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Kadoglou NPE, Khattab E, Velidakis N, Gkougkoudi E, Myrianthefs MM. The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension. J Pers Med 2024; 14:474. [PMID: 38793056 PMCID: PMC11122427 DOI: 10.3390/jpm14050474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
The right heart catheterisation constitutes the gold standard for pulmonary hypertension (PH) diagnosis. However, echocardiography remains a reliable, non-invasive, inexpensive, convenient, and easily reproducible modality not only for the preliminary screening of PH but also for PH prognosis. The aim of this review is to describe a cluster of echocardiographic parameters for the detection and prognosis of PH and analyse the challenges of echocardiography implementation in patients with suspected or established PH. The most important echocardiographic index is the calculation of pulmonary arterial systolic pressure (PASP) through the tricuspid regurgitation (TR). It has shown high correlation with invasive measurement of pulmonary pressure, but several drawbacks have questioned its accuracy. Besides this, the right ventricular outflow track acceleration time (RVOT-AT) has been proposed for PH diagnosis. A plethora of echocardiographic indices: right atrial area, pericardial effusion, the tricuspid annular plane systolic excursion (TAPSE), the TAPSE/PASP ratio, tricuspid annular systolic velocity (s'), can reflect the severity and prognosis of PH. Recent advances in echocardiography with 3-dimensional right ventricular (RV) ejection fraction, RV free wall strain and right atrial strain may further assist the prognosis of PH.
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Affiliation(s)
- Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Elina Khattab
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Nikolaos Velidakis
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Evaggelia Gkougkoudi
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Michael M. Myrianthefs
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Huang J, Zhang W, Fu W, Le J, Qi Y, Hou X, Pan X, Li R, He B. Noninvasive evaluation of pulmonary hypertension using the second heart sound parameters collected by a mobile cardiac acoustic monitoring system. Front Cardiovasc Med 2023; 10:1292647. [PMID: 38193021 PMCID: PMC10773866 DOI: 10.3389/fcvm.2023.1292647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
Background Pulmonary hypertension (PH) is linked to higher rates of morbidity and mortality worldwide. Early diagnosis of PH is important for clinical treatment. The estimated pulmonary artery systolic pressure (ePASP ≥ 35 mmHg) measured by echocardiography helps screen PH patients. In this paper, we report a novel PH screening method through a mobile cardiac acoustic monitoring system. Methods In the retrospective study, patients admitted to our hospital between January 2022 and April 2023 were classified into PH and control groups using ePASP and compared with acoustic cardiographic parameters. According to ePASP, PH severity was classified as mild, moderate, and severe. We analyzed the first and second heart sound (S1, S2) characteristics, including amplitude (S1A, S2A), energy (S1E, S2E), and frequency (S1F, S2F). Results The study included 209 subjects, divided into PH (n = 121) and control (n = 88) groups. Pearson correlation analysis confirmed the positive correlation between S2F and ePASP. The diagnostic performance of S2F as assessed by the area under the ROC curve was 0.775 for PH. The sensitivity and specificity of diagnosing ePASP ≥ 35 mmHg when S2F ≥ 36 Hz were found to be 79.34% and 67.05%, respectively, according to ROC analysis. Severity classification was performed using S2F, the area under the ROC curve was 0.712-0.838 for mild PH, 0.774-0.888 for moderate PH, and 0.826-0.940 for severe PH. Conclusions S2F collected by the mobile cardiac acoustic monitoring system offers a convenient method for remote PH screening, potentially improving PH management and outcomes.
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Affiliation(s)
- Jingjuan Huang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiwei Zhang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenxia Fu
- Department of Cardiac Function, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiawei Le
- Department of Cardiac Function, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiding Qi
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xumin Hou
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Pan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruogu Li
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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D'Alto M, Liccardo B, Di Maio M, Del Giudice C, Romeo E, Argiento P, Renon F, Vergara A, Di Vilio A, Caiazza E, Bossone E, Rea G, D'Andrea A, Gargani L, Golino P, Naeije R. Lung Ultrasound, Echocardiography, and Fluid Challenge for the Differential Diagnosis of Pulmonary Hypertension. J Am Soc Echocardiogr 2023; 36:1181-1189. [PMID: 37544385 DOI: 10.1016/j.echo.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES The differential diagnosis between pulmonary arterial hypertension (PAH) and postcapillary pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF) is sometimes difficult despite guidelines-derived standardized step-by-step diagnostic algorithms. We therefore explored the added value of lung ultrasound to a previously validated echocardiographic score of right heart catheterization measurements. METHODS Patients referred for PH underwent a right heart catheterization, echocardiography, and lung ultrasound before and after rapid infusion of 7 mL/kg of saline. A 7-point echocardiographic score based on cardiac chamber dimensions and estimates of filling pressures was implemented for the prediction of precapillary PH. Pulmonary congestion was identified by lung ultrasound B lines. RESULTS The study enrolled 70 patients with PAH and 77 patients with HFpEF. The PAH patients had a higher echocardiographic score (3.5 ± 1.8 vs 1.6 ± 1.5; P < .001). The HFpEF patients had more B lines both before (8.1 ± 4.2 vs 5.1 ± 3.0; P < .001) and after fluid challenge (14.6 ± 5.4 vs 7.6 ± 3.5; P < .001) and a more important increase (Δ) of B lines after fluid challenge (6.5 ± 2.9 vs 2.5 ± 1.6; P < .001). The sensitivity and specificity of the echocardiographic score (cutoff ≥2) alone for PAH were 0.91 and 0.49, respectively (area under the curve of 0.78). The best diagnostic improvement was observed with addition of ΔB lines + E/e' post-fluid challenge to the echocardiographic score, with a significant increase of the area under the curve (0.98) and (with a cutoff given by the presence of echo score ≥2, ΔB lines <4 and E/e' post < 11) a sensitivity of 0.90 (95% CI, 0.83; 0.97) and specificity of 0.84 (95% CI, 0.76; 0.93). CONCLUSIONS Lung ultrasound combined with echocardiography at baseline and after fluid challenge has an incremental value for the differential diagnosis between PAH and PH-HFpEF.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy.
| | - Biagio Liccardo
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Carmen Del Giudice
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Emanuele Romeo
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Paola Argiento
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Francesca Renon
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Andrea Vergara
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Alessandro Di Vilio
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Eleonora Caiazza
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Gaetano Rea
- Radiology Unit, Monaldi Hospital, Naples, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, "Umberto I" Hospital, Nocera Inferiore, Italy
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Paolo Golino
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Robert Naeije
- Department of Pathophysiology, Free University of Bruxelles, Bruxelles, Belgium
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Labrada L, Vaidy A, Vaidya A. Right ventricular assessment in pulmonary hypertension. Curr Opin Pulm Med 2023; 29:348-354. [PMID: 37410491 PMCID: PMC10408730 DOI: 10.1097/mcp.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of assessment of right ventricular function in the context of pulmonary hypertension and pulmonary arterial hypertension (PAH). We will review unique features of right ventricular anatomy, delineation of cause of pulmonary hypertension through careful right ventricular assessment, echocardiographic and hemodynamic evaluation, and the importance of this assessment in prognosis. RECENT FINDINGS The importance of performance in prognosis and risk assessment in patients with pulmonary hypertension has been continually emphasized in ongoing research. Representative parameters of right ventricular function have been shown to be predictive of prognosis in patients with pulmonary hypertension. Further, the importance of serial right ventricular assessment in risk assessment and prognosis has remained an emerging theme. SUMMARY Careful evaluation of right ventricular function is paramount in assessing the cause of pulmonary hypertension and severity of disease. Further, it has prognostic significance, as many representative parameters of right ventricular function have been linked with mortality. In our opinion, right ventricular function should be assessed serially throughout the course of treatment in pulmonary hypertension, and baseline parameters in addition to dynamic changes should be incorporated into risk assessment. Achieving normal or near-normal right ventricular performance may serve as a principal goal in the treatment of pulmonary hypertension.
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Affiliation(s)
- Lyana Labrada
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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Swinnen K, Verstraete K, Baratto C, Hardy L, De Vos M, Topalovic M, Claessen G, Quarck R, Belge C, Vachiery JL, Janssens W, Delcroix M. Machine learning to differentiate pulmonary hypertension due to left heart disease from pulmonary arterial hypertension. ERJ Open Res 2023; 9:00229-2023. [PMID: 37727672 PMCID: PMC10505948 DOI: 10.1183/23120541.00229-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/04/2023] [Indexed: 09/21/2023] Open
Abstract
Background and aims Pulmonary hypertension due to left heart disease (PH-LHD) is the most frequent form of PH. As differential diagnosis with pulmonary arterial hypertension (PAH) has therapeutic implications, it is important to accurately and noninvasively differentiate PH-LHD from PAH before referral to PH centres. The aim was to develop and validate a machine learning (ML) model to improve prediction of PH-LHD in a population of PAH and PH-LHD patients. Methods Noninvasive PH-LHD predictors from 172 PAH and 172 PH-LHD patients from the PH centre database at the University Hospitals of Leuven (Leuven, Belgium) were used to develop an ML model. The Jacobs score was used as performance benchmark. The dataset was split into a training and test set (70:30) and the best model was selected after 10-fold cross-validation on the training dataset (n=240). The final model was externally validated using 165 patients (91 PAH, 74 PH-LHD) from Erasme Hospital (Brussels, Belgium). Results In the internal test dataset (n=104), a random forest-based model correctly diagnosed 70% of PH-LHD patients (sensitivity: n=35/50), with 100% positive predicted value, 78% negative predicted value and 100% specificity. The model outperformed the Jacobs score, which identified 18% (n=9/50) of the patients with PH-LHD without false positives. In external validation, the model had 64% sensitivity at 100% specificity, while the Jacobs score had a sensitivity of 3% for no false positives. Conclusions ML significantly improves the sensitivity of PH-LHD prediction at 100% specificity. Such a model may substantially reduce the number of patients referred for invasive diagnostics without missing PAH diagnoses.
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Affiliation(s)
- Katleen Swinnen
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- These authors contributed equally
| | - Kenneth Verstraete
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
- These authors contributed equally
| | - Claudia Baratto
- Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Laura Hardy
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Maarten De Vos
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Guido Claessen
- Department of Cardiology, University Hospitals of Leuven, Leuven, Belgium
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Catharina Belge
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Jean-Luc Vachiery
- Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Wim Janssens
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
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Vedage NA, Forfia PR, Grafstrom A, Vaidya A. Virtual Echocardiography Screening Tool Identifies Pulmonary Arterial Hypertension Significantly Earlier Than High-Risk Clinical Diagnosis. Am J Cardiol 2023; 201:328-334. [PMID: 37406576 DOI: 10.1016/j.amjcard.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
Pulmonary arterial hypertension (PAH) is often a progressive, fatal disease. Because of nonspecificity of symptoms and limited awareness of PAH, patients are often diagnosed and referred late to accredited pulmonary hypertension (PH) centers, contributing to worsening survival and overall prognosis. The objective of the present study was to determine if the virtual echocardiography screening tool (VEST), a simple scoring system using routinely reported echocardiographic metrics, could capture earlier diagnoses of PAH before clinical recognition and referral to expert PH centers. This study is a retrospective analysis of 132 patients with PAH evaluated consecutively at 2 accredited referral PH centers. VEST scores and time to evaluation at PH center were quantified based on the first available echocardiogram before referral. Clinical risk assessment was calculated at initial evaluation by the PH center using the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) 2.0 calculator. An overwhelming majority (93%) of the study participants had markedly abnormal VEST scores predictive of PAH before evaluation at a PH referral center. The median delay from VEST to evaluation was >6 months at 206 days (quartile 1, quartile 3: 55, 757). At initial evaluation, 72% were intermediate or high-risk based on REVEAL 2.0 risk assessment. In conclusion, we propose that VEST is a powerful yet simple scoring tool that can capture high-risk patients with PAH, prompting earlier diagnosis and referrals to accredited PH centers, and allowing for earlier expert implementation of PH medical therapies.
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Affiliation(s)
- Natasha A Vedage
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Paul R Forfia
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Alexander Grafstrom
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Anjali Vaidya
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
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Abstract
Patients with heart failure (HF) often have pulmonary hypertension (PH), which is mainly post-capillary; however, some of them also develop a pre-capillary component. The exact mechanisms leading to combined pre- and post-capillary PH are not yet clear, but the phenomenon seems to start from a passive transmission of increased pressure from the left heart to the lungs, and then continues with the remodeling of both the alveolar and vascular components through different pathways. More importantly, it is not yet clear which patients are predisposed to develop the disease. These patients have some characteristics similar to those with idiopathic pulmonary arterial hypertension (e.g., young age and frequent incidence in female gender), but they share cardiovascular risk factors with patients with HF (e.g., obesity and diabetes), with both reduced and preserved ejection fraction. Thanks to echocardiography parameters and newly introduced scores, more tools are available to distinguish between idiopathic pulmonary arterial hypertension and combined PH and to guide patients' management. It may be hypothesized to treat patients in whom the pre-capillary component is predominant with specific therapies such as those for idiopathic pulmonary arterial hypertension; however, no adequately powered trials of PH-specific treatment are available in combined PH. Early evidence of clinical benefit has been proven in some trials on phosphodiesterase type 5 inhibitors, while data on prostacyclin analogues, endothelin-1 receptor antagonists, and soluble guanylate cyclase stimulators are still controversial.
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Moles VM, Grafton G. Pulmonary Hypertension in Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:533-540. [DOI: 10.1016/j.ccl.2022.06.007] [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: 11/02/2022]
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Gong C, Guo X, Wan K, Chen C, Chen X, Guo J, He J, Yin L, Wen B, Pu S, Chen Y. Corrected MRI Pulmonary Transit Time for Identification of Combined Precapillary and Postcapillary Pulmonary Hypertension in Patients With Left Heart Disease. J Magn Reson Imaging 2022; 57:1518-1528. [PMID: 37021578 DOI: 10.1002/jmri.28386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The identification of combined precapillary and postcapillary pulmonary hypertension (CpcPH) in patients with pulmonary hypertension (PH) due to left heart disease (LHD) can influence therapy and outcome and is currently based on invasively determined hemodynamic parameters. PURPOSE To investigate the diagnostic value of MRI-derived corrected pulmonary transit time (PTTc) in PH-LHD sub-grouped according to hemodynamic phenotypes. STUDY TYPE Prospective observational study. POPULATION A total of 60 patients with PH-LHD (18 with isolated postcapillary PH [IpcPH] and 42 with CpcPH), and 33 healthy subjects. FIELD STRENGTH/SEQUENCE A 3.0 T/balanced steady-state free precession cine and gradient echo-train echo planar pulse first-pass perfusion. ASSESSMENT In patients, right heart catheterization (RHC) and MRI were performed within 30 days. Pulmonary vascular resistance (PVR) was used as the diagnostic "reference standard." The PTTc was calculated as the time interval between the peaks of the biventricular signal-intensity/time curve and corrected for heart rate. PTTc was compared between patient groups and healthy subjects and its relationship to PVR assessed. The diagnostic accuracy of PTTc for distinguishing IpcPH and CpcPH was determined. STATISTICAL TESTS Student's t-test, Mann-Whitney U-test, linear and logistic regression analysis, and receiver-operating characteristic curves. Significance level: P < 0.05. RESULTS PTTc was significantly prolonged in CpcPH compared with IpcPH and normal controls (17.28 ± 7.67 vs. 8.82 ± 2.55 vs. 6.86 ± 2.11 seconds), and in IpcPH compared with normal controls (8.82 ± 2.55 vs. 6.86 ± 2.11 seconds). Prolonged PTTc was significantly associated with increased PVR. Furthermore, PTTc was a significantly independent predictor of CpcPH (odds ratio: 1.395, 95% confidence interval: 1.071-1.816). The area under curve was 0.852 at a cut-off value of 11.61 seconds for PTTc to distinguish between CpcPH and IpcPH (sensitivity 71.43% and specificity 94.12%). DATA CONCLUSION PTTc may be used to identify CpcPH. Our findings have potential to improve selection for invasive RHC for PH-LHD patients. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Chao Gong
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xinli Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Ke Wan
- Department of Geriatrics, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Chen Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xiaoling Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Jiajun Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Juan He
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Lidan Yin
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Bi Wen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Shoufang Pu
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Yucheng Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
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Reiter G, Kovacs G, Reiter C, Schmidt A, Fuchsjäger M, Olschewski H, Reiter U. Left atrial acceleration factor as a magnetic resonance 4D flow measure of mean pulmonary artery wedge pressure in pulmonary hypertension. Front Cardiovasc Med 2022; 9:972142. [PMID: 35990987 PMCID: PMC9381926 DOI: 10.3389/fcvm.2022.972142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background Mean pulmonary artery wedge pressure (PAWP) represents a right heart catheter (RHC) surrogate measure for mean left atrial (LA) pressure and is crucial for the clinical classification of pulmonary hypertension (PH). Hypothesizing that PAWP is related to acceleration of blood throughout the LA, we investigated whether an adequately introduced LA acceleration factor derived from magnetic resonance (MR) four-dimensional (4D) flow imaging could provide an estimate of PAWP in patients with known or suspected PH. Methods LA 4D flow data of 62 patients with known or suspected PH who underwent RHC and near-term 1.5 T cardiac MR (ClinicalTrials.gov identifier: NCT00575692) were retrospectively analyzed. Early diastolic LA peak outflow velocity (vE) as well as systolic (vS) and early diastolic (vD) LA peak inflow velocities were determined with prototype software to calculate the LA acceleration factor (α) defined as α = vE/[(vS + vD)/2]. Correlation, regression and Bland-Altman analysis were employed to investigate the relationship between α and PAWP, α-based diagnosis of elevated PAWP (>15 mmHg) was analyzed by receiver operating characteristic curve analysis. Results α correlated very strongly with PAWP (r = 0.94). Standard deviation of differences between RHC-derived PAWP and PAWP estimated from linear regression model (α = 0.61 + 0.10·PAWP) was 2.0 mmHg. Employing the linear-regression-derived cut-off α = 2.10, the α-based diagnosis of elevated PAWP revealed the area under the curve 0.97 with sensitivity/specificity 93%/92%. Conclusions The very close relationship between the LA acceleration factor α and RHC-derived PAWP suggests α as potential non-invasive parameter for the estimation of PAWP and the distinction between pre- and post-capillary PH.
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Affiliation(s)
- Gert Reiter
- Research & Development, Siemens Healthcare Diagnostics GmbH, Graz, Austria
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research Graz, Austria
| | - Clemens Reiter
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Albrecht Schmidt
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research Graz, Austria
| | - Ursula Reiter
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
- *Correspondence: Ursula Reiter
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Raza F, Dharmavaram N, Hess T, Dhingra R, Runo J, Chybowski A, Kozitza C, Batra S, Horn EM, Chesler N, Eldridge M. Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E /VCO 2 and ETCO 2 identify pulmonary vascular disease. Clin Cardiol 2022; 45:742-751. [PMID: 35419844 PMCID: PMC9286332 DOI: 10.1002/clc.23831] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management. HYPOTHESIS Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH. METHODS We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant. RESULTS The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2 = 0.70* and ETCO2 = 0.73*. Based on this, optimal thresholds of rest VE /VCO2 > 40 mm Hg and rest ETCO2 < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group. CONCLUSIONS In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2 > 40 mm Hg and ETCO2 < 30 mm Hg) identify PVD.
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Affiliation(s)
- Farhan Raza
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Naga Dharmavaram
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Timothy Hess
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Ravi Dhingra
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - James Runo
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Amy Chybowski
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Callyn Kozitza
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Supria Batra
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Evelyn M. Horn
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Naomi Chesler
- University of California‐Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringIrvineCaliforniaUSA
| | - Marlowe Eldridge
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of PediatricsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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Decreased Peak Left Atrial Longitudinal Strain Is Associated with Persistent Pulmonary Hypertension Associated with Left Heart Disease. J Clin Med 2022; 11:jcm11123510. [PMID: 35743580 PMCID: PMC9225174 DOI: 10.3390/jcm11123510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 02/05/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common form of PH and has significantly higher morbidity and mortality. We estimated the prevalence of PH-LHD on the follow-up echocardiography and the role of left atrial (LA) function in PH-LHD. From the STRATS-AHF registry composed of 4312 acute heart failure (HF) patients, we analyzed peak atrial longitudinal strain (PALS) in 1729 patients with follow-up echocardiographic examinations during mean 18.1 ± 13.5 months. PH was determined by the maximal velocity of tricuspid regurgitation (TR Vmax ≥ 3.4 m/s). Persistent PH was found in 373 patients (21.6%). The PH-LHD group was significantly older, and the prevalence of atrial fibrillation (AF), hypertension, diabetes, and heart failure with preserved ejection fraction were higher compared with the no PH-LHD group. Baseline left ventricular end-systolic volume and PALS were lower, and LA diameter, mitral E/E’ ratio, and TR Vmax were higher in the PH-LHD group. In the multivariate analysis, PALS (HR = 1.024, p = 0.040) was a significant variable after adjustment of LA diameter and mitral E/E’. A decreased PALS of <12.5% was the best cutoff value in the prediction of persistent PH-LHD (AUC = 0.594, sensitivity = 65.3%, specificity = 46.1%). PH-LHD was associated with increased HF hospitalization (HR = 2.344, p < 0.001) and mortality (HR = 2.015, p < 0.001) after adjusting for age and sex. In conclusion, persistent PH-LHD was found in 21.6% in the follow-up echocardiography and was associated with decreased PALS (<12.5%). PH-LHD persistence was associated with poor clinical outcomes. Thus, AHF patients with decreased PALS, especially <12.5%, should be followed with caution.
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Vaidya A, Oliveros E, Mulla W, Feinstein D, Hart L, Forfia P. Management of Pulmonary Arterial Hypertension in Pregnancy: Experience from a Nationally Accredited Center. J Cardiovasc Dev Dis 2022; 9:jcdd9060195. [PMID: 35735823 PMCID: PMC9224797 DOI: 10.3390/jcdd9060195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: In pulmonary arterial hypertension (PAH), pregnancy is regarded a contraindication due to high maternal and fetal morbidity and mortality. We report our experience in the management of pregnancies in PAH. (2) Methods: retrospective observational study in a nationally accredited pulmonary hypertension (PH) center from 2013 to 2021. (3) Results: seven pregnancies in six women with PAH, ranging from low to high risk and 21 to 37 years old. Half had known pre-existing PAH before pregnancy. One had a multifetal gestation, and one was pregnant twice under our care. PH medical therapy and serial clinical assessment throughout pregnancy were implemented with focused attention on optimizing right heart function. Delivery was planned by a multidisciplinary team involving PH cardiology, maternal fetal medicine, and obstetric anesthesiology. Patients delivered between 31 and 40 weeks of gestation; five of the seven were via cesarean section. All received regional anesthesia and were monitored in the PH intermediate step-down unit after delivery until discharge. In all cases, delivery was without complications with excellent outcomes for the mother and child. (4) Conclusions: Multidisciplinary and tailored management of PAH in pregnancy, emphasizing optimized right heart function prior to delivery, can result in excellent clinical outcomes in a referral PH center.
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Affiliation(s)
- Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
- Correspondence: ; Tel.: +1-215-707-7636
| | - Estefania Oliveros
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
| | - Wadia Mulla
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Diana Feinstein
- Obstetric Anesthesiology, Department of Anesthesiology, Temple University Hospital, Philadelphia, PA 19197, USA;
| | - Laura Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
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16
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Stubbs H, MacLellan A, McGettrick M, Jani B, Brewis M, Church C, Johnson M. Predicting Group II pulmonary hypertension: diagnostic accuracy of the H2FPEF and OPTICS scores in Scotland. Open Heart 2022; 9:openhrt-2022-002023. [PMID: 35477699 PMCID: PMC9047890 DOI: 10.1136/openhrt-2022-002023] [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: 03/18/2022] [Accepted: 04/07/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Group II pulmonary hypertension (PH) can be challenging to distinguish from Group I PH without proceeding to right heart catheterisation (RHC). The diagnostic accuracy of the H2FPEF and OPTICS scores was investigated in Scotland. METHODS Patients were included in the study if they were referred to the Scottish Pulmonary Vascular Unit between 2016 and 2020 and subsequently diagnosed with Group II PH or Group I PH which was either idiopathic, heritable or pulmonary veno-occlusive disease. The established cut offs for the H2FPEF and for the OPTICS scores were applied retrospectively to predict the presence of Group II PH. The diagnosis from the scores were compared with the MDT consensus diagnosis following RHC. RESULTS 107 patients with Group I PH and 86 patients with Group II PH were included. Retrospective application of the OPTICS score demonstrated that pretest scoring would detect 28% of cases with Group II PH yet at the cost of misdiagnosing 4% of patients with Group I as Group II PH (specificity 0.96). The H2FPEF score had a far greater sensitivity (0.70) yet reduced specificity (0.91), leading to misdiagnosis of 9% of Group I PH cases. CONCLUSION While the specificity of these scores was high, the lack of perfect specificity limits their utility as it results in missed patients with Group I PH. As a consequence, they cannot replace RHC as the means of diagnosing the aetiology of PH in their current form. The scores may still be used to support clinical judgement or to indicate the advisability for further provocative testing at RHC.
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Affiliation(s)
- Harrison Stubbs
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK .,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Alexander MacLellan
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Michael McGettrick
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Bhautesh Jani
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Melanie Brewis
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin Church
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
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Structural and Hemodynamic Changes of the Right Ventricle in PH-HFpEF. Int J Mol Sci 2022; 23:ijms23094554. [PMID: 35562945 PMCID: PMC9103781 DOI: 10.3390/ijms23094554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022] Open
Abstract
One of the most important diagnostic challenges in clinical practice is the distinction between pulmonary hypertension (PH) due to primitive pulmonary arterial hypertension (PAH) and PH due to left heart diseases. Both conditions share some common characteristics and pathophysiological pathways, making the two processes similar in several aspects. Their diagnostic differentiation is based on hemodynamic data on right heart catheterization, cardiac structural modifications, and therapeutic response. More specifically, PH secondary to heart failure with preserved ejection fraction (HFpEF) shares features with type 1 PH (PAH), especially when the combined pre- and post-capillary form (CpcPH) takes place in advanced stages of the disease. Right ventricular (RV) dysfunction is a common consequence related to worse prognosis and lower survival. This condition has recently been identified with a new classification based on clinical signs and progression markers. The role and prevalence of PH and RV dysfunction in HFpEF remain poorly identified, with wide variability in the literature reported from the largest clinical trials. Different parenchymal and vascular alterations affect the two diseases. Capillaries and arteriole vasoconstriction, vascular obliteration, and pulmonary blood fluid redistribution from the basal to the apical district are typical manifestations of type 1 PH. Conversely, PH related to HFpEF is primarily due to an increase of venules/capillaries parietal fibrosis, extracellular matrix deposition, and myocyte hypertrophy with a secondary “arteriolarization” of the vessels. Since the development of structural changes and the therapeutic target substantially differ, a better understanding of pathobiological processes underneath PH-HFpEF, and the identification of potential maladaptive RV mechanisms with an appropriate diagnostic tool, become mandatory in order to distinguish and manage these two similar forms of pulmonary hypertension.
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18
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Albani S, Stolfo D, Venkateshvaran A, Chubuchny V, Biondi F, De Luca A, Lo Giudice F, Pasanisi EM, Petersen C, Airò E, Bauleo C, Ciardetti M, Coceani M, Formichi B, Spiesshoefer J, Savarese G, Lund LH, Emdin M, Sinagra G, Manouras A, Giannoni A. Echocardiographic Biventricular Coupling Index to Predict Pre-Capillary Pulmonary Hypertension. J Am Soc Echocardiogr 2022; 35:715-726. [DOI: 10.1016/j.echo.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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19
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Luongo F, Miotti C, Scoccia G, Papa S, Manzi G, Cedrone N, Toto F, Malerba C, Papa G, Caputo A, Manguso G, Adamo F, Carmine DV, Badagliacca R. Future perspective in diabetic patients with pre- and post-capillary pulmonary hypertension. Heart Fail Rev 2022; 28:745-755. [PMID: 35098382 DOI: 10.1007/s10741-021-10208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/24/2022]
Abstract
Pulmonary hypertension is a clinical syndrome that may include multiple clinical conditions and can complicate the majority of cardiovascular and respiratory diseases. Pulmonary hypertension secondary to left heart disease is the prevalent clinical condition and accounts for two-thirds of all cases. Type 2 diabetes mellitus, which affects about 422 million adults worldwide, has emerged as an independent risk factor for the development of pulmonary hypertension in patients with left heart failure. While a correct diagnosis of pulmonary hypertension secondary to left heart disease requires invasive hemodynamic evaluation through right heart catheterization, several scores integrating clinical and echocardiographic parameters have been proposed to discriminate pre- and post-capillary types of pulmonary hypertension. Despite new emerging evidence on the pathophysiological mechanisms behind the effects of diabetes in patients with pre- and/or post-capillary pulmonary hypertension, no specific drug has been yet approved for this group of patients. In the last few years, the attention has been focused on the role of antidiabetic drugs in patients with pulmonary hypertension secondary to left heart failure, both in animal models and in clinical trials. The aim of the present review is to highlight the links emerged in the recent years between diabetes and pre- and/or post-capillary pulmonary hypertension and new perspectives for antidiabetic drugs in this setting.
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Affiliation(s)
- Federico Luongo
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Cristiano Miotti
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Gianmarco Scoccia
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Nadia Cedrone
- Internal Medicine Department, S. Pertini Hospital, Via dei Monti Tiburtini, 385, 00157, Roma RM. Rome, Italy
| | - Federica Toto
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Claudia Malerba
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Gennaro Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Annalisa Caputo
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Giulia Manguso
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Francesca Adamo
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Dario Vizza Carmine
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy.
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Maron BA, Choudhary G, Goldstein RL, Garshick E, Jankowich M, Tucker TJS, LaCerda KA, Hattler B, Dempsey EC, Sadikot RT, Shapiro S, Rounds SI, Goldstein RH. Tadalafil for veterans with chronic obstructive pulmonary disease-pulmonary hypertension: A multicenter, placebo-controlled randomized trial. Pulm Circ 2022; 12:e12043. [PMID: 35506072 PMCID: PMC9053004 DOI: 10.1002/pul2.12043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022] Open
Abstract
Treating Veterans with chronic obstructive pulmonary disease complicated by pulmonary hypertension (COPD-PH) using phosphodiesterase type-5 inhibitor pharmacotherapy is common, but efficacy data are lacking. To address this further, patients with COPD-PH from five Department of Veterans Affairs hospitals were randomized (1∶1) to receive placebo or oral tadalafil (40 mg/day) for 12 months. The primary endpoint was changed from baseline in 6-min walk distance at 12 months. Secondary endpoints included change from baseline in pulmonary vascular resistance, mean pulmonary artery pressure, and symptom burden by the University of California San Diego shortness of breath questionnaire scale at 6 months. A total of 42 subjects (all male; 68 ± 7.6 years old) were randomized to placebo (N = 14) or tadalafil (N = 28). The group imbalance was related to under-enrollment. Compared to placebo, no significant difference was observed in the tadalafil group for change from the primary endpoint or change in mean pulmonary artery pressure or pulmonary vascular resistance from baseline at 6 months. A clinically meaningful improvement was observed in the secondary endpoint of shortness of breath questionnaire score in the tadalafil versus placebo group at 6 months. There was no significant difference in major adverse events between treatment groups, and tadalafil was well tolerated overall. For Veterans with COPD-PH enrolled in this study, once-daily treatment with tadalafil did not improve 6-min walk distance or cardiopulmonary hemodynamics although a decrease in shortness of breath was observed. Under-enrollment and imbalanced randomization confound interpreting conclusions from this clinical trial and limit the generalization of our findings.
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Affiliation(s)
- Bradley A. Maron
- Department of Medicine, Section of Cardiology and Division of Pulmonary, Allergy, Sleep, and Critical Care MedicineVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Division of Cardiovascular MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Gaurav Choudhary
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Rebekah L. Goldstein
- Research and Development ServiceVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Eric Garshick
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Jankowich
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Troo J. S. Tucker
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Kathleen A. LaCerda
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Brack Hattler
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
| | - Edward C. Dempsey
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
- Pulmonary Sciences and Critical Care Medicine SectionUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Ruxana T. Sadikot
- Department of MedicineAtlanta Veterans Affairs Medical CenterDecaturGeorgiaUSA
| | - Shelley Shapiro
- Department of Cardiology, Cardiology Section Greater Los AngelesVA Healthcare SystemLos AngelesCaliforniaUSA
- Division of Pulmonary Critical CareDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Sharon I. Rounds
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Ronald H. Goldstein
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Department of MedicineBoston University School of MedicineBostonMassachusettsUSA
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21
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Edmonston DL, Matsouaka R, Shah SH, Rajagopal S, Wolf M. Noninvasive Risk Score to Screen for Pulmonary Hypertension With Elevated Pulmonary Vascular Resistance in Diseases of Chronic Volume Overload. Am J Cardiol 2021; 159:113-120. [PMID: 34497006 PMCID: PMC10153469 DOI: 10.1016/j.amjcard.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Volume overload promotes pulmonary hypertension (PH) through pulmonary venous hypertension. However, PH with elevated pulmonary vascular resistance (hereafter PH-PVR) may develop in patients with diseases of volume overload, such as heart failure or chronic kidney disease (CKD). In such cases, volume management alone may be insufficient to slow PH progression. An accurate, noninvasive method to screen for PH-PVR in these diseases would facilitate early targeted therapy. We integrated invasive hemodynamic and echocardiography data collected from a single-center clinical cohort and identified patients with CKD or heart failure at the time of assessment. We applied penalized regression to derive a risk score of clinical parameters and echocardiography data associated with PH-PVR and categorized patients into low- (≤5 points), intermediate- (6-10 points), or high-risk (>10 points) groups. Using an internal validation strategy, we evaluated the ability of this risk score to predict PH-PVR and determined the association of this risk classification with 3-year all-cause mortality. Of 2422 patients, 42.4% had PH-PVR. In adjusted analyses, tricuspid regurgitant velocity, right ventricular function, BMI, heart rate, and hemoglobin most strongly associated with PH-PVR. The risk score significantly associated with PH-PVR (age-adjusted odds ratio 11.69 for the highest-risk group, 95% confidence interval [CI] 6.54-20.92). The high-risk group also associated with a significantly higher risk of 3-year all-cause mortality in adjusted analyses (hazard ratio 1.85, 95% CI 1.50-2.27). In conclusion, a noninvasive risk score derived from echocardiography and clinical parameters significantly associated with PH-PVR and all-cause mortality in a cohort of patients with CKD and heart failure.
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22
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Cardiac acoustic biomarkers as surrogate markers to diagnose the phenotypes of pulmonary hypertension: an exploratory study. Heart Vessels 2021; 37:593-600. [PMID: 34599380 PMCID: PMC8917031 DOI: 10.1007/s00380-021-01943-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022]
Abstract
Pulmonary hypertension (PH) is commonly associated with left heart disease. In this retrospective study, using the database of a clinical study conducted between January 2008 and July 2008, the phenotypes of PH were classified using non-invasive cardiac acoustic biomarkers (CABs) and compared with classification by echocardiography. Records with same-day measurement of acoustic cardiography and right heart catheterization (RHC) parameters were included; cases with congenital heart disease were excluded. Using the RHC measurements, PH was classified as pre-capillary PH (Prec-PH), isolated post-capillary PH (Ipc-PH), and combined pre-capillary and post-capillary PH (Cpc-PH). The first, second, third, and fourth heart sounds (S1, S2, S3, and S4) were quantified as CABs (intensity, complexity, and strength). Forty subjects were selected: 5 had Prec-PH, 5 had Ipc-PH, 8 had Cpc-PH, and 22 had No-PH. CABs were significantly correlated with RHC measurements, with significant differences among phenotypes. Phenotype classification was performed using various CABs, and the diagnostic performance as assessed by the area under the receiver operating characteristic curve was 0.674–0.720 for Prec-PH, 0.657–0.807 for Ipc-PH, and 0.742 for Cpc-PH. High negative and low positive predictive values for phenotype identification were observed. CABs may provide an ambulatory measurement method with home-monitoring friendliness which is more convenient than standard examinations to identify presence of PH and its phenotypes.
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Airale L, Vallelonga F, Forni T, Leone D, Magnino C, Avenatti E, Iannaccone A, Astarita A, Mingrone G, Cesareo M, Giordana C, Omedè P, Moretti C, Veglio F, Pedrizzetti G, Milan A. A Novel Approach to Left Ventricular Filling Pressure Assessment: The Role of Hemodynamic Forces Analysis. Front Cardiovasc Med 2021; 8:704909. [PMID: 34568448 PMCID: PMC8455914 DOI: 10.3389/fcvm.2021.704909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Diastolic function in patients with heart failure is usually impaired, resulting in increased left ventricular (LV) filling pressures, whose gold standard assessment is right heart catheterization (RHC). Hemodynamic force (HDF) analysis is a novel echocardiographic tool, providing an original approach to cardiac function assessment through the speckle-tracking technology. The aim of our study was to evaluate the use of HDFs, both alone and included in a new predictive model, as a potential novel diagnostic tool of the diastolic function. Methods: HDF analysis was retrospectively performed in 67 patients enrolled in the “Right1 study.” All patients underwent RHC and echocardiography up to 2 h apart. Increased LV filling pressure (ILFP) was defined as pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg. Results: Out of 67 patients, 33 (49.2%) showed ILFP at RHC. Diastolic longitudinal force (DLF), the mean amplitude of longitudinal forces during diastole, was associated with the presence of ILFP (OR = 0.84 [0.70; 0.99], p = 0.046). The PCWP prediction score we built including DLF, ejection fraction, left atrial enlargement, and e' septal showed an AUC of 0.83 [0.76–0.89], with an optimal internal validation. When applied to our population, the score showed a sensitivity of 72.7% and a specificity of 85.3%, which became 66.7 and 94.4%, respectively, when applied to patients classified with “indeterminate diastolic function” according to the current recommendations. Conclusion: HDF analysis could be an additional useful tool in diastolic function assessment. A scoring system including HDFs might improve echocardiographic accuracy in estimating LV filling pressures. Further carefully designed studies could be useful to clarify the additional value of this new technology.
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Affiliation(s)
- Lorenzo Airale
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Fabrizio Vallelonga
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Tommaso Forni
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Dario Leone
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Corrado Magnino
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Eleonora Avenatti
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Andrea Iannaccone
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Anna Astarita
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Giulia Mingrone
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Marco Cesareo
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Carlo Giordana
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Pierluigi Omedè
- Hemodynamic Laboratory, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Claudio Moretti
- Hemodynamic Laboratory, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Franco Veglio
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Gianni Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Alberto Milan
- Internal Medicine and Hypertension Division, Department of Medical Sciences, Azienda Ospedaliera Universitaria (AOU) "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
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24
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Fontes Oliveira M, Oliveira MI, Furtado I, Carvalho L, Gonçalves F, Reis A, Santos M. External validation of different clinical and echocardiographic scores to distinguish post- from precapillary pulmonary hypertension. Echocardiography 2021; 38:1558-1566. [PMID: 34355812 DOI: 10.1111/echo.15172] [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: 02/07/2021] [Revised: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Even though right heart catheterization (RHC) is the gold-standard method to characterise Pulmonary Hypertension (PH), it cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to differentiate PH secondary to heart failure with preserved ejection fraction (PH-HFpEF) from pre-capillary PH. We aimed to compare the performance of non-invasive parameters in a population with suspected PH. METHODS We retrospectively included consecutive patients who underwent RHC for suspected PH. Patients with a non-invasive evaluation clearly suggestive of left heart disease were excluded. We assessed the performance of non-invasive pulmonary vascular resistance (PVR), echocardiographic pulmonary to left atrial ratio (ePLAR), and Opotowsky, Richter, Berthelot, and D'Alto scores using the area under curve (AUC) of the receiver operating characteristic curves. RESULTS Of the 142 included patients, 61 patients had pre-capillary PH, 49 had PH-HFpEF, and 32 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in 71-100% of our patients. Using the original cut-offs, Opotowsky was the score that best predicted precapillary PH (96% sensitivity, 41% specificity, AUC .69), followed by D'Alto (98% sensitivity, 22% specificity, AUC .60) and Berthelot (32% sensitivity, 90% specificity, AUC .60). Richter score did not discriminate between phenotypes (AUC .50). Using optimised cut-offs, a Berthelot score < 9 predicted precapillary PH with 73% sensitivity and 74% specificity (AUC .73). Single echocardiographic parameters as non-invasive PVR (85% sensitivity, 59% specificity, AUC .72) and ePLAR (73% sensitivity, 76% specificity, AUC .75) showed better prediction performance than the composite studied scores. CONCLUSION Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with moderate performance. The application of these non-invasive parameters in clinical practice can help refine referral to RHC in a population with clinically suspected PH.
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Affiliation(s)
- Marta Fontes Oliveira
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Maria Isilda Oliveira
- Centre of Physical Activity, Health and Leisure, Faculdade de Desporto da Universidade do Porto, R. Dr. Plácido da Costa 91, Porto, Portugal
| | - Inês Furtado
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Luísa Carvalho
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Fabienne Gonçalves
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Abílio Reis
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Mário Santos
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal.,Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
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25
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Maron BA, Abman SH, Elliott CG, Frantz RP, Hopper RK, Horn EM, Nicolls MR, Shlobin OA, Shah SJ, Kovacs G, Olschewski H, Rosenzweig EB. Pulmonary Arterial Hypertension: Diagnosis, Treatment, and Novel Advances. Am J Respir Crit Care Med 2021; 203:1472-1487. [PMID: 33861689 PMCID: PMC8483220 DOI: 10.1164/rccm.202012-4317so] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The diagnosis and management of pulmonary arterial hypertension (PAH) includes several advances, such as a broader recognition of extrapulmonary vascular organ system involvement, validated point-of-care clinical assessment tools, and focus on the early initiation of multiple pharmacotherapeutics in appropriate patients. Indeed, a principal goal in PAH today is an early diagnosis for prompt initiation of treatment to achieve a minimal symptom burden; optimize the patient's biochemical, hemodynamic, and functional profile; and limit adverse events. To accomplish this end, clinicians must be familiar with novel risk factors and the revised hemodynamic definition for PAH. Fresh insights into the role of developmental biology (i.e., perinatal health) may also be useful for predicting incident PAH in early adulthood. Emergent or underused approaches to PAH management include a novel TGF-β ligand trap pharmacotherapy, remote pulmonary arterial pressure monitoring, next-generation imaging using inert gas-based magnetic resonance and other technologies, right atrial pacing, and pulmonary arterial denervation. These and other PAH state of the art advances are summarized here for the wider pulmonary medicine community.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Steven H Abman
- Section of Pulmonary Medicine, Children's Hospital Colorado and the University of Colorado Anschutz Medical Center, University of Colorado, Aurora, Colorado
| | - C Greg Elliott
- Intermountain Medical Center and the University of Utah, Salt Lake City, Utah
| | - Robert P Frantz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Rachel K Hopper
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Graduate School of Medical Sciences, Cornell University, New York, New York
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System and School of Medicine, Stanford University, Stanford, California
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Horst Olschewski
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Erika B Rosenzweig
- Department of Pediatrics and.,Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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26
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Maeder MT, Weber L, Buser M, Brenner R, Joerg L, Rickli H. Pulmonary Hypertension in Patients With Heart Failure With Mid-Range Ejection Fraction. Front Cardiovasc Med 2021; 8:694240. [PMID: 34307506 PMCID: PMC8298862 DOI: 10.3389/fcvm.2021.694240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is common in patients with heart failure (HF). The role of PH in patients with HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) has been extensively characterized during the last years. In contrast, the pathophysiology of HF with mid-range LVEF (HFmrEF), and in particular the role of PH in this context, are largely unknown. There is a paucity of data in this field, and the prevalence of PH, the underlying mechanisms, and the optimal therapy are not well-defined. Although often studied together there is increasing evidence that despite similarities with both HFrEF and HFpEF, HFmrEF also differs from both entities. The present review provides a summary of the current concepts of the mechanisms and clinical impact of PH in patients with HFmrEF, a proposal for the non-invasive and invasive diagnostic approach required to define the pathophysiology of PH and its management, and a discussion of future directions based on insights from mechanistic studies and randomized trials. We also provide an outlook regarding gaps in evidence, future clinical challenges, and research opportunities.
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Affiliation(s)
- Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lukas Weber
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marc Buser
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roman Brenner
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lucas Joerg
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
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27
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Vasilev V, Popovic D, Ristic GG, Arena R, Radunovic G, Ristic A. H 2 FPEF score predicts atherosclerosis presence in patients with systemic connective tissue disease. Clin Cardiol 2021; 44:946-954. [PMID: 34075600 PMCID: PMC8259163 DOI: 10.1002/clc.23621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/17/2021] [Accepted: 04/27/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are common cause of morbidity and mortality in patients with systemic connective tissue diseases (SCTD) due to accelerated atherosclerosis which couldn't be explained by traditional risk factors (CVDRF). HYPOTHESIS We hypothesized that recently developed score predicting probability of heart failure with preserved ejection fraction (H2 FPEF), as well as a measure of right ventricular-pulmonary vasculature coupling [tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio], are predictive of atherosclerosis in SCTD. METHODS 203 patients (178 females) diagnosed with SCTD underwent standard and stress-echocardiography (SE) with TAPSE/PASP and left ventricular (LV) diastolic filling pressure (E/e') measurements, carotid ultrasound and computed tomographic coronary angiography. Patients who were SE positive for ischemia underwent coronary angiography (34/203). The H2 FPEF score was calculated according to age, body mass index, presence of atrial fibrillation, ≥2 antihypertensives, E/e' and PASP. RESULTS Mean LV ejection fraction was 66.3 ± 7.1%. Atherosclerosis was present in 150/203 patients according to: 1) intima-media thickness>0.9 mm; and 2) Agatstone score > 300 or Syntax score ≥ 1. On binary logistic regression analysis, including CVDRF prevalence, echocardiographic parameters and H2 FPEF score, only H2 FPEF score remained significant for the prediction of atherosclerosis presence (χ2 = 19.3, HR 2.6, CI 1.5-4.3, p < 0.001), and resting TAPSE/PASP for the prediction of a SE positive for ischemia (χ2 = 10.4, HR 0.01, CI = 0.01-0.22, p = 0.004). On ROC analysis, the optimal threshold value for identifying patients with atherosclerosis was a H2 FPEF score ≥2 (Sn 60.4%, Sp 69.4%, area 0.67, SE = 0.05, p < 0.001). CONCLUSIONS H2 FPEF score and resting TAPSE/PASP demonstrated clinical value for an atherosclerosis diagnosis in patients diagnosed with SCTD.
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Affiliation(s)
| | - Dejana Popovic
- Division of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Gorica G Ristic
- Department of Rheumatology and Clinical Immunology, Military Medical Academy and Medical Faculty of the Belgrade Defence University, Belgrade, Serbia
| | - Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Goran Radunovic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Rheumatology, Belgrade, Serbia
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Division of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
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28
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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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29
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Kanwar MK, Tedford RJ, Thenappan T, De Marco T, Park M, McLaughlin V. Elevated Pulmonary Pressure Noted on Echocardiogram: A Simplified Approach to Next Steps. J Am Heart Assoc 2021; 10:e017684. [PMID: 33719491 PMCID: PMC8174323 DOI: 10.1161/jaha.120.017684] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
An elevated right ventricular/pulmonary artery systolic pressure suggestive of pulmonary hypertension (PH) is a common finding noted on echocardiography and is considered a marker for poor clinical outcomes, regardless of the cause. Even mild elevation of pulmonary pressure can be considered a modifiable risk factor, informing the trajectory of patients' clinical outcome. Although guidelines have been published detailing diagnostic and management algorithms, this echocardiographic finding is often underappreciated or not acted upon. Hence, patients with PH are often diagnosed in clinical practice when hemodynamic abnormalities are already moderate or severe. This results in delayed initiation of potentially effective therapies, referral to PH centers, and greater patient morbidity and mortality. This mini‐review presents a succinct, simplified case‐based approach to the “next steps” in the work‐up of PH, once elevated pulmonary pressures have been noted on an echocardiogram. Our goal is for clinicians to develop a good overview of diagnostic approach to PH and recognition of high‐risk features that may require early referral.
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Affiliation(s)
| | - Ryan J Tedford
- Department of Medicine Medical University of South Carolina Charleston SC
| | | | | | - Myung Park
- Cardiovascular Disease CHI Franciscan Tacoma WA
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30
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Cardiopulmonary Hemodynamics in Pulmonary Hypertension and Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:2671-2681. [PMID: 33243385 DOI: 10.1016/j.jacc.2020.10.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension (PH) is an independent risk factor for adverse clinical outcome, particularly in left heart disease (LHD) patients. Recent advances have clarified the mean pulmonary artery pressure (mPAP) range that is above normal and is associated with clinical events, including mortality. This progress has for the first time resulted in a new clinical definition of PH that is evidenced-based, is inclusive of mPAP >20 mm Hg, and emphasizes early diagnosis. Additionally, pulmonary vascular resistance (PVR) 2.2 to 3.0 WU, considered previously to be normal, appears to associate with elevated clinical risk. A revised approach to classifying PH patients as pre-capillary, isolated post-capillary, or combined pre-/post-capillary PH now guides point-of-care diagnosis, risk stratification, and treatment. Exercise hemodynamic or confrontational fluid challenge studies may also aid decision-making for patients with PH-LHD or otherwise unexplained dyspnea. This collective progress in pulmonary vascular and heart failure medicine reinforces the critical importance of accurate hemodynamic assessment.
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31
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Chubuchny V, Pugliese NR, Taddei C, Poggianti E, Spini V, Barison A, Formichi B, Airò E, Bauleo C, Prediletto R, Pastormerlo LE, Coceani M, Ciardetti M, Petersen C, Pasanisi E, Lombardi C, Emdin M, Giannoni A. A novel echocardiographic method for estimation of pulmonary artery wedge pressure and pulmonary vascular resistance. ESC Heart Fail 2021; 8:1216-1229. [PMID: 33566429 PMCID: PMC8006655 DOI: 10.1002/ehf2.13183] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/26/2020] [Accepted: 12/03/2020] [Indexed: 01/28/2023] Open
Abstract
Aims This study aimed to evaluate a novel echocardiographic algorithm for quantitative estimation of pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance (PVR) in patients with heart failure and pulmonary hypertension (PH) scheduled to right heart catheterization (RHC). Methods and results In this monocentric study, 795 consecutive patients (427 men; age 68.4 ± 12.1 years) undergoing echocardiography and RHC were evaluated. Multiple regression analysis was performed to identify echocardiographic predictors of PAWP and PVR measured by RHC in the derivation group (the first 200 patients). The diagnostic accuracy of the model was then tested in the validation group (the remaining 595 patients). PH was confirmed by RHC in 507 (63.8%) patients, with 192 (24.2%) cases of precapillary PH, 248 (31.2%) of postcapillary PH, and 67 (8.4%) of combined PH. At regression analysis, tricuspid regurgitation maximal velocity, mitral E/e′ ratio, left ventricular ejection fraction, right ventricular fractional area change, inferior vena cava diameter, and left atrial volume index were included in the model (R = 0.8, P < 0.001). The model showed a high diagnostic accuracy in estimating elevated PAWP (area under the receiver operating characteristic curve = 0.97, 92% sensitivity, and 93% specificity, P < 0.001) and PVR (area under the receiver operating characteristic curve = 0.96, 89% sensitivity, and 92% specificity, P < 0.001), outperforming 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations (P < 0.001) and Abbas' equation (P < 0.001). Bland–Altman analysis showed satisfactory limits of agreement between echocardiography and RHC for PAWP (bias 0.7, 95% confidence interval −7.3 to 8.7) and PVR (bias −0.1, 95% confidence interval −2.2 to 1.9 Wood units), without indeterminate cases. Conclusions A novel quantitative echocardiographic approach for the estimation of PAWP and PVR has high diagnostic accuracy in patients with heart failure and PH.
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Affiliation(s)
- Vladislav Chubuchny
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | | | - Claudia Taddei
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Elisa Poggianti
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Valentina Spini
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Andrea Barison
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, 56127, Italy
| | - Bruno Formichi
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy.,CNR Institute of Clinical Physiology, Pisa, Italy
| | - Edoardo Airò
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Carolina Bauleo
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Renato Prediletto
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy.,CNR Institute of Clinical Physiology, Pisa, Italy
| | - Luigi Emilio Pastormerlo
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Michele Coceani
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Marco Ciardetti
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Christina Petersen
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Emilio Pasanisi
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Carlo Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Michele Emdin
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, 56127, Italy
| | - Alberto Giannoni
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, Pisa, 56127, Italy
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Chiba Y, Iwano H, Kaga S, Shinkawa M, Murayama M, Ohira H, Ishizaka S, Sarashina M, Tsujinaga S, Yokoyama S, Nakabachi M, Nishino H, Okada K, Kamiya K, Nagai T, Anzai T. Influence of advanced pulmonary vascular remodeling on accuracy of echocardiographic parameters of left ventricular filling pressure. Pulm Circ 2021; 11:2045894020983723. [PMID: 33532058 PMCID: PMC7829463 DOI: 10.1177/2045894020983723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/07/2020] [Indexed: 01/20/2023] Open
Abstract
Evaluation of left ventricular filling pressure plays an important role in the
clinical management of pulmonary hypertension. However, the accuracy of
echocardiographic parameters for the determination of left ventricular filling
pressure in the presence of pulmonary vascular lesions has not been fully
addressed. We retrospectively investigated 124 patients with pulmonary
hypertension due to pulmonary vascular lesions (noncardiac pulmonary
hypertension group) and 113 patients with ischemic heart disease (control group)
who underwent right heart catheterization and echocardiography. The noncardiac
pulmonary hypertension group was subdivided into less-advanced and advanced
groups according to median pulmonary vascular resistance. Pulmonary artery wedge
pressure was determined as left ventricular filling pressure. As
echocardiographic parameters of left ventricular filling pressure, the ratio of
early- (E) to late-diastolic transmitral flow velocity (E/A), ratio of E to
early-diastolic mitral annular velocity (E/e′), and left atrial volume index
were measured. In the less-advanced noncardiac pulmonary hypertension and
control groups, positive correlations were observed between pulmonary artery
wedge pressure and late-diastolic transmitral flow velocity
(R = 0.41, P = 0.002 and
R = 0.71, P < 0.001, respectively) and left
atrial volume index (R = 0.53, P < 0.001
and R = 0.41, P < 0.001), whereas in the
advanced noncardiac pulmonary hypertension group, pulmonary artery wedge
pressure was only correlated with left atrial volume index
(R = 0.27, P = 0.032). In the controls, only
pulmonary artery wedge pressure determined E (β = 0.48,
P < 0.001), whereas both pulmonary artery wedge pressure and
pulmonary vascular resistance were independent determinants of E (β = 0.29,
P < 0.001 and β = –0.28, P = 0.001,
respectively) in the noncardiac pulmonary hypertension group. In conclusion, in
the presence of advanced pulmonary vascular lesions, conventional
echocardiographic parameters may not accurately reflect left ventricular filling
pressure. Elevated pulmonary vascular resistance would lower the E, even when
pulmonary artery wedge pressure is elevated, resulting in blunting of
echocardiographic parameters for the detection of elevated left ventricular
filling pressure.
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Affiliation(s)
- Yasuyuki Chiba
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Iwano
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Sanae Kaga
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Mio Shinkawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Michito Murayama
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Ohira
- Faculty of Medicine and Graduate School of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Suguru Ishizaka
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Miwa Sarashina
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Shingo Tsujinaga
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Shinobu Yokoyama
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Masahiro Nakabachi
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Hisao Nishino
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kazunori Okada
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Faculty of Medicine and Graduate School of Medicine, Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
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Költő G, Tőkés-Füzesi M, Papp E, Adravetz Z, Komócsi A, Egyed M, Faludi R. Screening for precapillary pulmonary hypertension in chronic myeloproliferative disorders: the role of N-terminal pro-B-type natriuretic peptide and vascular endothelial growth factor - a pilot study. Arch Med Sci 2021; 17:1628-1635. [PMID: 34900042 PMCID: PMC8641504 DOI: 10.5114/aoms.2020.93315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Precapillary pulmonary hypertension (PH) implies a worse prognosis in myeloproliferative neoplasms (MPN). N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in cardiopulmonary involvement. In MPN patients with precapillary PH, elevated vascular endothelial growth factor (VEGF) values, but in left heart (LH) disease patients, decreased values were reported. Our aim was to determine whether a combination of NT-proBNP and VEGF is suitable for the detection of the precapillary forms of PH in MPN patients. MATERIAL AND METHODS Eighty-one MPN patients were investigated. Pulmonary hypertension was defined as Doppler-derived systolic pulmonary artery pressure (sPAP) ≥ 40 mm Hg. Patient groups with cardiopulmonary involvement (precapillary PH, PH due to LH disease, left ventricular ejection fraction < 50%, atrial fibrillation) or LH disease (PH due to LH disease, left ventricular ejection fraction < 50%, atrial fibrillation) were identified. RESULTS In 9 patients PH was associated with LH disease. In 2 patients precapillary PH was found with extremely high NT-proBNP values. NT-proBNP significantly correlated with sPAP (r = 0.550; p < 0.001). NT-proBNP ≥ 466 pg/ml was the best predictor of cardiopulmonary involvement (AUC: 0.962, sensitivity: 86.7%, specificity: 93.9%). No correlation was found between VEGF levels and sPAP values. VEGF ≤ 431 pg/ml was the best predictor of LH disease (AUC: 0.609, sensitivity: 76.9%, specificity: 62.7%). CONCLUSIONS NT-proBNP levels reflect cardiopulmonary involvement with high accuracy, but the combination of NT-proBNP and VEGF is not suitable for the detection of precapillary PH as the diagnostic power of VEGF is limited. Highly elevated NT-proBNP levels may suggest precapillary PH but further investigation is necessary for the exclusion of LH disease or atrial fibrillation.
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Affiliation(s)
- Gyöngyvér Költő
- Department of Cardiology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Margit Tőkés-Füzesi
- Department of Laboratory Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Előd Papp
- Department of Cardiology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- Department of Internal Medicine, Szent Lukács Hospital, Dombóvár, Hungary
| | - Zsófia Adravetz
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Miklós Egyed
- Department of Hematology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Réka Faludi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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Implications of Elevated Pulmonary Artery Pressure for Transcatheter Mitral Repair: Time for Comprehensive Hemodynamic Investigation. J Am Coll Cardiol 2020; 76:2607-2610. [PMID: 33243381 DOI: 10.1016/j.jacc.2020.09.604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/29/2020] [Indexed: 11/20/2022]
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Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
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Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
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Mandras SA, Mehta HS, Vaidya A. Pulmonary Hypertension: A Brief Guide for Clinicians. Mayo Clin Proc 2020; 95:1978-1988. [PMID: 32861339 DOI: 10.1016/j.mayocp.2020.04.039] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/03/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022]
Abstract
Pulmonary hypertension (PH) is classified into 5 clinical subgroups: pulmonary arterial hypertension (PAH), PH due to left-sided heart disease, PH due to chronic lung disease, chronic thromboembolic PH (CTEPH), and PH with an unclear and/or multifactorial mechanisms. A range of underlying conditions can lead to these disorders. Overall, PH affects approximately 1% of the global population, and over half of patients with heart failure may be affected. Cardiologists are therefore likely to encounter PH in their practice. Routine tests in patients with symptoms and physical findings suggestive of PH include electrocardiography, chest radiography, and pulmonary function tests. Transthoracic echocardiography is used to estimate the probability of PH. All patients with suspected or confirmed PH, without confirmed left-sided heart or lung diseases, should have a ventilation-perfusion scan to exclude CTEPH. Right-sided heart catheterization is essential for accurate diagnosis and classification. All patients with PAH or CTEPH must be referred to a specialist center. Surgical pulmonary endarterectomy is the treatment of choice for eligible patients with CTEPH. Targeted treatments (phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogues, and prostacyclin receptor agonists) are licensed for patients with PAH. The soluble guanylate cyclase stimulator riociguat is the only licensed targeted therapy for patients with inoperable or persistent/recurrent CTEPH. Management of PH resulting from left-sided heart disease primarily involves treatment of the underlying condition.
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Affiliation(s)
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple University Lewis Katz School of Medicine, Philadelphia, PA
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37
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Jansen SMA, Huis In 't Veld AE, Jacobs W, Grotjohan HP, Waskowsky M, van der Maten J, van der Weerdt A, Hoekstra R, Overbeek MJ, Mollema SA, Tolen PHCG, Hassan El Bouazzaoui LH, Vriend JWJ, Roorda JMM, de Nooijer R, van der Lee I, Voogel BAJ, Peels K, Macken T, Aerts JM, Vonk Noordegraaf A, Handoko ML, de Man FS, Bogaard HJ. Noninvasive Prediction of Elevated Wedge Pressure in Pulmonary Hypertension Patients Without Clear Signs of Left-Sided Heart Disease: External Validation of the OPTICS Risk Score. J Am Heart Assoc 2020; 9:e015992. [PMID: 32750312 PMCID: PMC7792270 DOI: 10.1161/jaha.119.015992] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Although most newly presenting patients with pulmonary hypertension (PH) have elevated pulmonary artery wedge pressure, identification of so‐called postcapillary PH can be challenging. A noninvasive tool predicting elevated pulmonary artery wedge pressure in patients with incident PH may help avoid unnecessary invasive diagnostic procedures. Methods and Results A combination of clinical data, ECG, and echocardiographic parameters was used to refine a previously developed left heart failure risk score in a retrospective cohort of pre‐ and postcapillary PH patients. This updated score (renamed the OPTICS risk score) was externally validated in a prospective cohort of patients from 12 Dutch nonreferral centers the OPTICS network. Using the updated OPTICS risk score, the presence of postcapillary PH could be predicted on the basis of body mass index ≥30, diabetes mellitus, atrial fibrillation, dyslipidemia, history of valvular surgery, sum of SV1 (deflection in V1 in millimeters) and RV6 (deflection in V6 in millimeters) on ECG, and left atrial dilation. The external validation cohort included 81 postcapillary PH patients and 66 precapillary PH patients. Using a predefined cutoff of >104, the OPTICS score had 100% specificity for postcapillary PH (sensitivity, 22%). In addition, we investigated whether a high probability of heart failure with preserved ejection fraction, assessed by the H2FPEF score (obesity, atrial fibrillation, age >60 yrs, ≥2 antihypertensives, E/e' >9, and pulmonary artery systolic pressure by echo >35 mmHg), similarly predicted the presence of elevated pulmonary artery wedge pressure. High probability of heart failure with preserved ejection fraction (H2FPEF score ≥6) was less specific for postcapillary PH. Conclusions In a community setting, the OPTICS risk score can predict elevated pulmonary artery wedge pressure in PH patients without clear signs of left‐sided heart disease. The OPTICS risk score may be used to tailor the decision to perform invasive diagnostic testing.
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Affiliation(s)
- Samara M A Jansen
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
| | | | - Wouter Jacobs
- Department of Pulmonology of the Martini Ziekenhuis Groningen Groningen The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kathinka Peels
- Catharina Ziekenhuis Eindhoven Eindhoven The Netherlands
| | - Thomas Macken
- Jeroen Bosch ziekenhuis Den Bosch Hertogenbosch The Netherlands
| | | | | | - M Louis Handoko
- Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Frances S de Man
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
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Ullah W, Minalyan A, Saleem S, Nadeem N, Abdullah HM, Abdalla A, Chan V, Saeed R, Khan M, Collins S, Mukhtar M, Grover H, Sattar Y, Panchal A, Narayana Gowda S, Khwaja U, Lashari B, Fischman DL. Comparative accuracy of non-invasive imaging versus right heart catheterization for the diagnosis of pulmonary hypertension: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2020; 29:100568. [PMID: 32642551 PMCID: PMC7334462 DOI: 10.1016/j.ijcha.2020.100568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Right heart catheterization (RHC) is the gold-standard in the diagnosis of pulmonary hypertension (PH) but at the cost of procedure-related complications. We sought to determine the comparative accuracy of RHC versus non-invasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and transthoracic echocardiography (TTE). METHODS Pulmonary hypertension was defined as a mean pulmonary artery pressure (mPAP) of>20 mmHg. Multiple databases were queried for relevant articles. Raw data were pooled using a bivariate model to calculate the measures of diagnostic accuracy and to estimate Hierarchical Summary Receiver Operating Characteristic (HSROC) on Stata 13. RESULTS A total of 51 studies with a total patient population of 3947 were selected. The pooled sensitivity and specificity of MRI for diagnosing PH was 0.92(95% confidence interval (CI) 0.88-0.96) and 0.86 (95% CI, 0.77-0.95), respectively. The net sensitivities for CT scan and TTE were 0.79 (95% CI 0.72-0.89) and 0.85 (95% CI 0.83-0.91), respectively. The overall specificity was 0.82 (0.76-0.92) for the CT scan and 0.71 (95% CI 0.61-0.84) for TTE. The diagnostic odds ratio (DOR) for MRI was 124 (95% CI 36-433) compared to 30 (95% CI 11-78) and 24 (95% 11-38) for CT scan and TTE, respectively. Chi-squared (x2) test showed moderate heterogeneity on the test for equality of sensitivities and specificities. CONCLUSIONS MRI has the highest sensitivity and specificity compared to CT and TTE. MRI can potentially serve as a surrogate technique to RHC for the diagnosis of PH.
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Affiliation(s)
- Waqas Ullah
- Abington Jefferson Health, PA, United States
| | | | - Sameer Saleem
- University of Kentucky, Bowling Green, KY, United States
| | | | - Hafez M. Abdullah
- University of South Dakota Sanford School of Medicine, SD, United States
| | | | | | - Rehan Saeed
- Abington Jefferson Health, PA, United States
| | - Maria Khan
- Ochsner Louisiana State University, Shreveport, United States
| | | | | | | | | | - Ankur Panchal
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Echocardiographic Diagnosis of Postcapillary Pulmonary Hypertension: A RIGHT1 Substudy. HEARTS 2020. [DOI: 10.3390/hearts1020006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pulmonary hypertension is observed in 70% of patients with left ventricular (LV) dysfunction. Right heart catheterization is the gold standard for a complete evaluation of Pulmonary Hypertension (PH); however, echocardiography represents a powerful initial diagnostic tool. The aim of our study was to evaluate the accuracy of echocardiography for the diagnosis of postcapillary PH, i.e., due to increased left ventricular filling pressures. Methods and Results: We recruited patients with a diagnosis of PH from the RIGHT1 study (Right heart invasive and echocardiographic hemodynamic evaluation in Turin 1). Transthoracic echocardiography was performed within 60 min of cardiac catheterization. High LV filling pressures were defined by a pulmonary arterial wedge pressure (PAWP) greater than 15 mmHg. We assessed numerous morphological and functional features of LV, and their association with PAWP. 128 patients were diagnosed with PH. We observed a significant association between PAWP, the left atrial volume indexed by BSA (LAVi, R2 = 0.27; p < 0.0001) and the E/e’ ratio (R2 = 0.27; p < 0.0001). With these parameters, we implemented a diagnostic algorithm to identify high ventricular filling pressures in PH patients. The application of this algorithm could help identify patients with a diagnosis of postcapillary PH due to high ventricular filling pressures (E/E’ > 15). Conclusions: The echocardiographic parameters with the best association with PAWP in PH patients are E/e’ and LAVi. For these patients, our diagnostic algorithm could improve the diagnostic precision for the definition of subgroups.
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Vaidya A, Golbus JR, Vedage NA, Mazurek J, Raza F, Forfia PR. Virtual echocardiography screening tool to differentiate hemodynamic profiles in pulmonary hypertension. Pulm Circ 2020; 10:2045894020950225. [PMID: 32994924 PMCID: PMC7504864 DOI: 10.1177/2045894020950225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023] Open
Abstract
This study validated a novel virtual echocardiography screening tool (VEST), which utilized routinely reported echocardiography parameters to predict hemodynamic profiles in pulmonary hypertension (PH) and identify PH due to pulmonary vascular disease (PHPVD). Direct echocardiography imaging review has been shown to predict hemodynamic profiles in PH; however, routine use often overemphasizes Doppler-estimated pulmonary artery systolic pressure (PASPDE), which lacks discriminatory power among hemodynamically varied PH subgroups. In patients with PH of varying subtypes at a tertiary referral center, reported echocardiographic findings needed for VEST, including left atrial size, E:e' and systolic interventricular septal flattening, were obtained. Receiver operating characteristic analyses assessed the predictive performance of VEST vs. PASPDE in identifying PHPVD, which was later confirmed by right heart catheterization. VEST demonstrated far superior discriminatory power than PASPDE in identifying PHPVD. A positive score was 80.0% sensitive and 75.6% specific for PHPVD with an area under the curve of 0.81. PASPDE exhibited poorer discriminatory power with an area under the curve of 0.56. VEST's strong discriminatory ability remained unchanged when validated in a second cohort from another tertiary center. We demonstrated that this novel VEST using three routine parameters that can be easily extracted from standard echocardiographic reports can successfully capture PH patients with a high likelihood of PHPVD. During the Covid-19 pandemic, when right heart catheterization and timely access to experts at accredited PH centers may have limited widespread availability, this may assist physicians to rapidly and remotely evaluate PH patients to ensure timely and appropriate care.
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Affiliation(s)
- Anjali Vaidya
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
| | - Jessica R. Golbus
- Department of Medicine, Cardiovascular
Division, University of Michigan, Ann Arbor, MI, USA
| | - Natasha A. Vedage
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
| | - Jeremy Mazurek
- Department of Medicine, Cardiovascular
Division, Heart Failure and Pulmonary Hypertension Program, Hospital of the
University of Pennsylvania, Philadelphia, PA, USA
| | - Farhan Raza
- Department of Medicine, Cardiovascular
Division, University of Wisconsin, Madison, WI, USA
| | - Paul R. Forfia
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
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Higher Mortality in Case of Small Left Atrium on Nongated Computed Tomography Pulmonary Angiography Is Associated With the Presence of Malignancy. J Thorac Imaging 2020; 36:236-241. [PMID: 32341314 DOI: 10.1097/rti.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the association between small left atria (LA) according to computed tomography pulmonary angiography (CTPA) and mortality among individuals without pulmonary embolism, and to examine which volumes begin to portend adverse outcomes. MATERIALS AND METHODS Left atrial volume indices (LAVIs) of 752 consecutive patients who underwent CTPA, in which pulmonary embolism were ruled out, were measured retrospectively using an automatic 4-chamber volumetric analysis software. Groups of 5 percentiles within the lower quartile were investigated, and the interquartile range (25th to 75th percentiles) was regarded as the control group. RESULTS Patients within the lower 25th LAVI percentiles (<33 mL/m2; n=188) were younger and had less cardiovascular morbidities, while malignancies were less common in the control group (LAVI: 33 to 54 mL/m2; n=376). Percentiles 5th to 25th did not demonstrate an independent association with mortality. After adjustment for baseline characteristics, the risk for 30-day and 1-year mortality was 5.6 (95% confidence interval: 2.1-14.8, P=0.001) and 6.1 (95% confidence interval: 2.4-15.1, P<0.001) times higher, respectively, among the lowest five LAVI percentiles (<24 mL/m2) compared with the control group. Among patients with small LA who died within 1 year, 83% had a diagnosis of malignancy. Albeit, only a minority (3%) of patients with malignancies had small LA. CONCLUSIONS Individuals undergoing CTPA whose LAVI is within the lowest five percentiles have a markedly increased risk for short-term and long-term mortality. The risk can probably be attributed to an underlying malignancy. The feasibility of 4-chamber volumetric analysis while avoiding a time-consuming process due to the automatic properties enables the introduction of this feature to clinical practice.
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Popovic D, Arena R, Jakovljevic D, Ristic A, Guazzi M. Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction. Clin Cardiol 2020; 43:698-705. [PMID: 32271482 PMCID: PMC7368295 DOI: 10.1002/clc.23367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background Continued high mortality in heart failure patients indicates the need for additional methods of risk stratification and phenotyping. Hypothesis We hypothesized that ventricular arrhythmias that do not meet test‐termination criteria (non‐terminating ventricular arrhythmias [NTVA]) during cardiopulmonary exercise testing (CPET) may help in phenotyping disease severity and prognosis in heart failure with reduced (HFrEF) and midrange (HFmrEF)/preserved (HFpEF) left ventricular ejection fraction (LVEF). Methods About 319 patients with heart failure (199 HFrEF; 80 HFmrEF; 41 HFpEF) underwent CPET. Tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were measured by echocardiography. B‐type natriuretic peptide (BNP) at rest and peak exercise was also determined. The patients were tracked for primary (cardiac death) and secondary composite outcomes (all‐cause death, heart transplantation/left ventricular assist device implantation, hospitalization for cardiac reasons). Results Forty‐seven (15%) of the patients demonstrated NTVA during CPET, regardless of coronary artery disease prevalence. Patients without arrhythmias had a significantly higher LVEF (P < .05), TAPSE/PASP ratio (P < .001), peak oxygen consumption (P < .01), lower resting and peak BNP (P < .001), and the minute ventilation/carbon dioxide production slope (P < .001) compared to those with NTVA. Seventy‐one patients died during the tracking period, 54 for cardiac reasons. NTVA during CPET was a significant predictor of primary and secondary outcomes in the total heart failure cohort (HR: 5.3, 3.7; 95% CI: 3.1‐9.1, 2.4‐5.5; P < .001, respectively), as well as in subgroups categorized according to reduced and middle‐range/preserved LVEF (P < .001). Conclusion Exercise‐induced ventricular arrhythmias that do not reach test‐termination criteria are nonetheless indicative of an advanced disease severity phenotype and worse prognosis.
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Affiliation(s)
- Dejana Popovic
- Clinic for Cardiology, University Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Ross Arena
- Department of Physical Therapy, College of Applied Science, University at Illinois, Chicago, Illinois, USA
| | - Djordje Jakovljevic
- Cardiovascular Research Centre, Institute of Cellular Medicine, Medical School, Newcastle, University & Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arsen Ristic
- Clinic for Cardiology, University Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, University Cardiology Department, I.R.C.C.S, Policlinico San Donato University Hospital, Milan, Italy
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43
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2020; 139:e698-e800. [PMID: 30586767 DOI: 10.1161/cir.0000000000000603] [Citation(s) in RCA: 230] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Karen K Stout
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Curt J Daniels
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jamil A Aboulhosn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Biykem Bozkurt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Craig S Broberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jack M Colman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephen R Crumb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Joseph A Dearani
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephanie Fuller
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michelle Gurvitz
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Paul Khairy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michael J Landzberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Arwa Saidi
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Anne Marie Valente
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - George F Van Hare
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
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Correale M, Tricarico L, Padovano G, Ferraretti A, Monaco I, Musci RL, Galgano G, Di Biase M, Brunetti ND. Echocardiographic score for prediction of pulmonary hypertension at catheterization. J Cardiovasc Med (Hagerstown) 2019; 20:809-815. [DOI: 10.2459/jcm.0000000000000853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Agrawal V, D'Alto M, Naeije R, Romeo E, Xu M, Assad TR, Robbins IM, Newman JH, Pugh ME, Hemnes AR, Brittain EL. Echocardiographic Detection of Occult Diastolic Dysfunction in Pulmonary Hypertension After Fluid Challenge. J Am Heart Assoc 2019; 8:e012504. [PMID: 31475602 PMCID: PMC6755835 DOI: 10.1161/jaha.119.012504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Identification of occult diastolic dysfunction often requires invasive right heart catheterization with provocative maneuvers such as fluid challenge. Non-invasive predictors of occult diastolic dysfunction have not been identified. We hypothesized that echocardiographic measures of diastolic function are associated with occult diastolic dysfunction identified at catheterization. Methods and Results We retrospectively examined hemodynamic and echocardiographic data from consecutive patients referred for right heart catheterization with fluid challenge from 2009 to 2017. A replication cohort of 52 patients who prospectively underwent simultaneous echocardiography and right heart catheterization before and after fluid challenge at Monaldi Hospital, Naples, Italy. In the retrospective cohort of 126 patients (83% female, 56+14 years), 27/126 (21%) had occult diastolic dysfunction. After adjusting for tricuspid regurgitant velocity and left atrial volume index, E velocity (odds ratio 1.8, 95% CI 1.1-2.9, P=0.01) and E/e' (odds ratio 1.9, 95% CI 1.1-3, P=0.005) were associated with occult diastolic dysfunction with an optimal threshold of E/e' >8.6 for occult diastolic dysfunction (sensitivity 70%, specificity 64%). In the prospective cohort, 5/52 (10%) patients had diastolic dysfunction after fluid challenge. Resting E/e' (odds ratio 8.75, 95% CI 2.3-33, P=0.001) and E velocity (odds ratio 7.7, 95% CI 2-29, P=0.003) remained associated with occult diastolic dysfunction with optimal threshold of E/e' >8 (sensitivity 73%, specificity 90%). Conclusions Among patients referred for right heart catheterization with fluid challenge, E velocity and E/e' are associated with occult diastolic dysfunction after fluid challenge. These findings suggest that routine echocardiographic measurements may help identify patients like to have occult diastolic dysfunction non-invasively.
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Affiliation(s)
- Vineet Agrawal
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Michele D'Alto
- Department of Cardiology University "L. Vanvitelli" - Monaldi Hospital Naples Italy
| | - Robert Naeije
- Department of Cardiology Erasme University Hospital Brussels Belgium
| | - Emanuele Romeo
- Department of Cardiology University "L. Vanvitelli" - Monaldi Hospital Naples Italy
| | - Meng Xu
- Department of Biostatistics Vanderbilt University Nashville TN
| | - Tufik R Assad
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Ivan M Robbins
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - John H Newman
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Meredith E Pugh
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Anna R Hemnes
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Evan L Brittain
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
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Bhattacharya PT, Troutman GS, Mao F, Fox AL, Tanna MS, Zamani P, Grandin EW, Menachem JN, Birati EY, Chirinos JA, Mazimba S, Smith KA, Kawut SM, Forfia PR, Vaidya A, Mazurek JA. Right ventricular outflow tract velocity time integral-to-pulmonary artery systolic pressure ratio: a non-invasive metric of pulmonary arterial compliance differs across the spectrum of pulmonary hypertension. Pulm Circ 2019; 9:2045894019841978. [PMID: 30880577 PMCID: PMC6540515 DOI: 10.1177/2045894019841978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arterial compliance (PAC), invasively assessed by the ratio of stroke
volume to pulmonary arterial (PA) pulse pressure, is a sensitive marker of right
ventricular (RV)-PA coupling that differs across the spectrum of pulmonary
hypertension (PH) and is predictive of outcomes. We assessed whether the
echocardiographically derived ratio of RV outflow tract velocity time integral
to PA systolic pressure (RVOT-VTI/PASP) (a) correlates with invasive PAC, (b)
discriminates heart failure with preserved ejection-associated PH (HFpEF-PH)
from pulmonary arterial hypertension (PAH), and (c) is associated with
functional capacity. We performed a retrospective cohort study of patients with
PAH (n = 70) and HFpEF-PH (n = 86), which was further dichotomized by diastolic
pressure gradient (DPG) into isolated post-capillary PH (DPG < 7 mmHg;
Ipc-PH, n = 54), and combined post- and pre-capillary PH (DPG ≥ 7 mm Hg; Cpc-PH,
n = 32). Of the 156 patients, 146 had measurable RVOT-VTI or PASP and were
included in further analysis. RVOT-VTI/PASP correlated with invasive PAC overall
(ρ = 0.61, P < 0.001) and for the PAH (ρ = 0.38,
P = 0.002) and HFpEF-PH (ρ = 0.63,
P < 0.001) groups individually. RVOT-VTI/PASP differed
significantly across the PH spectrum (PAH: 0.13 [0.010–0.25] vs. Cpc-PH: 0.20
[0.12–0.25] vs. Ipc-PH: 0.35 [0.22–0.44]; P < 0.001),
distinguished HFpEF-PH from PAH (AUC = 0.72, 95% CI = 0.63–0.81) and Cpc-PH from
Ipc-PH (AUC = 0.78, 95% CI = 0.68–0.88), and remained independently predictive
of 6-min walk distance after multivariate analysis (standardized
β-coefficient = 27.7, 95% CI = 9.2–46.3; P = 0.004).
Echocardiographic RVOT-VTI/PASP is a novel non-invasive metric of PAC that
differs across the spectrum of PH. It distinguishes the degree of pre-capillary
disease within HFpEF-PH and is predictive of functional capacity.
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Affiliation(s)
- Priyanka T. Bhattacharya
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S. Troutman
- Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Frances Mao
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arieh L. Fox
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Monique S. Tanna
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Payman Zamani
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - E. Wilson Grandin
- Division of Cardiology, Richard A. and
Susan F. Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan N. Menachem
- Department of Medicine, Division of
Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | - Edo Y. Birati
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Julio A. Chirinos
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Sula Mazimba
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Steven M. Kawut
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Paul R. Forfia
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Jeremy A. Mazurek
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Jeremy A. Mazurek, Division of
Cardiovascular Medicine Hospital of the University of Pennsylvania, Perelman
Center for Advanced Medicine, South Pavilion, 11th Floor, Suite 11-179, 3400
Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease with significant morbidity. It is a result of an alternate natural history in which there is limited resolution of thromboemboli with pulmonary artery obstruction leading to pulmonary hypertension (PH). CTEPH requires a thorough clinical assessment including pulmonary hemodynamics and radiologic evaluation in addition to consultation with an expert center. Surgical intervention remains the optimal management strategy. Select patients may be candidates for catheter-based intervention with balloon pulmonary angioplasty in centers with clinical expertise. Inoperable patients or those with post-intervention PH are treated with pulmonary hypertension-targeted medical therapy.
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Affiliation(s)
- Jean M Elwing
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0564, Cincinnati, OH 45267, USA.
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and Pulmonary Thromboendarterectomy Program, Advanced Heart Failure and Cardiac Transplant, Temple University School of Medicine, Temple University Hospital, 9th Floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - William R Auger
- CTEPH Program, UC San Diego Health, University of California, San Diego, 9300 Campus Point Drive #7381, La Jolla, CA 92037, USA
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Krieger EV, Stout KK, Grosse-Wortmann L. How to Image Congenital Left Heart Obstruction in Adults. Circ Cardiovasc Imaging 2019; 10:CIRCIMAGING.116.004271. [PMID: 28495822 DOI: 10.1161/circimaging.116.004271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Eric V Krieger
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.)
| | - Karen K Stout
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.)
| | - Lars Grosse-Wortmann
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.).
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49
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Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
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Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
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50
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Agrawal V, Byrd BF, Brittain EL. Echocardiographic evaluation of diastolic function in the setting of pulmonary hypertension. Pulm Circ 2019; 9:2045894019826043. [PMID: 30783522 PMCID: PMC6366003 DOI: 10.1177/2045894019826043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022] Open
Abstract
Heart failure due to diastolic dysfunction and pulmonary hypertension are frequent comorbid conditions with significant morbidity and mortality. Identifying the presence and etiology of diastolic dysfunction in the setting of pulmonary hypertension remains challenging despite profound therapeutic and prognostic implications. Additionally, there is little guidance in identifying and parsing etiology of diastolic dysfunction in patients found to have pulmonary hypertension. This review discusses the complex interplay between left ventricular diastolic dysfunction and pulmonary hypertension. With an explicit focus on the use of echocardiography for determination of diastolic dysfunction and etiology of pulmonary hypertension, this review also provides a comprehensive review of the literature and provides a framework by which to assess diastolic dysfunction echocardiographically in the setting of pulmonary hypertension.
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Affiliation(s)
- Vineet Agrawal
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin F Byrd
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan L Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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