Center, Nephrology Division, Department of Medicine, Boston, MA
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Institute of Clinical and Translational Research Baylor College of Medicine, Houston, TX
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2
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Torbicki A, Channick R, Galiè N, Kiely DG, Moceri P, Peacock A, Swift AJ, Tawakol A, Vonk Noordegraaf A, Flores D, Martin N, Rosenkranz S. Effect of Macitentan in Pulmonary Arterial Hypertension and the Relationship Between Echocardiography and cMRI Variables: REPAIR Echocardiography Sub-study Results. Cardiol Ther 2024; 13:173-190. [PMID: 38281309 PMCID: PMC10899124 DOI: 10.1007/s40119-023-00345-2] [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: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION The aim of this sub-study was to evaluate the relationship between echocardiography (echo) and cardiac magnetic resonance imaging (cMRI) variables and to utilize echo to assess the effect of macitentan on right ventricle (RV) structure and function. METHODS REPAIR (NCT02310672) was a prospective, multicenter, single-arm, open-label, 52-week, phase 4 study in pulmonary arterial hypertension (PAH) patients, which investigated the effect of macitentan 10 mg as monotherapy, or in combination with a phosphodiesterase 5 inhibitor, on RV structure, function, and hemodynamics using cMRI and right heart catheterization. In this sub-study, patients were also assessed by echo at screening and at weeks 26 and/or 52. Post hoc correlation analyses between echo and cMRI variables were performed using Pearson's correlation coefficient, Spearman's correlation coefficient, and Bland-Altman analyses. RESULTS The Echo sub-study included 45 patients. Improvements in echo-assessed RV stroke volume (RVSV), left ventricular SV (LVSV), LV end-diastolic volume (LVEDV), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and in 2D global longitudinal RV strain (2D GLRVS) were observed at weeks 26 and 52 compared to baseline. There was a strong correlation between echo (LVSV, 2D GLRVS, and LVEDV) and cMRI variables, with a moderate correlation for RVSV. Bland-Altman analyses showed a good agreement for LVSV measured by echo versus cMRI, whereas an overestimation in echo-assessed RVSV was observed compared to cMRI (bias of - 15 mL). Hemodynamic and functional variables, as well as safety, were comparable between the Echo sub-study and REPAIR. CONCLUSIONS A good relationship between relevant echo and cMRI parameters was shown. Improvements in RV structure and function with macitentan treatment was observed by echo, consistent with results observed by cMRI in the primary analysis of the REPAIR study. Echo is a valuable complementary method to cMRI, with the potential to non-invasively monitor treatment response at follow-up. TRIAL REGISTRATION NUMBER REPAIR NCT02310672.
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Affiliation(s)
- Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Disease and Cardiology, Centre for Postgraduate Medical Education ECZ-Otwock, ERN-LUNG Member, F. Chopin Hospital European Health Centre, ul. Borowa 14/18, 05-400, Otwock, Poland.
| | | | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna and Dipartimento DIMES, Università di Bologna, Bologna, Italy
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, NIHR Biomedical Research Centre Sheffield and University of Sheffield, Sheffield, UK
| | - Pamela Moceri
- Cardiology Department, UR2CA, Pasteur University Hospital, Côte-d'Azur University, Nice, France
| | | | - Andrew J Swift
- Department of Infection, Immunity & Cardiovascular Disease, National Institute for Health and Care Research Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, UK
| | - Ahmed Tawakol
- Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | | - Dayana Flores
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Global Medical Affairs, Allschwil, Switzerland
| | - Nicolas Martin
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Statistical Decision Science, Allschwil, Switzerland
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center, University Hospital Cologne, and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Abu‐Rmaileh M, Mirza O, Patel C, Shah T, Hardin EA, Bartolome SD, Chin KM. Prognosis of pulmonary arterial hypertension patients with pericardial effusion before and after initiation of parenteral prostacyclin therapy. Pulm Circ 2023; 13:e12226. [PMID: 37063747 PMCID: PMC10103584 DOI: 10.1002/pul2.12226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/18/2023] Open
Abstract
Few studies have evaluated the effects of pulmonary arterial hypertension therapies on pericardial effusion. We evaluated hemodynamics, echocardiograms, and outcomes for 119 parenteral prostanoid-treated patients. We discovered an increased frequency of pericardial effusions posttreatment, and that a moderate-large pericardial effusion at initiation, but not at 1st follow-up, was significantly associated with mortality.
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Affiliation(s)
| | - Omer Mirza
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Pulmonary and Critical Care MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Chandni Patel
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Pulmonary and Critical Care MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Trushil Shah
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Pulmonary and Critical Care MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Elizabeth A. Hardin
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Cardiovascular MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Sonja D. Bartolome
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Pulmonary and Critical Care MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Kelly M. Chin
- UT Southwestern Department of Internal MedicineDallasTexasUSA
- Division of Pulmonary and Critical Care MedicineUT Southwestern Medical CenterDallasTexasUSA
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Prognostic Value of Echocardiographic Variables Prior to and Following Initiation of Parenteral Prostacyclin Therapy. Chest 2022; 162:669-683. [DOI: 10.1016/j.chest.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 12/31/2022] Open
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Qin X, Lei C, Yan L, Sun H, Liu X, Guo Z, Sun W, Guo X, Fang Q. Proteomic and Metabolomic Analyses of Right Ventricular Failure due to Pulmonary Arterial Hypertension. Front Mol Biosci 2022; 9:834179. [PMID: 35865003 PMCID: PMC9294162 DOI: 10.3389/fmolb.2022.834179] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/20/2022] [Indexed: 11/23/2022] Open
Abstract
Right ventricular failure (RVF) is the independent and strongest predictor of mortality in pulmonary arterial hypertension (PAH), but, at present, there are no preventive and therapeutic strategies directly targeting the failing right ventricle (RV). The underlying mechanism of RV hypertrophy (RVH) and dysfunction needs to be explored in depth. In this study, we used myocardial proteomics combined with metabolomics to elucidate potential pathophysiological changes of RV remodeling in a monocrotaline (MCT)-induced PAH rat model. The proteins and metabolites extracted from the RV myocardium were identified using label-free liquid chromatography–tandem mass spectrometry (LC-MS/MS). The bioinformatic analysis indicated that elevated intracellular Ca2+ concentrations and inflammation may contribute to myocardial proliferation and contraction, which may be beneficial for maintaining the compensated state of the RV. In the RVF stage, ferroptosis, mitochondrial metabolic shift, and insulin resistance are significantly involved. Dysregulated iron homeostasis, glutathione metabolism, and lipid peroxidation related to ferroptosis may contribute to RV decompensation. In conclusion, we depicted a proteomic and metabolomic profile of the RV myocardium during the progression of MCT-induced PAH, and also provided the insights for potential therapeutic targets facilitating the retardation or reversal of RV dysfunction in PAH.
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Affiliation(s)
- Xiaohan Qin
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chuxiang Lei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Li Yan
- Department of Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Haidan Sun
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoyan Liu
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhengguang Guo
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Wei Sun
- Core Facility of Instrument, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoxiao Guo
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Xiaoxiao Guo, ; Quan Fang,
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Xiaoxiao Guo, ; Quan Fang,
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6
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Mukherjee M, Mercurio V, Balasubramanian A, Shah AA, Hsu S, Simpson CE, Damico R, Kolb TM, Hassoun PM, Mathai SC. Defining minimal detectable difference in echocardiographic measures of right ventricular function in systemic sclerosis. Arthritis Res Ther 2022; 24:146. [PMID: 35717399 PMCID: PMC9206258 DOI: 10.1186/s13075-022-02835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Echocardiography (2DE) is integral for screening and longitudinal evaluation of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). In the present study, we sought to establish the reliability, repeatability, and reproducibility of 2DE parameters in SSc patients with and without PAH and to define the minimal detectable difference (MDD), the smallest change detected beyond measurement error. METHODS SSc patients without known PAH and with invasively confirmed PAH on stable therapies underwent 2DE with strain at two time points. Analysis of variance (ANOVA) and coefficients of variation (CV) were calculated to assess for repeatability, reliability, and reproducibility. Intra- and inter-observer agreement were assessed using intraclass correlation. Bland-Altman analysis explored the level of agreement between evaluations. MDD was calculated using the standard error of measurement for each parameter by cohort. RESULTS ANOVA demonstrated few significant differences between evaluations across groups. Global right ventricular longitudinal systolic strain (GRVLSS, 9.7%) and fractional area change (FAC, 21.3%) had the largest CV, while tricuspid annular plane excursion (TAPSE), S' wave, and right ventricular outflow track velocity time integral (RVOT VTI) were 0.87%, 3.2%, and 6.0%, respectively. Intra- and inter-observer agreement was excellent. MDD for TAPSE, FAC, S' wave, RVOT VTI, GRVLSS, and RVSP were 0.11 cm, 0.03%, 1.27 cm/s, 0.81 cm, 1.14%, and 6.5 mmHg, respectively. CONCLUSIONS We demonstrate minimal measurement error in clinically important 2DE-based measures in SSc patients with and without PAH. Defining the MDD in this population has important implications for PAH screening, assessment of therapeutic response, and sample size calculations for future clinical trials.
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Affiliation(s)
- Monica Mukherjee
- Divisions of Cardiology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Ami A Shah
- Divison of Rheumatology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Steven Hsu
- Divisions of Cardiology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Rachel Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA.
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7
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Subclinical right ventricular dysfunction in patients with mitral stenosis. J Echocardiogr 2022; 20:87-96. [PMID: 35040010 DOI: 10.1007/s12574-021-00554-5] [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: 09/25/2020] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Right ventricular (RV) dysfunction is a strong predictor of poor outcomes of patients with mitral stenosis (MS). The aim of this study was to detect a subclinical right ventricular dysfunction in patients with MS. METHODS We conducted a prospective study from January 2015 to June 2019 in 104 asymptomatic patients with MS (mean age: 46.1 ± 4.27 years), and compared to a group of 52 age and sex matched healthy subjects. Standard and speckle tracking echocardiography were performed; parameters of RV function were measured and compared. RESULTS Although they were in normal range, RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler and pulsed wave Doppler RV myocardial performance index (MPI) and peak systolic velocity (S') were decreased in patients with MS (p < 0.05). The global RV longitudinal strain (LSGRV) and the longitudinal strain of the free wall of the right ventricular (LSFRV) were lower in patients with MS (p, respectively, at 0.001 and < 0.001), 53.5% (n = 47) of patients had LSFRV < - 20%. A significant difference was noted between LSFRV and 2D strain of the septal wall (p = 0.002). No difference was found between patients with severe MS and moderate MS regarding LSFRV and LSGRV. No correlation between LSFRV and FAC (p = 0.85), MPI (p = 0.62), TAPSE (p = 0.31) and S' (p = 0.78) was found. CONCLUSION Our study showed the presence of subclinical systolic dysfunction of the right ventricle in patients with MS.
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8
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Echocardiography in Pulmonary Arterial Hypertension: Is It Time to Reconsider Its Prognostic Utility? J Clin Med 2021; 10:jcm10132826. [PMID: 34206876 PMCID: PMC8268493 DOI: 10.3390/jcm10132826] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 12/26/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by an insult in the pulmonary vasculature, with subsequent right ventricular (RV) adaptation to the increased afterload that ultimately leads to RV failure. The awareness of the importance of RV function in PAH has increased considerably because right heart failure is the predominant cause of death in PAH patients. Given its wide availability and reduced cost, echocardiography is of paramount importance in the evaluation of the right heart in PAH. Several echocardiographic parameters have been shown to have prognostic implications in PAH; however, the role of echocardiography in the risk assessment of the PAH patient is limited under the current guidelines. This review discusses the echocardiographic evaluation of the RV in PAH and during therapy, and its prognostic implications, as well as the potential significant role of repeated echocardiographic assessment in the follow-up of patients with PAH.
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9
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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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Mandoli GE, De Carli G, Pastore MC, Cameli P, Contorni F, D'Alessandro M, Bargagli E, Mondillo S, Cameli M. Right cardiac involvement in lung diseases: a multimodality approach from diagnosis to prognostication. J Intern Med 2021; 289:440-449. [PMID: 32996153 DOI: 10.1111/joim.13179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/12/2020] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
Lung diseases are amongst the main healthcare issues in the general population, having a high burden of morbidity and mortality. The cardiovascular system has a key role in patients affected by respiratory disorders. More specifically, the right ventricle (RV) enables the impaired lung function to be overcome in an initial stage of disease process, reducing the severity of dyspnoea. In addition, two of the main causes of death in this setting are RV failure and sudden cardiac death (SCD). Echocardiography is regarded as a useful and easily available tool in assessing RV function. Several noninvasive echocardiographic parameters of elevated pulmonary pressures and RV function have been proposed. The combination of different parameters and imaging methods is paramount and researches regarding RV impairment using these indices has been specifically addressed in relation to the chronic obstructive and restrictive lung disease in order to guide the clinicians in the management of these patients. Cardiac involvement in lung diseases is often observed, and RV changes are reported also in early stages of pulmonary diseases. The role of right ventricle in chronic respiratory disease patients has to be evaluated in detail to describe the response to therapy and the degree of disease progression through multimodality and advanced imaging techniques. The aim of this review is to describe the different pathophysiological mechanisms of cardiac impairment in primary lung disease (such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF) and sarcoidosis) and to summarize the role of cardiac multimodality imaging in the diagnosis and the prognosis of these diseases.
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Affiliation(s)
- G E Mandoli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - G De Carli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M C Pastore
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - P Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - F Contorni
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M D'Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - E Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - S Mondillo
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) is a disease that carries a significant mortality left untreated. This article aims to review pharmacotherapeutics for PAH. RECENT FINDINGS PAH-specific therapies have evolved over the last three decades and have expanded from one therapy in the 1990s to 14 FDA-approved medications. Current therapies are directed at restoring the imbalance of vasoactive mediators that include nitric oxide, endothelin and prostacyclin. Although these agents are effective as monotherapy, recent trials have promulgated the strategy of upfront combination therapy. The availability of oral prostacyclin agonists has also allowed for expanded treatment options. Risk assessment is vital in guiding therapy for PAH patients. There is ongoing focus on targeting pathological mechanisms of the disease via novel therapies and repurposing existing drugs. SUMMARY There is an array of medications available for the treatment of PAH. Prudent combination of therapies to maximize treatment effect can improve morbidity and mortality. This article reviews the data supporting these therapies and attempts to outline an approach to patient management.
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12
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Wang L, Halliday G, Huot JR, Satoh T, Baust JJ, Fisher A, Cook T, Hu J, Avolio T, Goncharov DA, Bai Y, Vanderpool RR, Considine RV, Bonetto A, Tan J, Bachman TN, Sebastiani A, Mora AL, Machado RF, Goncharova EA, Gladwin MT, Lai YC. Treatment With Treprostinil and Metformin Normalizes Hyperglycemia and Improves Cardiac Function in Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction. Arterioscler Thromb Vasc Biol 2020; 40:1543-1558. [PMID: 32268788 PMCID: PMC7255946 DOI: 10.1161/atvbaha.119.313883] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) due to left heart disease (group 2), especially in the setting of heart failure with preserved ejection fraction (HFpEF), is the most common cause of PH worldwide; however, at present, there is no proven effective therapy available for its treatment. PH-HFpEF is associated with insulin resistance and features of metabolic syndrome. The stable prostacyclin analog, treprostinil, is an effective and widely used Food and Drug Administration-approved drug for the treatment of pulmonary arterial hypertension. While the effect of treprostinil on metabolic syndrome is unknown, a recent study suggests that the prostacyclin analog beraprost can improve glucose intolerance and insulin sensitivity. We sought to evaluate the effectiveness of treprostinil in the treatment of metabolic syndrome-associated PH-HFpEF. Approach and Results: Treprostinil treatment was given to mice with mild metabolic syndrome-associated PH-HFpEF induced by high-fat diet and to SU5416/obese ZSF1 rats, a model created by the treatment of rats with a more profound metabolic syndrome due to double leptin receptor defect (obese ZSF1) with a vascular endothelial growth factor receptor blocker SU5416. In high-fat diet-exposed mice, chronic treatment with treprostinil reduced hyperglycemia and pulmonary hypertension. In SU5416/Obese ZSF1 rats, treprostinil improved hyperglycemia with similar efficacy to that of metformin (a first-line drug for type 2 diabetes mellitus); the glucose-lowering effect of treprostinil was further potentiated by the combined treatment with metformin. Early treatment with treprostinil in SU5416/Obese ZSF1 rats lowered pulmonary pressures, and a late treatment with treprostinil together with metformin improved pulmonary artery acceleration time to ejection time ratio and tricuspid annular plane systolic excursion with AMPK (AMP-activated protein kinase) activation in skeletal muscle and the right ventricle. CONCLUSIONS Our data suggest a potential use of treprostinil as an early treatment for mild metabolic syndrome-associated PH-HFpEF and that combined treatment with treprostinil and metformin may improve hyperglycemia and cardiac function in a more severe disease.
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Affiliation(s)
- Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- The Third Xiangya Hospital, Central South University; Changsha, Hunan, China
| | - Gunner Halliday
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Joshua R. Huot
- Department of Surgery, Indiana University School of Medicine
| | - Taijyu Satoh
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jeff J. Baust
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Amanda Fisher
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Todd Cook
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Jian Hu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Theodore Avolio
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Dmitry A. Goncharov
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Yang Bai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Clinical Pharmacology, College of Pharmacy, China Medical University, Shenyang, Liaoning, China
| | | | | | - Andrea Bonetto
- Department of Surgery, Indiana University School of Medicine
| | - Jiangning Tan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Timothy N. Bachman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Andrea Sebastiani
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Ana L. Mora
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Roberto F. Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Elena A. Goncharova
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine
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13
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Mendes AA, Roncal CGP, Oliveira FRAD, Albuquerque ESD, Góes GHB, Piscoya ICDV, Sobral Filho DC. Demographic and clinical characteristics of pulmonary arterial hypertension caused by schistosomiasis are indistinguishable from other etiologies. Rev Soc Bras Med Trop 2020; 53:e20190418. [PMID: 32049203 PMCID: PMC7083352 DOI: 10.1590/0037-8682-0418-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/25/2019] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION: Pulmonary arterial hypertension (PAH) is a serious pulmonary circulation
disease caused by several etiologies, including schistosomiasis. The present
study retrospectively evaluated the clinical and hemodynamic characteristics
of patients with schistosomal PAH (PAH-Sch) compared to those of non-Sch PAH
patients (non-Sch PAH). METHODS: Patients treated at the Pronto-Socorro Cardiológico de Pernambuco and
diagnosed by right cardiac catheterization were divided into PAH-Sch and
non-Sch PAH groups. Their socio-demographic and clinical characteristics,
N-terminal-pro B-type natriuretic peptide (NT-proBNP), and echocardiography
and hemodynamic parameters were retrospectively reviewed. RESULTS: Among the included 98 patients (mean age, 45 ± 14 years; 68 women [69.4%]),
we found 56 PAH-Sch and 42 non-Sch PAH. The age distribution was
heterogeneous in the PAH-Sch group, with patients predominantly ranging from
50-59 (p <0.004). Dyspnea was the most common symptom, reported by 92
patients (93.8%), and commonly present for over two years prior to
diagnosis. Clinical symptoms were similar in both groups, with no
differences in functional class, pulmonary artery systolic pressure (p =
0.102), 6-minute walk test score (p = 0.234), NT-proBNP serum levels (p =
0.081), or hemodynamic parameters. CONCLUSIONS: Patients with PAH-Sch present clinical, laboratory, and hemodynamic profiles
similar to those with PAH resulting from other etiologies of poor prognosis.
PAH is an important manifestation of schistosomiasis in endemic regions that
is often diagnosed late.
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Affiliation(s)
- Adriano Assis Mendes
- Universidade de Pernambuco, Departamento de Hipertensão Pulmonar, Pronto-Socorro Cardiológico de Pernambuco, Recife, PE, Brasil
| | - Carlos Guilhermo Piscoya Roncal
- Universidade de Pernambuco, Departamento de Hipertensão Pulmonar, Pronto-Socorro Cardiológico de Pernambuco, Recife, PE, Brasil.,Universidade de Pernambuco, Departamento de Ecocardiografia, Recife, PE, Brasil
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14
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Abstract
The term cor pulmonale has traditionally been used as a synonym for right heart failure due to chronic respiratory diseases, although this condition is less frequently seen in the modern era because of the use of long-term oxygen therapy along with aggressive measures directed at optimizing ventilation and gas exchange. The mechanisms by which adaptation or maladaptation of right heart structure and function in the broader setting of pulmonary vascular disease, either intrinsic to the pulmonary circulation or due to respiratory diseases, have garnered considerable interest along with the development of medical and surgical treatments for pulmonary hypertension. Thus, the right heart is no longer considered an "innocent bystander" in pulmonary hypertension, but rather a key component in its pathophysiology. Furthermore, the status of right heart function is a major determinant of outcome. Accordingly, the right heart has become a potential, appealing target for novel therapies to treat hypertensive pulmonary vascular disease.
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15
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Abstract
Pulmonary arterial hypertension (PAH) is a condition associated with substantial morbidity and mortality. Over the last 25 years there has been a significant evolution in the therapies to treat PAH. These therapies are effective for patients with group I PAH and group IV PH [chronic thromboembolic pulmonary hypertension (CTEPH)]. PAH is characterized by an imbalance of nitric oxide, prostacyclin and endothelin levels, and current pharmacotherapy involves these three pathways. Earlier clinical trials involving PAH-specific therapies evaluated improvements in 6-minute walk time as a primary improvement whereas contemporary trials have been larger and focused on morbidity and mortality reductions. While there may be a role for monotherapy in disease management, most patients should be considered for dual or triple therapy.
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Affiliation(s)
- Vishal Parikh
- Texas Heart Institute, Baylor College of Medicine, Houston, TX, USA
| | - Anju Bhardwaj
- Center for Advanced Cardiopulmonary Therapies and Transplantation at McGovern Medical School, Houston, TX, USA
| | - Ajith Nair
- Winters Center for Heart Failure Research, Michael E. DeBakey VA Medical Center, Texas Heart Institute Educational Faculty, Baylor College of Medicine, Houston, TX, USA
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16
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Sildenafil Monotherapy to Treat Portopulmonary Hypertension Before Liver Transplant. Transplant Proc 2019; 51:1435-1438. [PMID: 31079941 DOI: 10.1016/j.transproceed.2019.01.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/28/2019] [Indexed: 12/23/2022]
Abstract
Portopulmonary hypertension (PPHTN) is a rare complication of liver cirrhosis. Patients with severe PPHTN are contraindicated for liver transplant because of the associated risk of intraoperative acute right heart failure during reperfusion phase or massive volume infusion. Therefore, it has been recommended that patients with moderate to severe PPHTN undergo medical treatment to lower the pulmonary artery pressure before undergoing transplant. Herein, we report 3 patients with severe PPHTN who underwent sildenafil monotherapy before living donor liver transplant. None of the patients experienced associated adverse effects during sildenafil treatment, and the pulmonary artery pressure was effectively reduced before transplant. The first patient was diagnosed during anesthesia prior to transplant, and the mean pulmonary artery pressure was reduced by 34% after treatment. The second and third patients were followed-up with echography, and the estimated pulmonary artery systolic pressure were reduced by 34% and 47%, respectively. Pretransplant right heart catheterization also confirmed the reduction of the mean pulmonary artery pressure. Intraoperative hemodynamic parameters were stable, and the 3 patients were discharged uneventfully. After transplant, sildenafil was discontinued, and all patients remained in a stable clinical and functional status during follow-up.
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17
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Barnes H, Yeoh H, Fothergill T, Burns A, Humbert M, Williams T. Prostacyclin for pulmonary arterial hypertension. Cochrane Database Syst Rev 2019; 5:CD012785. [PMID: 31042010 PMCID: PMC6492481 DOI: 10.1002/14651858.cd012785.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by pulmonary vascular changes, leads to elevated pulmonary artery pressures, dyspnoea, a reduction in exercise tolerance, right heart failure, and ultimately death.Prostacyclin analogue drugs mimic endogenous prostacyclin which leads to vasodilation, inhibition of platelet aggregation, and reversal of vascular remodelling. Prostacyclin's short half-life theoretically enhances selectivity for the pulmonary vascular bed by direct (via central venous catheter) administration. Initial continuous infusion prostacyclins were efficacious, but use of intravenous access increases the risk of adverse events. Newer and safer subcutaneous, oral and inhaled preparations are now available, though possibly less potent.Selexipag is an oral selective prostacyclin receptor (IP receptor) agonist that works similarly to prostacyclin, potentially more stable, with less complex administration and titration. OBJECTIVES To determine the efficacy and safety of prostacyclin, prostacyclin analogues or prostacyclin receptor agonists for PAH in adults and children. SEARCH METHODS We performed searches on CENTRAL, MEDLINE, and Embase up to 16 September 2018. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles. SELECTION CRITERIA We included any randomised controlled trials (RCTs) which compared prostacyclin, prostacyclin analogues or prostacyclin receptor agonists to control (placebo, any other treatment or usual care) for at least six weeks. DATA COLLECTION AND ANALYSIS We used standard methods specified by Cochrane. Primary outcomes included change in World Health Organization (WHO) functional class, six-minute walk distance (6MWD), and mortality. MAIN RESULTS Seventeen trials with 3765 mostly adult participants were included; median trial duration was 12 weeks. Fifteen trials used prostacyclin analogues: intravenous (N = 4); subcutaneous (N = 1); oral (N = 5); inhaled (N = 5); two used oral prostacyclin receptor agonists. Three intravenous and two inhaled trials were open-label.Participants using prostacyclin had 2.39 times greater odds of improving by at least one WHO functional class (95% confidence interval (CI) 1.72 to 3.32; 24 per 100 (95% CI 18.5 to 30.4) with prostacyclin compared to 12 per 100 with control; 8 trials, 1066 participants; moderate-certainty evidence). Improvement occurred with intravenous (odds ratio (OR) 14.96, 95% CI 4.76 to 47.04), and inhaled (OR 2.94, 95% CI 1.53 to 5.66), but not with oral preparations. Participants using prostacyclin increased their 6MWD by 19.50 metres (95% CI 14.82 to 24.19; 13 trials, 2283 participants; low-certainty evidence), which was clinically significant with intravenous (mean difference (MD) 91.76 metres; 95% CI 58.97 to 124.55), but not with non-intravenous preparations (subcutaneous: MD 16.00 metres, 95% CI 7.38 to 24.62; oral: MD 14.76 metres, 95% CI 7.81 to 21.70; inhaled: MD 26.97 metres, 95% CI 17.21 to 36.73). Mortality was reduced in the intravenous (OR 0.29, 95% CI 0.12 to 0.69; risk of death 6 per 100 (95% CI 2.38 to 12.31) with prostacyclin compared to 17 per 100 with control; 4 trials, 255 participants), but not in the non-intravenous studies (OR 0.82, 95% CI 0.48 to 1.40; risk of death 21 per 1000 (95% CI 12.00 to 34.20) with prostacyclin compared to 25 per 1000 with control; moderate-certainty evidence; 12 trials, 2299 participants). We reduced the certainty of evidence due to few studies per subgroup and use of open-label trials.Prostacyclins improved cardiopulmonary haemodynamics (reduction in mean pulmonary artery pressure by 3.60 mmHg (95% CI -4.73 to -2.48); pulmonary vascular resistance by 2.81 WU (95% CI -3.80 to -1.82); right atrial pressure by 1.90 mmHg (95% CI -2.58 to -1.22), and increase in cardiac index by 0.31 L/min/m2 (95% CI 0.23 to 0.38); low-certainty evidence), improved dyspnoea (low-certainty evidence, and improved quality of life (moderate-certainty evidence), when compared to control. When only subcutaneous/inhaled trials were included the effect was still significant, but the magnitude was smaller. There was no difference across oral trials.Adverse events were increased in all prostacyclin preparations, including vasodilation (OR 5.03, 95% CI 3.84 to 6.58), headache (OR 3.16, 95% CI 2.62 to 3.80), jaw pain (OR 5.25, 95% CI 3.96 to 6.98), diarrhoea (OR 2.81, 95% CI 2.29 to 3.46), nausea/vomiting (OR 2.39, 95% CI 1.98 to 2.88), myalgias (OR 2.75, 95% CI 1.65 to 4.58), upper respiratory tract events (OR 1.61, 95% CI 1.22 to 2.13), extremity pain (OR 3.36, 95% CI 2.32 to 4.85), and infusion site reactions (OR 14.41, 95% CI 9.16 to 22.66). In the intravenous trials, there was a 12%-25% risk of serious non-fatal events including sepsis, haemorrhage, pneumothorax and pulmonary embolism.Two trials (1199 participants) compared oral selexipag to placebo; no trials compared selexipag with prostacyclin. There was a small 12.62 metre improvement in 6MWD (95% CI 1.90 to 23.34; high-certainty evidence), and weak evidence for haemodynamics. The effect was uncertain for WHO functional class. The risk of death with selexipag was five per 100 compared to three per 100 with placebo, though the CI crossed zero so the true effect is uncertain (risk difference (RD) 0.02 (95% CI -0.00 to 0.04). There was less clinical worsening with selexipag (OR 0.47, 95% CI 0.37 to 0.60), though more side effects, including vasodilation (OR 2.67, 95% CI 1.72 to 4.17), headache (OR 3.91, 95% CI 3.07 to 4.98), jaw pain (OR 5.33, 95% CI 3.64 to 7.81), diarrhoea (OR 3.11, 95% CI 2.39 to 4.05), nausea/vomiting (OR 2.92, 95% CI 2.29 to 3.73), pain in the extremities (OR 2.44, 95% CI 1.69 to 3.52), and myalgias (OR 3.05, 95% CI 2.02 to 4.58). AUTHORS' CONCLUSIONS This review demonstrates clinical and statistical benefit for intravenous prostacyclin (compared to control) with improved functional class, 6MWD, mortality, symptoms scores, and cardiopulmonary haemodynamics, but at a cost of adverse events. This may be due to a true effect, or may be overestimated due to the inclusion of small, short or open-label studies. There was a statistical and small clinical benefit in function and haemodynamics for inhaled prostacyclin, but the effect is uncertain for mortality. The effect of oral prostacyclins are less certain. Selexipag demonstrated less clinical worsening without discernable impact on survival, increased adverse events; and the effect on other outcomes is less certain. Real-world registry data may provide further information about clinical effect.
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Affiliation(s)
- Hayley Barnes
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
| | - Hui‐Ling Yeoh
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
| | | | | | - Marc Humbert
- Université Paris‐SaclayHôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Inserm U999, Univ. Paris‐SudLe Kremlin‐BicêtreFrance
| | - Trevor Williams
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
- Monash UniversityDepartment of MedicineMelbourneAustralia
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18
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Cordina RL, Playford D, Lang I, Celermajer DS. State-of-the-Art Review: Echocardiography in Pulmonary Hypertension. Heart Lung Circ 2019; 28:1351-1364. [PMID: 31109891 DOI: 10.1016/j.hlc.2019.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 02/08/2019] [Accepted: 03/05/2019] [Indexed: 02/01/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal disease that frequently presents with dyspnoea on exertion and results in increased right ventricular afterload and right ventricular failure. Although cardiac catheterisation is required for a formal diagnosis, transthoracic echocardiography (TTE) has a central role as a screening tool in those with symptoms and those at risk for developing pulmonary vascular disease. Echocardiographic techniques can be employed to estimate pulmonary artery pressure and resistance, right atrial pressure as well as to derive indirect information about right heart structure and function. Potential causes for pulmonary hypertension may also be identified such as congenital heart disease or left ventricular diastolic dysfunction. An increasing body of evidence has demonstrated the important prognostic utility of echocardiographic data in pulmonary hypertension and highlighted the potential for TTE to help clinicians understand whether treatment responses have been adequate or an escalation in therapy is necessary, as therapeutic options continue to expand for patients with pulmonary arterial hypertension. Although traditional echocardiographic techniques only allow surrogate measures of right ventricular systolic function due to the complex shape of the chamber, newer techniques have enabled three-dimensional assessment of the right ventricle to assess right ventricular volume and contractility. This review will discuss traditional methods as well as newer echocardiographic methods in the setting of pulmonary hypertension.
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Affiliation(s)
- Rachael L Cordina
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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19
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Nowak J, Hudzik B, Niedziela JT, Rozentryt P, Ochman M, Przybyłowski P, Zembala M, Gąsior M. The role of echocardiographic parameters in predicting survival of patients with lung diseases referred for lung transplantation. CLINICAL RESPIRATORY JOURNAL 2019; 13:212-221. [PMID: 30706698 DOI: 10.1111/crj.13000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/13/2019] [Accepted: 01/26/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Idiopathic pulmonary fibrosis (IPF) and chronic obstructive pulmonary disease (COPD) show poor prognosis. The importance of left (LV) and right (RV) ventricular morphology and function in patients with end-stage lung diseases referred for lung transplantation (LT) is not well established. OBJECTIVES To assess whether LV and RV echocardiographic parameters influence survival of patients with IPF, COPD and other interstitial lung diseases (ILD) awaiting LT. METHODS In 65 patients (20 patients with COPD, 37 with IPF and 8 with other ILD), we performed transthoracic echocardiography and right heart catheterization. Echocardiographic parameters were assessed with regard to 1-year all-cause mortality. RESULTS The mortality rate was higher in patients with smaller dimensions of LV end-systolic (LVESD) and end-diastolic (LVEDD) diameter (HR 3.03, 95% CI 1.16-7.69, P = .023; and HR 2.9, 95% CI 1.16-7.14, P = .022; respectively), higher RV-to-LV (RV/LV-4CH) ratio (HR 7.6, 95% CI 1.6-29.5, P = .009) and RV proximal outflow tract (RVOT-PLAX) dilatation (HR 2.69, 95% CI 1.22-5.96, P = .015). These associations were independent of age, gender, body mass index, VC, FEV1% and pulmonary diagnosis. The subanalysis of IPF patients demonstrated that the smaller LVESD and LVEDD increased mortality rate (HR 15.0, 95% CI 2.87-89.72, P = .003; HR 4.95, 95% CI 1.5-15.5, P = .006; respectively). No such associations were found in the COPD patients. CONCLUSION LV echocardiographic parameters (LVESD or LVEDD) are useful in predicting survival in patients with end-stage lung diseases, mainly in IPF patients awaiting LT. Other parameters (RV/LV-4CH and RVOT-PLAX dilatation) may also influence survival.
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Affiliation(s)
- Jolanta Nowak
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Bartosz Hudzik
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease, Zabrze, Poland.,Department of Cardiovascular Disease Prevention, School of Public Health, Medical University of Silesia, Bytom, Poland
| | - Jacek T Niedziela
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Piotr Rozentryt
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease, Zabrze, Poland.,Department of Social Medicine and Prevention, School of Public Health in Bytom, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Disease, First Department of General Surgery, Jagiellonian University, Krakow, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
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20
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Mahfouz RA, Gouda M, Galal I, Amin MI. Right ventricular dyssynchrony and functional capacity before and after percutaneous balloon mitral valvuloplasty in patients with mitral stenosis: Determinants and clinical impact. Echocardiography 2019; 36:297-305. [PMID: 30569563 DOI: 10.1111/echo.14227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We aimed to investigate the utility of right ventricular (RV) dyssynchrony to assess functional capacity utilizing 6-minute walking test distance (6MWTD) and to measure brain natriuretic peptide levels (BNP) in patients with mitral stenosis (MS) and to study its value to predict adverse outcome following percutaneous balloon mitral valvuloplasty (PBMV). METHODS A total of 108 patients with moderate to severe MS (26.5 ± 7.5 years) were included in this study. All were candidates for PBMV. RV strain curves were obtained using two-dimensional speckle-tracking echocardiography, and standard deviation (SD) of 4 segments without RV apex (-SD4) was also assessed. 6MWT and BNP were before and after 12 months following PBMV. RESULTS RV-SD4 was significantly prolonged in patients with MS compared with controls (P < 0.001). Patients with 6MWTD ≤300 m had a significantly increased RV-SD4 (P < 0.001) and had higher BNP values (P < 0.03) compared with those with 6MWTD >300 m. RV-SD4 showed a strong correlation with 6MWT and BNP level. RV-SD4 was the strongest independent predictor of adverse outcome following PBMV (P < 0.0001). Receiver operating characteristic analysis showed that RV-SD4 ≥24 ms was the cutoff value which predicts the adverse outcome following PBMV. A considerable improvement of mean 6MWT with significant reduction of BNP levels after 12 months of follow-up (P < 0.001) in subjects with RV dyssynchrony <24 ms. CONCLUSION Right ventricular dyssynchrony is a useful predictor of functional status, as assessed with 6MWTD and BNP level in patients with MS. Furthermore, it might be considered as an independent predictor of adverse outcome following PMBV.
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Affiliation(s)
- Ragab A Mahfouz
- Cardiology Department, Zagazig University Hospital, Zagazig, Egypt
| | - Mohamed Gouda
- Cardiology Department, Zagazig University Hospital, Zagazig, Egypt
| | - Islam Galal
- Cardiology Department, Zagazig University Hospital, Zagazig, Egypt
| | - Mohamed I Amin
- Cardiology Department, Zagazig University Hospital, Zagazig, Egypt
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Wang H, Wang Q, Tian Z, Guo X, Lai J, Li M, Zhao J, Liu Y, Zeng X, Fang Q. Right Ventricular Function is Associated With Quality of Life in Patients With Systemic Lupus Erythematosus Associated Pulmonary Arterial Hypertension. Heart Lung Circ 2018; 28:1655-1663. [PMID: 30301670 DOI: 10.1016/j.hlc.2018.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/26/2018] [Accepted: 09/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Right ventricular (RV) function has been identified as an important determinant of outcome in patients with pulmonary hypertension. We aimed to investigate the relationship between echocardiographic-derived RV function and health-related quality of life (HRQOL) in patients with systemic lupus erythematosus associated pulmonary arterial hypertension (SLE-APAH), and to identify the best echocardiographic parameter for evaluating RV function in these patients. METHODS Sixty (60) consecutive patients with SLE-APAH (all female, mean age 33.6±8.2years) were recruited from May 2013 to November 2014. Echocardiograph, right heart catheterisation, SLE disease activity index (SLEDAI), and functional status and SF-36 generic questionnaire were assessed. RESULTS Echocardiograph-derived RV systolic function was significantly correlated with haemodynamics (p<0.05), with tricuspid annular plane systolic excursion (TAPSE) showing the strongest correlation with pulmonary vascular resistance (R2=0.278, p<0.001) and cardiac index (R2=0.215, p<0.001). Patients with a TAPSE<17mm had a shorter 6-minute-walk-distance (6MWD), lower mixed venous oxygen saturation, and higher plasma N-terminal pro-brain natriuretic peptide (p<0.05). Patients with TAPSE <17mm had lower physical component summary (PCS) and mental component summary (MCS) scores than those with TAPSE ≥17mm (35.5±13.2 vs. 55.0±15.5; 46.3±15.3 vs. 64.8±18.8, respectively, all p<0.05). On multiple regression analysis, a TAPSE <17mm was independently related to lower PCS (β -15.797, 95% confidence interval [CI] -24.746 to -6.848, p=0.001) and lower MCS (β -12.887, 95% CI -24.018 to -1.755, p=0.024). CONCLUSIONS TAPSE is a useful index for RV function assessment, and is associated with HRQOL in patients with SLE-APAH.
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Affiliation(s)
- Hui Wang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoxiao Guo
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinzhi Lai
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4606053. [PMID: 29850519 PMCID: PMC5914124 DOI: 10.1155/2018/4606053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/02/2018] [Accepted: 02/27/2018] [Indexed: 11/17/2022]
Abstract
Introduction Several diagnostic tests have been recommended for risk assessment in pulmonary hypertension (PH), but the role of electrocardiography (ECG) in monitoring of PH patients has not been yet established. Therefore the aim of the study was to evaluate which ECG patterns characteristic for pulmonary hypertension can predict hemodynamic improvement in patients treated with targeted therapies. Methods Consecutive patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) were eligible to be included if they had had performed two consecutive right heart catheterization (RHC) procedures before and after starting of targeted therapies. Patients were followed up from June 2009 to July 2017. ECG patterns of right ventricular hypertrophy according to American College of Cardiology Foundation were assessed. Results We enrolled 80 patients with PAH and 11 patients with inoperable CTEPH. The follow-up RHC was performed within 12.6 ± 10.0 months after starting therapy. Based on median change of pulmonary vascular resistance, we divided our patients into two subgroups: with and without significant hemodynamic improvement. RV1, maxRV1,2 + maxSI,aVL − SV1, and PII improved along with the improvement of hemodynamic parameters including PVR. They predicted hemodynamic improvement with similarly good accuracy as shown in ROC analysis: RV1 (AUC: 0.75; 95% CI: 0.63–0.84), PII (AUC: 0.67, 95% CI: 0.56–0.77), and maxRV1,2 + maxSI,aVL − SV1 (0.73; 95% CI: 0.63–0.82). In Cox regression only change in RV1 remained significant mortality predictor (HR: 1.12, 95% CI: 1.01–1.24). Conclusion Electrocardiogram may be useful in predicting hemodynamic effects of targeted therapy in precapillary pulmonary hypertension. Decrease of RV1, maxRV1,2 + maxSI,aVL − SV1, and PII corresponds with hemodynamic improvement after treatment. Of these changes a decrease of R wave amplitude in V1 is associated with better survival.
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Frank BS, Ivy DD. Diagnosis, Evaluation and Treatment of Pulmonary Arterial Hypertension in Children. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E44. [PMID: 29570688 PMCID: PMC5920390 DOI: 10.3390/children5040044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Pulmonary Hypertension (PH), the syndrome of elevated pressure in the pulmonary arteries, is associated with significant morbidity and mortality for affected children. PH is associated with a wide variety of potential underlying causes, including cardiac, pulmonary, hematologic and rheumatologic abnormalities. Regardless of the cause, for many patients the natural history of PH involves progressive elevation in pulmonary arterial resistance and pressure, right ventricular dysfunction, and eventually heart failure. In recent years, a number of pulmonary arterial hypertension (PAH)-targeted therapies have become available to reduce pulmonary artery pressure and improve outcome. A growing body of evidence in both the adult and pediatric literature demonstrates enhanced quality of life, functional status, and survival among treated patients. This review provides a description of select etiologies of PH seen in pediatrics and an update on the most recent data pertaining to evaluation and management of children with PH/PAH. The available evidence for specific classes of PAH-targeted therapies in pediatrics is additionally discussed.
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Affiliation(s)
- Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
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Badagliacca R, Raina A, Ghio S, D’Alto M, Confalonieri M, Correale M, Corda M, Paciocco G, Lombardi C, Mulè M, Poscia R, Scelsi L, Argiento P, Sciomer S, Benza RL, Vizza CD. Influence of various therapeutic strategies on right ventricular morphology, function and hemodynamics in pulmonary arterial hypertension. J Heart Lung Transplant 2018; 37:365-375. [DOI: 10.1016/j.healun.2017.08.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 08/03/2017] [Accepted: 08/24/2017] [Indexed: 01/22/2023] Open
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Wright LM, Dwyer N, Celermajer D, Kritharides L, Marwick TH. Follow-Up of Pulmonary Hypertension With Echocardiography. JACC Cardiovasc Imaging 2017; 9:733-46. [PMID: 27282440 DOI: 10.1016/j.jcmg.2016.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 10/21/2022]
Abstract
Individual patient response to effective therapies for pulmonary hypertension (PAH) is variable and difficult to quantify. Consequently, management decisions regarding initiation and continuation of therapy are highly dependent on the results of investigations. Registry data show that changes in cardiac index, mean right atrial pressure, and mean pulmonary artery pressure have the greatest influence on survival. It is recognized that pulmonary artery pressure (PASP) responses to PAH-specific drugs are heterogeneous. However, follow-up testing is strongly focused on assessing changes in PASP and functional status (6-min walk). The goals of therapy, which should be highlighted in follow-up imaging, include not only reduction of PASP, decrease in pulmonary vascular resistance, and improvements in right ventricular function, cardiac output, and tricuspid regurgitation. This paper reviews the echocardiographic follow-up of pulmonary hypertension, and especially focuses on right ventricular function-a major determinant of outcome, for which reliable echocardiographic assessment has become more feasible.
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Affiliation(s)
- Leah M Wright
- Menzies Institute for Medical Research, Hobart, Australia; Royal Hobart Hospital, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | | | | | - Thomas H Marwick
- Menzies Institute for Medical Research, Hobart, Australia; Royal Hobart Hospital, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia.
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Badagliacca R, Poscia R, Pezzuto B, Papa S, Reali M, Pesce F, Manzi G, Gianfrilli D, Ciciarello F, Sciomer S, Biondi-Zoccai G, Torre R, Fedele F, Vizza CD. Prognostic relevance of right heart reverse remodeling in idiopathic pulmonary arterial hypertension. J Heart Lung Transplant 2017; 37:S1053-2498(17)32041-7. [PMID: 29107544 DOI: 10.1016/j.healun.2017.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/03/2017] [Accepted: 09/26/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Right ventricular (RV) failure is a major determinant of symptoms and shortened survival in pulmonary arterial hypertension (PAH). This study assessed the prognostic relevance of increased right heart (RH) dimensions determined by echocardiography and RH reverse remodeling (RHRR) with targeted therapies in idiopathic PAH (IPAH). METHODS The study prospectively monitored 102 therapy-naïve IPAH patients for the presence of clinical worsening. Baseline evaluation included RH catheterization and echocardiography. RHRR at the 1-year follow-up was defined by a decrease in RV end-diastolic area, right atrial area, and the left ventricular systolic eccentricity index. RESULTS At the 1-year follow-up, 18 of 102 patients (17.6%) presented with RHRR. A decrease in pulmonary vascular resistance was the only independent determinant of RHRR. The 94 surviving patients were monitored for 995 ± 529 days. RHRR was an independent prognostic factor and significantly improved the power of the prognostic model based on traditional clinical and hemodynamic parameters. The respective event-free survival rates at 1, 3, and 5 years were 94%, 94%, and 94% in patients with RHRR and 75%, 55%, and 24% in those without RHRR (p = 0.0001). Interestingly, RHRR was able to further stratify patients' risk assessment through the Registry to Evaluate Early And Long-term PAH Disease Management risk score. CONCLUSIONS RHRR after 1 year of treatment is an independent predictor of prognosis in IPAH. The likelihood of RHRR is proportional to decreased pulmonary vascular resistance.
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Affiliation(s)
- Roberto Badagliacca
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy.
| | - Roberto Poscia
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Beatrice Pezzuto
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Papa
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Manuela Reali
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Pesce
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Giovanna Manzi
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Ciciarello
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Susanna Sciomer
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Roberto Torre
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Fedele
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Departments of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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Metas en hipertensión pulmonar. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Venkatachalam S, Wu G, Ahmad M. Echocardiographic assessment of the right ventricle in the current era: Application in clinical practice. Echocardiography 2017; 34:1930-1947. [PMID: 28833543 DOI: 10.1111/echo.13651] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The right ventricle has unique structural and functional characteristics. It is now well recognized that the so-called forgotten ventricle is a key player in cardiovascular physiology. Furthermore, there is accumulating evidence that demonstrates right ventricular dysfunction as an important marker of morbidity and mortality in several commonly encountered clinical situations such as heart failure, pulmonary hypertension, pulmonary embolism, right ventricular myocardial infarction, and adult congenital heart disease. In contrast to the left ventricle, echocardiographic assessment of right ventricular function is more challenging as volume estimations are not possible without the use of three-dimensional (3D) echocardiography. Guidelines on chamber quantification provide a standardized approach to assessment of the right ventricle. The technique and limitations of each of the parameters for RV size and function need to be fully understood. In this era of multimodality imaging, echocardiography continues to remain a useful tool for the initial assessment and follow-up of patients with right heart pathology. Several novel approaches such as 3D and strain imaging of the right ventricle have expanded the usefulness of this indispensable modality.
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Affiliation(s)
- Sridhar Venkatachalam
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Geru Wu
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Masood Ahmad
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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van de Veerdonk MC, Huis In T Veld AE, Marcus JT, Westerhof N, Heymans MW, Bogaard HJ, Vonk-Noordegraaf A. Upfront combination therapy reduces right ventricular volumes in pulmonary arterial hypertension. Eur Respir J 2017; 49:49/6/1700007. [PMID: 28663315 DOI: 10.1183/13993003.00007-2017] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/11/2017] [Indexed: 11/05/2022]
Abstract
In pulmonary arterial hypertension (PAH), upfront combination therapy is associated with better clinical outcomes and a greater reduction in N-terminal pro-brain natriuretic peptide (NT-proBNP) than monotherapy. NT-proBNP levels reflect right ventricular (RV) wall stress, which increases when the right ventricle dilates. This study explored the impact of upfront combination therapy on RV volumes compared with monotherapy in PAH patients.This retrospective study involved 80 incident PAH patients (New York Heart Association class II and III) who were treated with upfront combination therapy (n=35) (i.e. endothelin receptor antagonists (ERAs) plus phosphodiesterase-5-inhibitors (PDE5Is)) or monotherapy (n=45) (i.e. either ERAs or PDE5Is). All patients underwent right-sided heart catheterisation and cardiac magnetic resonance imaging at baseline and after 1-year follow-up.Combination therapy resulted in more significant reductions in pulmonary vascular resistance and pulmonary pressures than monotherapy. NT-proBNP was decreased by ∼77% in the combination therapy group compared with a ∼51% reduction after monotherapy (p<0.001). RV volumes and calculated RV wall stress improved after combination therapy (both p<0.001) but remained unchanged after monotherapy (both p=NS). RV ejection fraction improved more in the combination therapy group than in the monotherapy group (p<0.001).In PAH patients, upfront combination therapy was associated with improved RV volumes.
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Affiliation(s)
- Mariëlle C van de Veerdonk
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands.,Department of Cardiology, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Anna E Huis In T Veld
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Department of Physics and Medical Technologies, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
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30
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Liu W, Wang Y, Zhou J, Bai H, Wang F, Wang J. The Association of Functional Capacity With Right Atrial Deformation in Patients With Pulmonary Arterial Hypertension: A Study With Two-Dimensional Speckle Tracking. Heart Lung Circ 2017; 27:350-358. [PMID: 29150155 DOI: 10.1016/j.hlc.2017.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 01/03/2017] [Accepted: 02/15/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to assess right atrial (RA) myocardial mechanics in pulmonary hypertension (PH) patients using two-dimensional speckle tracking (2D-STE), and define the relationship between RA function and exercise capacity in PH patients. METHODS Thirty-eight consecutive PH patients were studied and compared with a control group of 25 healthy volunteers. Peak atrial longitudinal strain (PALS), RA strain rate were measured in all subjects. PALS values were obtained by averaging all segments (global PALS), and by averaging segments measured in the four-chamber view. RESULTS Right atrial PALS was significantly lower in PH patients than in controls, and gradually reduced with the development of cardiac insufficiency. A significantly positive correlation between global PALS and 6-minute walk distance (6MWD) was found (p=0.003). Furthermore, global PALS demonstrated the highest diagnostic accuracy (AUC of 0.979) and excellent sensitivity and specificity of 86.8% and 84%, respectively, to predict functional status using a cut-off value less than 38.08%. CONCLUSIONS Right atrial deformation is significantly damaged in PH patients. Right atrial reservoir function can be estimated using 2D-STE, which gradually decreases in PH patients with different World Health Organization-functional class (WHO-FC). Right atrial PALS is a valuable factor for predicting the functional status and exercise capacity in PH patients.
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Affiliation(s)
- Weiwei Liu
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China
| | - Yueheng Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China.
| | - Jinling Zhou
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China
| | - Hui Bai
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China
| | - Feng Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China
| | - Ju Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, China
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31
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Wong DJ, Sampat U, Gibson MA, Auger WR, Madani MM, Daniels LB, Raisinghani AB, DeMaria AN, Blanchard DG. Tricuspid annular plane systolic excursion in chronic thromboembolic pulmonary hypertension before and after pulmonary thromboendarterectomy. Echocardiography 2016; 33:1805-1809. [DOI: 10.1111/echo.13364] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Darrin J. Wong
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Unnati Sampat
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Michael A. Gibson
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - William R. Auger
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Michael M. Madani
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Lori B. Daniels
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Ajit B. Raisinghani
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Anthony N. DeMaria
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
| | - Daniel G. Blanchard
- UCSD School of Medicine; University of California San Diego Cardiovascular Center; La Jolla California
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Abstract
The prevalence of PH is increasing in the pediatric population, because of improved recognition and increased survival of patients, and remains a significant cause of morbidity and mortality. Recent studies have improved the understanding of pediatric PH, but management remains challenging because of a lack of evidence-based clinical trials. The growing contribution of developmental lung disease requires dedicated research to explore the use of existing therapies as well as the creation of novel therapies. Adequate study of pediatric PH will require multicenter collaboration due to the small numbers of patients, multifactorial disease causes, and practice variability.
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Affiliation(s)
- Dunbar Ivy
- Section of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO 80045, USA.
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33
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Crnkovic S, Schmidt A, Egemnazarov B, Wilhelm J, Marsh LM, Ghanim B, Klepetko W, Olschewski A, Olschewski H, Kwapiszewska G. Functional and molecular factors associated with TAPSE in hypoxic pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2016; 311:L59-73. [PMID: 27106290 DOI: 10.1152/ajplung.00381.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 04/17/2016] [Indexed: 01/11/2023] Open
Abstract
Adaptation of the right ventricle (RV) to increased afterload is crucial for survival in pulmonary hypertension (PH), but it is challenging to assess RV function and identify associated molecular mechanisms. The aim of the current study was to analyze the relationship between invasive and noninvasive parameters of RV morphology and function and associated molecular changes. The response of mice to normobaric hypoxia was assessed by hechocardiography, invasive hemodynamics, and histological and molecular analyses. Plasma levels of possibly novel markers of RV remodeling were measured by ELISA in patients with idiopathic pulmonary arterial hypertension (IPAH) and matched healthy controls. Chronic hypoxia-induced PH was accompanied by significantly decreased tricuspid annular plane systolic excursion (TAPSE) and unchanged RV contractility index and tau. RV hypertrophy was present without an increase in fibrosis. There was no change in α- and β-major histocompatibility class or natriuretic peptides expression. Comparative microarray analysis identified two soluble factors, fibroblast growth factor-5 (FGF5) and interleukin-22 receptor alpha-2 (IL22RA2), as being possibly associated with RV remodeling. We observed significantly higher plasma levels of IL22RA2, but not FGF5, in patients with IPAH. Hypoxic pulmonary hypertension in a stage of RV remodeling with preserved systolic function is associated with decreased pulmonary vascular compliance, mild diastolic RV dysfunction, and significant decrease in TAPSE. Subtle gene expression changes in the RV vs. the left ventricle upon chronic hypoxia suggest that the majority of changes are due to hypoxia and not due to changes in afterload. Increased IL22RA2 levels might represent a novel RV adaptive mechanism.
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Affiliation(s)
- Slaven Crnkovic
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Department of Experimental Anaesthesiology, Medical University of Graz, Graz, Austria
| | - Albrecht Schmidt
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Jochen Wilhelm
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - Leigh M Marsh
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Bahil Ghanim
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Department of Thoracic Surgery, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Department of Experimental Anaesthesiology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; and
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Department of Experimental Anaesthesiology, Medical University of Graz, Graz, Austria
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Arya B, Kerstein D, Leu CS, Hayes D, Zuckerman WA, Krishnan U, Lai WW. Echocardiographic Assessment of Right Atrial Pressure in a Pediatric and Young Adult Population. Pediatr Cardiol 2016; 37:558-67. [PMID: 26667961 DOI: 10.1007/s00246-015-1315-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/21/2015] [Indexed: 12/13/2022]
Abstract
Right atrial pressure (RAP) reflects right-sided cardiac hemodynamics and is useful in management of patients with cardiac and systemic disease. Studies in older adults demonstrated that inferior vena cava (IVC) diameter, IVC collapsibility index, hepatic vein systolic filling fraction (SFF), and right atrial volume (RAV) correlated with mean RAP at catheterization. This study aimed to assess the utility of echocardiographic parameters for assessment of RAP in children and young adults. Patients with pulmonary hypertension or heart transplantation undergoing right heart catheterization were recruited for this prospective observational pilot study. Transthoracic echocardiographic assessment of RAP was performed simultaneously with catheterization. For each parameter, three consecutive cardiac cycles were recorded. Long- and short-axis images of the IVC were obtained. RAV was assessed by area-length and biplane methods. IVC diameters and RAV were indexed to body surface area (BSA)(0.5) and (BSA)(1.4), respectively. Relationships between echocardiographic parameters and mean RAP were correlated using "Pearson's r." Fifty subjects aged 0.3-23 years (median 13, mean 12.3 ± 7 years) were enrolled. Mean RAP correlated modestly with RAV (r = 0.51, p < 0.001). Long-axis IVCmax (r = 0.30, p < 0.05) and tricuspid E wave velocity (r = 0.36, p < 0.01) also correlated with mean RAP. RV free wall tissue Doppler velocities, IVC collapsibility index, and hepatic vein SFF had no relation to mean RAP. In a pediatric and young adult population with pulmonary hypertension or heart transplantation, echocardiographic assessment of RAV and long-axis IVCmax provided a reasonable estimate of mean RAP. IVC collapsibility index and hepatic vein SFF demonstrated no association with mean RAP.
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Affiliation(s)
- Bhawna Arya
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, M/S RC.2.820, PO Box 5371, Seattle, WA, 98105, USA.
| | - Diane Kerstein
- Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Denise Hayes
- Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Usha Krishnan
- Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Wyman W Lai
- Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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35
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Bruggen CEVD, Spruijt OA, Meijboom LJ, Noordegraaf AV. Pulmonary hypertension. IMAGING 2016. [DOI: 10.1183/2312508x.10002715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Addressing the Controversy of Estimating Pulmonary Arterial Pressure by Echocardiography. J Am Soc Echocardiogr 2016; 29:93-102. [DOI: 10.1016/j.echo.2015.11.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Indexed: 12/16/2022]
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37
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Hirashiki A, Kondo T, Okumura T, Kamimura Y, Nakano Y, Fukaya K, Sawamura A, Morimoto R, Adachi S, Takeshita K, Murohara T. Cardiopulmonary Exercise Testing as a Tool for Diagnosing Pulmonary Hypertension in Patients with Dilated Cardiomyopathy. Ann Noninvasive Electrocardiol 2016; 21:263-71. [PMID: 26833673 PMCID: PMC6931611 DOI: 10.1111/anec.12308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/07/2015] [Indexed: 01/25/2023] Open
Abstract
Background Recently, it has become increasingly recognized that pulmonary hypertension (PH) is a particularly threatening result of left‐sided heart disease. However, there have been few investigations of the impact of cardiopulmonary exercise testing (CPX) variables on PH in dilated cardiomyopathy (DCM). We evaluated the usefulness of crucial CPX variables for detecting elevated pulmonary arterial pressure (PAP) in patients with DCM. Methods Ninety subjects with DCM underwent cardiac catheterization and CPX at our hospital. Receiver operator characteristic (ROC) analysis was performed to assess the ability of CPX variables to distinguish between the presence and absence of PH. Results Overall mean values were: mean PAP (mPAP), 18.0 ± 9.6 mmHg; plasma brain natriuretic peptide, 233 ± 295 pg/mL; and left ventricular ejection fraction, 30.2 ± 11.0%. Patients were allocated to one of two groups on the basis of mean PAP, namely DCM without PH [mean PAP (mPAP) <25 mmHg; n = 75] and DCM with PH (mPAP ≥25 mmHg; n = 15). A cutoff achieved percentage of predicted peak VO2 (%PPeak VO2) of 52.5% was the best predictor of an mPAP ≥25 mmHg in the ROC analysis (area under curve: 0.911). In the multivariate analysis, %PPeak VO2 was the only significant independent predictor of PH (Wald 6.52, odds ratio 0.892, 95% CI 0.818–0.974; P = 0.011). Conclusions %PPeak VO2 was strongly associated with the presence of PH in patients with DCM. Taken together, these findings indicate that CPX variables could be important for diagnosing PH in patients with DCM.
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Affiliation(s)
- Akihiro Hirashiki
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Kamimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Fukaya
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akinori Sawamura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyosuke Takeshita
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Pristera N, Musarra R, Schilz R, Hoit BD. The Role of Echocardiography in the Evaluation of Pulmonary Arterial Hypertension. Echocardiography 2015; 33:105-16. [PMID: 26522749 DOI: 10.1111/echo.13113] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The evaluation of pulmonary arterial hypertension (PAH) requires a multimodality approach that combines invasive and noninvasive imaging studies to ensure accurate diagnosis and classification. Given the complexity of the hemodynamic relationships between the left heart, pulmonary circulation, and right heart, the diagnosis of PAH is often a challenging task. Right heart catheterization is the gold standard for diagnosis, providing the hemodynamic information that defines the disease. Nonetheless, echocardiography continues to be a valuable tool in the approach to the patient with suspected PAH. Echocardiographic assessment generates a wealth of information about the response of the right heart to elevated pulmonary pressures and provides essential diagnostic and prognostic data to the clinician. Numerous measurements can be used to identify alterations in right heart morphology, pressure, and function; although each variable in isolation may have little utility, meaningful information is revealed when multiple parameters are considered together. In this article, we will review the echocardiographic measurements employed in assessment of the right heart and seek to clarify the role of echocardiography in the diagnostic workup of PAH.
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Affiliation(s)
| | - Ray Musarra
- Harrington Heart and Vascular Institute, University Hospital Case Medical Center, Cleveland, Ohio.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Robert Schilz
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Brian D Hoit
- Case Western Reserve University, Cleveland, Ohio.,Harrington Heart and Vascular Institute, University Hospital Case Medical Center, Cleveland, Ohio.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio
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Use of outcome measures in pulmonary hypertension clinical trials. Am Heart J 2015; 170:419-29.e3. [PMID: 26385024 DOI: 10.1016/j.ahj.2015.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of surrogate measures in pulmonary hypertension (PH) clinical trials and how it relates to clinical practice. BACKGROUND Studies of pulmonary arterial hypertension (PAH) employ a variety of surrogate measures in addition to clinical events because of a small patient population, participant burden, and costs. The use of these measures in PH drug trials is poorly defined. METHODS We searched PubMed/MEDLINE/Embase for randomized or prospective cohort PAH clinical treatment trials from 1985 to 2013. Extracted data included intervention, trial duration, study design, patient characteristics, and primary and secondary outcome measures. To compare with clinical practice, we assessed the use of surrogate measures in a clinical sample of patients on PH medications at Duke University Medical Center between 2003 and 2014. RESULTS Between 1985 and 2013, 126 PAH trials were identified and analyzed. Surrogate measures served as primary endpoints in 119 trials (94.0%). Inclusion of invasive hemodynamics decreased over time (78.6%, 75.0%, 52.2%; P for trend = .02), while functional testing (7.1%, 60.0%, 81.5%; P for trend < .0001) and functional status or quality of life (0%, 47.6%, 62.8%; P for trend < .0001) increased in PAH trials over the same time periods. Echocardiography data were reported as a primary or secondary outcome in 32 trials (25.4%) with increased use from 1985-1994 to 1995-2004 (7.1% vs 35.0%, P = .04), but the trend did not continue to 2005-2013 (25.0%). In comparison, among 450 patients on PAH therapies at our institution between 2003 and 2013, clinical assessments regularly incorporated serial echocardiography and 6-minute walk distance tests (92% and 95% of patients, respectively) and repeat measurement of invasive hemodynamics (46% of patients). CONCLUSIONS The majority of PAH trials have utilized surrogate measures as primary endpoints. The use of these surrogate endpoints has evolved significantly over time with increasing use of patient-centered endpoints and decreasing or stable use of imaging and invasive measures. In contrast, imaging and invasive measures are commonly used in contemporary clinical practice. Further research is needed to validate and standardize currently used measures.
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40
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Idrees M, Alnajashi K, Abdulhameed J, Khan A, Batubara E, Alotay A, Fayed A, Aldammas S, Alseif M, Alawwad H, Abusabaa Y, Almobrad M, Kashour T. Saudi experience in the management of pulmonary arterial hypertension; the outcome of PAH therapy with the exclusion of chronic parenteral prostacyclin. Ann Thorac Med 2015; 10:204-11. [PMID: 26229564 PMCID: PMC4518352 DOI: 10.4103/1817-1737.160842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 04/18/2015] [Indexed: 12/16/2022] Open
Abstract
AIMS The purpose of this study is to present our center's experience in managing patients with pulmonary arterial hypertension (PAH). The main objective is to describe patients' management profile and treatment outcome. METHODS This study presents the results from a single pulmonary hypertension (PH) specialized center in Saudi Arabia. Both incidence and prevalence cases are included. We have previously reported the clinical and physiological characteristics at the time of diagnosis for this cohort of patients. In this study, we describe the clinical management and the outcome of therapy in the same cohort, who were prospectively followed for a mean of 22 months. RESULTS A total of 107 patients were identified as having PAH. At the time of enrollment, 56.1% of patients were in modified New York Heart Association functional class (NYHA FC) III and 16.8% were in IV. Phosphdiesterase-5 inhibitor was the most commonly used target therapy (82.2%) followed by endothelin receptors antagonist (74.4%). Only five patients (4.7%) were candidate to use calcium channel blockers. Seventy-nine patients (73.8 %) received a combination nonparenteral target therapy. Thirty-one patients (28.9%) died during the follow-up period. Modified NYHA FC III and IV patients, portopulmonary hypertension, heritable PAH, and PAH associated with connective tissue diseases had the highest mortality rate (P < 0.001). CONCLUSION Our patients are detected at advanced stage of the disease, and thus the mortality is still unacceptably high. Advanced functional class at presentation and certain disease subgroups are associated with increased mortality.
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Affiliation(s)
- Majdy Idrees
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Khalid Alnajashi
- Section of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Jasim Abdulhameed
- Section of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Atika Khan
- Section of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Enas Batubara
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Abdelmajeed Alotay
- Section of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Amal Fayed
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Saleh Aldammas
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Moaad Alseif
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Husam Alawwad
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Yahya Abusabaa
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Mashael Almobrad
- Pulmonary Medicine Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Science, King Fahd Cardiac Center, King Khalid University Hospital, Riyadh, Saudi Arabia
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Badagliacca R, Poscia R, Pezzuto B, Nocioni M, Mezzapesa M, Francone M, Giannetta E, Papa S, Gambardella C, Sciomer S, Volterrani M, Fedele F, Dario Vizza C. Right ventricular remodeling in idiopathic pulmonary arterial hypertension: adaptive versus maladaptive morphology. J Heart Lung Transplant 2015; 34:395-403. [DOI: 10.1016/j.healun.2014.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/19/2014] [Accepted: 11/04/2014] [Indexed: 11/29/2022] Open
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Ohira H, Beanlands RS, Davies RA, Mielniczuk L. The role of nuclear imaging in pulmonary hypertension. J Nucl Cardiol 2015; 22:141-57. [PMID: 25161042 DOI: 10.1007/s12350-014-9960-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/17/2014] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension (PH) is a disease characterized by a chronic elevation of pulmonary artery pressure from various causes. Pulmonary artery hypertension (PAH) is one of subtype which results in premature death often as a result of right ventricular (RV) dysfunction. In spite of the recent progress in novel cardiac imaging techniques and new drugs for PAH, there remain significant unresolved issues including a need for earlier diagnosis, refinement of risk stratification, and monitoring the effects of treatment. Cardiac and pulmonary imaging with transthoracic echocardiography (TTE) with Doppler, magnetic resonance imaging (MRI), and computed tomography (CT) are done routinely in many clinical centers. However, routine and emerging nuclear techniques may have a pivotal role of assessment of the patient with PH, and is currently the subject of significant research. Potential Roles for Nuclear Imaging in the Evaluation of the PH Patient: (1) Evaluation of cardiac structure and function (RNA) (non-nuclear techniques would include TTE, CT, and MRI). (2) Functional imaging. This includes the use of ventilation-perfusion scintigraphy (V/Q scan) to diagnose chronic thromboembolic pulmonary hypertension (CTEPH), 123l-metaiodobenzylguanidine (MIBG) imaging to evaluate the cardiac sympathetic nervous system (non-nuclear techniques include invasive right heart catheterization and TTE). (3) Measurement of RV perfusion (with gated SPECT studies). (4) Evaluation of cardiac and pulmonary metabolism (PET scans). This review article will summarize the pathophysiology, classification, natural history, and diagnostic approach of PH. Current and emerging nuclear techniques will be discussed under the four themes of evaluation of structure, functional imaging, flow, and metabolism. These will be compared to current and emerging nuclear and non-nuclear diagnostic tests in the evaluation and management of patients with PH. We will also discuss research applications exploring new insights into flow and metabolism in the right heart and lung and the application of new radioligands.
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Affiliation(s)
- H Ohira
- Advanced Heart Disease and Pulmonary Hypertension Programs, National Cardiac PET Centre, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Room 3409, Ottawa, ON, K1Y 4W7, Canada
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43
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Held M, Grün M, Holl R, Hübner G, Kaiser R, Karl S, Kolb M, Schäfers HJ, Wilkens H, Jany B. Cardiopulmonary exercise testing to detect chronic thromboembolic pulmonary hypertension in patients with normal echocardiography. Respiration 2015; 87:379-87. [PMID: 24732343 DOI: 10.1159/000358565] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious complication of pulmonary embolism (PE). Taking into account the reported incidence of CTEPH after acute PE, the number of patients with undiagnosed CTEPH may be high. OBJECTIVES We aimed to determine if cardiopulmonary exercise testing (CPET) could serve as complementary tool in the diagnosis of CTEPH and can detect CTEPH in patients with normal echocardiography. METHODS At diagnosis, we analyzed the data of CPET parameters in 42 patients with proven CTEPH and 51 controls, and evaluated the performance of two scores. RESULTS VE/VCO2 slope, EQO2, EQCO2, P(A-a)O2, end-tidal partial pressure of CO2 at anaerobic threshold (PETCO2) and capillary to end-tidal carbon dioxide gradient [P(c-ET)CO2] were significantly different between patients with CTEPH and controls (p < 0.001). P(c-ET)CO2 was the single parameter with the highest sensitivity (85.7%) and specificity (88.2%). A score combining VE/VCO2 slope, P(A-a)O2, P(c-ET)CO2, PETCO2 [4-parameter-CPET (4-P-CPET) score] reached a sensitivity of 83.3% and a specificity of 92.2% after cross-validation. In 42 patients with CTEPH, echocardiography identified PH in 29 patients (69%), but it was normal in 13 patients (31%). All patients with normal or unmeasurable right ventricular systolic pressure had a pathological CPET. Twelve of the 13 patients (92%) were detected by both CPET scores. CONCLUSION CPET is a useful noninvasive diagnostic tool for the detection of CTEPH in patients with suspected PH but normal echocardiography. The 4-P-CPET score provides a high sensitivity with the highest specificity.
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Affiliation(s)
- Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital, Julius Maximilian University of Würzburg, Würzburg, Germany
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D'Alto M, Romeo E, Argiento P, Di Salvo G, Badagliacca R, Cirillo AP, Kaemmerer H, Bossone E, Naeije R. Pulmonary arterial hypertension: the key role of echocardiography. Echocardiography 2014; 32 Suppl 1:S23-37. [PMID: 25244441 DOI: 10.1111/echo.12283] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Echocardiography is a key screening tool in the diagnostic algorithm of pulmonary arterial hypertension (PAH). It provides an estimate of right ventricular function and pulmonary artery pressure, either at rest or during exercise, and is useful in ruling out secondary causes of pulmonary hypertension (PH) such as left heart disease or congenital heart disease. Several studies have showed that echocardiography is insufficiently precise as single tool for the ultimate diagnosis of PH respect to the right heart catheterization, considered the gold standard technique. Echocardiography is valuable in assessing prognosis and treatment options, monitoring the efficacy of specific therapeutic interventions, and detecting the preclinical stages of disease. The ideal imaging modality for accurate noninvasive assessment of the right heart should be accurate and precise, not influenced by loading conditions, routinely practicable and easily repeatable. For all such reasons and considering that PAH is a rare and severe condition, a complete noninvasive assessment of right heart function requires a deep knowledge of the disease and a multimodality approach.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Second University of Naples - Monaldi Hospital, Naples, Italy
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45
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Held M, Hesse A, Gött F, Holl R, Hübner G, Kolb P, Langen HJ, Romen T, Walter F, Schäfers HJ, Wilkens H, Jany B. A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study. BMC Pulm Med 2014; 14:141. [PMID: 25168781 PMCID: PMC4152276 DOI: 10.1186/1471-2466-14-141] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 08/18/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a long-term complication following an acute pulmonary embolism (PE). It is frequently diagnosed at advanced stages which is concerning as delayed treatment has important implications for favourable clinical outcome. Performing a follow-up examination of patients diagnosed with acute PE regardless of persisting symptoms and using all available technical procedures would be both cost-intensive and possibly ineffective. Focusing diagnostic procedures therefore on only symptomatic patients may be a practical approach for detecting relevant CTEPH.This study aimed to evaluate if a follow-up program for patients with acute PE based on telephone monitoring of symptoms and further examination of only symptomatic patients could detect CTEPH. In addition, we investigated the role of cardiopulmonary exercise testing (CPET) as a diagnostic tool. METHODS In a prospective cohort study all consecutive patients with newly diagnosed PE (n=170, 76 males, 94 females within 26 months) were recruited according to the inclusion and exclusion criteria. Patients were contacted via telephone and asked to answer standardized questions relating to symptoms. At the time of the final analysis 130 patients had been contacted. Symptomatic patients underwent a structured evaluation with echocardiography, CPET and complete work-up for CTEPH. RESULTS 37.7%, 25.5% and 29.3% of the patients reported symptoms after three, six, and twelve months respectively. Subsequent clinical evaluation of these symptomatic patients saw 20.4%, 11.5% and 18.8% of patients at the respective three, six and twelve months time points having an echocardiography suggesting pulmonary hypertension (PH). CTEPH with pathological imaging and a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg at rest was confirmed in eight subjects. Three subjects with mismatch perfusion defects showed an exercise induced increase of PAP without increasing pulmonary artery occlusion pressure (PAOP). Two subjects with pulmonary hypertension at rest and one with an exercise induced increase of mPAP with normal PAOP showed perfusion defects without echocardiographic signs of PH but a suspicious CPET. CONCLUSION A follow-up program based on telephone monitoring of symptoms and further structured evaluation of symptomatic subjects can detect patients with CTEPH. CPET may serve as a complementary diagnostic tool.
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Affiliation(s)
- Matthias Held
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Alexander Hesse
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Franziska Gött
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Regina Holl
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Gudrun Hübner
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Philipp Kolb
- Firestone Institute for Respiratory Health, Department of Medicine, Pathology & Molecular Medicine, McMaster University, 50 Charlton Ave East, T2131, Hamilton, ON L8N 4A6, Canada
| | - Heinz Jakob Langen
- Medical Mission Hospital, Department of Radiology, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Tobias Romen
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Franziska Walter
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
| | - Hans Joachim Schäfers
- University Hospital Homburg Saar, Clinic for Thoracic and Cardiovascular Surgery, Kirrberger Strasse, Homburg, Saar D 66421, Germany
| | - Heinrike Wilkens
- Department of Internal Medicine V, Respiratory and Critical Care Medicine, University Hospital Homburg Saar, Kirrberger Strasse, Homburg, Saar D 66421, Germany
| | - Berthold Jany
- Medical Mission Hospital, Department of Internal Medicine, Academic Teaching Hospital of the Julius-Maximilian University of Würzburg, Salvatorstrasse 7, Würzburg 97067, Germany
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Idrees MM, Saleemi S, Azem MA, Aldammas S, Alhazmi M, Khan J, Gari A, Aldabbagh M, Sakkijha H, Aldalaan A, Alnajashi K, Alhabeeb W, Nizami I, Kouatli A, Chehab M, Tamimi O, Banjar H, Kashour T, Lopes A, Minai O, Hassoun P, Pasha Q, Mayer E, Butrous G, Bhagavathula S, Ghio S, Swiston J, Boueiz A, Tonelli A, Levy RD, Hoeper M, Levy RD. Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates. Ann Thorac Med 2014; 9:S1-S15. [PMID: 25076987 PMCID: PMC4114283 DOI: 10.4103/1817-1737.134006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 11/26/2022] Open
Abstract
The Saudi Association for Pulmonary Hypertension (previously called Saudi Advisory Group for Pulmonary Hypertension) has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008.[1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension (PH). One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH.
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Affiliation(s)
- Majdy M Idrees
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sarfraz Saleemi
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - M Ali Azem
- Department of Critical Care Medicine, King Fahd Medical Center, Dammam, Saudi Arabia
| | - Saleh Aldammas
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Manal Alhazmi
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Javid Khan
- Department of Pulmonary Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdulgafour Gari
- Department of Pulmonary Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Maha Aldabbagh
- Department of Pediatric, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Husam Sakkijha
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Abdulla Aldalaan
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Alnajashi
- Department of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Waleed Alhabeeb
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Imran Nizami
- Department of Organ Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amjad Kouatli
- Department of Pediatric Cardiology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - May Chehab
- Department of Pediatric Intensive Care, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Omar Tamimi
- Department of Pediatric Cardiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanaa Banjar
- Department of Pediatric, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Science, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Antonio Lopes
- Department of Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Omar Minai
- Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Paul Hassoun
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qadar Pasha
- Department of CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Ghazwan Butrous
- Department of Cardiopulmonary science, Imperial College, London, UK
| | | | - Stefano Ghio
- Department of Fondazione IR IRCCS Policlinico San Matteo, Pavia, Italy
| | - John Swiston
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adel Boueiz
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Robert D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marius Hoeper
- Department of Pulmonary Hypertension Program, Hanover Medical School, Hanover, Germany
| | - Rober D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
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Tonelli AR, Conci D, Tamarappoo B, Newman J, Dweik RA. Prognostic value of echocardiographic changes in patients with pulmonary arterial hypertension receiving parenteral prostacyclin therapy. J Am Soc Echocardiogr 2014; 27:733-741.e2. [PMID: 24780356 PMCID: PMC4065815 DOI: 10.1016/j.echo.2014.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is unknown whether the echocardiographic changes observed after treatment of patients with pulmonary arterial hypertension have prognostic value. METHODS Subjects with pulmonary arterial hypertension, confirmed by right heart catheterization, who underwent Doppler echocardiography before (baseline) and after 1 year of treatment (follow-up) with parenteral prostacyclin analogues were retrospectively identified. Echocardiographic parameters were measured offline by two investigators. RESULTS A total of 48 patients were included (mean age, 45 ± 14 years; 83% women). Compared with baseline, follow-up echocardiography showed reductions in right atrial area (mean percentage change, 12 ± 25%; P < .001), right ventricular (RV) basal and middle cavity dimensions (mean percentage change, 8.5 ± 14% [P < .001] and 6.8 ± 17% [P = .005], respectively), and peak tricuspid regurgitant velocity (mean percentage change, 10 ± 14%; P < .001). Tricuspid annular plane systolic excursion (mean percentage change, 36 ± 43%; P < .001) and RV outflow tract time-velocity integral (mean percentage change, 48 ± 66%; P < .001) increased. During a median follow-up period of 52.5 months (interquartile range, 20.5-80 months), 18 patients (37.5%) died, mostly (n = 15 [83%]) from progression of pulmonary arterial hypertension. The changes in RV end-diastolic area (hazard ratio [HR per 10% decrease, 0.73; 95% confidence interval [CI], 0.57-0.93), tricuspid valve regurgitation velocity (HR per 10 cm/sec decrease, 0.58; 95% CI, 0.37-0.89), RV outflow tract velocity-time integral (HR per 10% increase, 0.90; 95% CI, 0.83-0.98), and subjective RV function (HR per 1 unit of improvement [e.g., from moderate to mild], 0.55; 95% CI, 0.31-0.96) were associated with overall mortality. CONCLUSIONS Echocardiographic parameters that estimate RV systolic pressure and assess RV morphology and function improve after 1 year of prostacyclin analogue treatment, and the degree of change has prognostic implications.
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Affiliation(s)
- Adriano R. Tonelli
- Staff, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diego Conci
- Fellow, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Balaji Tamarappoo
- Staff, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jennie Newman
- Nurse, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Director of Pulmonary Vascular Diseases Program, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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48
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Badagliacca R, Poscia R, Pezzuto B, Papa S, Gambardella C, Francone M, Mezzapesa M, Nocioni M, Nona A, Rosati R, Sciomer S, Fedele F, Dario Vizza C. Right ventricular dyssynchrony in idiopathic pulmonary arterial hypertension: determinants and impact on pump function. J Heart Lung Transplant 2014; 34:381-9. [PMID: 25087105 DOI: 10.1016/j.healun.2014.06.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dyssynchrony has been described in pulmonary arterial hypertension (PAH), but no evidence is available on its morphologic determinants and its effect on systolic function. The aim of this study was to evaluate the morphologic determinants of RV dyssynchrony by echocardiographic and cardiac magnetic resonance imaging and its effect on systolic function. METHODS In 60 consecutive idiopathic PAH (IPAH) patients with narrow QRS, RV dyssynchrony was evaluated by 2D speckle-tracking echocardiography, calculating the standard deviation of the times to peak systolic strain for the four mid-basal RV segments (RV-SD4). Patients were grouped by the median value of RV-SD4 (19 milliseconds) and compared for RV remodeling and systolic function parameters, WHO class, pulmonary hemodynamics and 6-minute walk test (6MWT). RESULTS Despite similar pulmonary vascular resistance and mean pulmonary arterial pressure, patients with RV-SD4 at >19 milliseconds had advanced WHO class and worse 6MWT, RV hemodynamics, RV remodeling and systolic function parameters compared with patients at ≤19 milliseconds. The morphologic determinants of RV dyssynchrony resulted RV end-diastolic area, LV diastolic eccentricity index and RV mass volume ratio (r = 0.69, r(2) = 0.47, p < 0.0001). Finally, we found a significant inverse correlation between RV mid-basal segments post-systolic shortening time and cardiac index (r = -0.64, r(2) = 0.41, p = 0.001), accounting for the significant correlation between RV-SD4 and cardiac index (r = 0.57, r(2) = 0.32, p = 0.003). CONCLUSIONS In IPAH with narrow QRS, RV dyssynchrony is associated with RV dilation and eccentric hypertrophy pattern, suggesting a role of segmental wall stress heterogeneity as the major determinant of mechanical delay. Post-systolic shortening, as inefficient contraction, contributes to pump dysfunction.
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Affiliation(s)
| | - Roberto Poscia
- Departments of a?>Cardiovascular and Respiratory Science
| | | | - Silvia Papa
- Departments of a?>Cardiovascular and Respiratory Science
| | | | - Marco Francone
- Radiological Science, Sapienza University of Rome, Rome, Italy
| | | | | | - Alfred Nona
- Departments of a?>Cardiovascular and Respiratory Science
| | - Riccardo Rosati
- Radiological Science, Sapienza University of Rome, Rome, Italy
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49
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Gupta V, Krasuski RA. Inhaled treprostinil sodium for pulmonary hypertension. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.885834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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50
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Shah AM, Campbell P, Rocha GQ, Peacock A, Barst RJ, Quinn D, Solomon SD. Effect of imatinib as add-on therapy on echocardiographic measures of right ventricular function in patients with significant pulmonary arterial hypertension. Eur Heart J 2014; 36:623-32. [PMID: 24566799 DOI: 10.1093/eurheartj/ehu035] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Imatinib mesylate, as add-on therapy in patients with pulmonary arterial hypertension (PAH) who remain inadequately treated despite receiving at least two PAH-specific drugs, improves exercise capacity and haemodynamics. We evaluated whether 24 weeks of add-on therapy with imatinib compared with placebo also improves right ventricular (RV) function assessed by echocardiography. METHODS AND RESULTS Echocardiograms were obtained at baseline, 12 weeks, and 24 weeks in 74 patients randomized to imatinib or placebo in the Imatinib in Pulmonary arterial hypertension, a Randomized Efficacy Study (IMPRES) trial. Right ventricular function was assessed by tissue Doppler tricuspid annular peak systolic velocity (TA S'), tricuspid annular plane systolic excursion (TAPSE), RV Tei index, and RV fractional area change. Between-treatment-group differences in the changes from baseline to week-24 were assessed using an ANCOVA with the last observation carried forward. At week-24 patients randomized to imatinib demonstrated greater improvements in TA S' (1.6 ± 2.3 imatinib vs. 0.5 ± 2.4 cm/s placebo, P = 0.007) and RV Tei index (-0.11 ± 0.18 imatinib vs. 0.05 ± 0.18 placebo, P = 0.005) compared with placebo, but not in TAPSE (0.07 ± 0.44 imatinib vs. 0.03 ± 0.32 cm placebo, P = 0.08). Imatinib therapy was also associated with significant reduction in peak tricuspid regurgitation velocity, increase in LV size, and improvement in LV early diastolic relaxation velocity. CONCLUSIONS Among patients with advanced PAH who remain symptomatic on at least two PAH-specific drugs, treatment with imatinib compared with placebo is associated with significant improvements in echocardiographic measures of RV function, in addition to LV size and LV early diastolic relaxation. CLINICAL TRIAL REGISTRATION NCT00902174 (Clinicaltrials.gov).
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Affiliation(s)
- Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Patricia Campbell
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Gabriela Querejeta Rocha
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Andrew Peacock
- Scottish Pulmonary Vascular Unit, Regional Heart and Lung Centre, Glasgow, UK
| | - Robyn J Barst
- Division of Pediatric Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
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