1
|
Kiko T, Asano R, Endo H, Nishi N, Hayashi H, Ueda J, Aoki T, Tsuji A, Ogo T. Clinical outcomes of upfront combination therapy for portopulmonary hypertension. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200294. [PMID: 38872733 PMCID: PMC11168483 DOI: 10.1016/j.ijcrp.2024.200294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
Background Limited data exists on upfront combination therapy for portopulmonary hypertension. We evaluated the clinical efficacy, long-term outcomes, and safety of upfront combination therapy in patients with portopulmonary hypertension. Methods We performed a retrospective, single-center cohort study involving a final analysis of 33 consecutive patients diagnosed with portopulmonary hypertension who were taking pulmonary arterial hypertension-specific medication. We compared hemodynamic parameters, risk profiles, composite clinical worsening events, and safety between monotherapy (n = 23) and upfront combination therapy (n = 10). Results Twenty-seven patients (82 %) were classified into the Child-Pugh A stage. The change ratios of pulmonary vascular resistance (-32 % vs. -57 %, P = 0.006) were significantly better with upfront combination therapy. Upfront combination therapy also showed significant improvement in risk profiles. Kaplan-Meier analysis showed that the composite event-free rate was significantly lower in patients who received upfront combination therapy than in those who received monotherapy (P = 0.016), although no statistical differences were observed in all-cause death. In the univariate Cox proportional hazards analysis, upfront combination therapy was a factor for decreasing composite clinical worsening outcomes (hazard ratio 0.190, 95 % confidence interval 0.042-0.854; P = 0.030). No significant hepatic impairments were observed over 2 years of follow-up in the upfront combination group. Conclusions In patients with portopulmonary hypertension, upfront combination therapy significantly improved symptoms and short-term hemodynamics, and reduced long-term clinical worsening events without serious adverse effects. This study's findings suggest that patients with portopulmonary hypertension presenting with mild hepatic impairment benefit from upfront combination therapy.
Collapse
Affiliation(s)
- Takatoyo Kiko
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Ryotaro Asano
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Japan
| | - Hiroyuki Endo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Naruhiro Nishi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroya Hayashi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Jin Ueda
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Tatsuo Aoki
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Akihiro Tsuji
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| |
Collapse
|
2
|
Meng H, Deng Y, Liao J, Wu DD, Li LX, Chen X, Lan WF. β-catenin mediates monocrotaline-induced pulmonary hypertension via glycolysis in rats. BMC Cardiovasc Disord 2024; 24:381. [PMID: 39044140 PMCID: PMC11264393 DOI: 10.1186/s12872-024-04000-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 06/21/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Metabolic abnormalities and immune inflammation are deeply involved in pulmonary vascular remodelling and the development of pulmonary hypertension (PH). However, the regulatory mechanisms of glycolysis in macrophages are still elusive. Cumulative evidence indicates that β-catenin plays a crucial role in metabolic reprogramming. This study aimed to investigate the effect of β-catenin on macrophage glycolysis in PH. METHODS LPS-induced BMDMs were generated via in vitro experiments. A monocrotaline (MCT)-induced PH rat model was established, and the β-catenin inhibitor XAV939 was administered in vivo. The role of β-catenin in glycolysis was analysed. The degree of pulmonary vascular remodelling was measured. RESULTS β-catenin was significantly increased in both in vitro and in vivo models. In LPS-induced BMDMs, β-catenin increased the levels of hexokinase 2 (HK2), phosphofructokinase (PFK), M2-pyruvate kinase (PKM2), lactate dehydrogenase (LDH), and lactate (LA) and the expression of inflammatory cytokines and promoted PASMC proliferation and migration in vitro. XAV939 decreased the level of glycolysis and downregulated the expression of inflammatory cytokines in vivo. MCT promoted pulmonary arterial structural remodelling and right ventricular hypertrophy, and XAV939 alleviated these changes. CONCLUSIONS Our findings suggest that β-catenin is involved in the development of PH by promoting glycolysis and the inflammatory response in macrophages. Inhibition of β-catenin could improve the progression of PH.
Collapse
MESH Headings
- Animals
- Glycolysis/drug effects
- Monocrotaline
- beta Catenin/metabolism
- Hypertension, Pulmonary/chemically induced
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/physiopathology
- Disease Models, Animal
- Male
- Rats, Sprague-Dawley
- Vascular Remodeling/drug effects
- Macrophages/metabolism
- Macrophages/drug effects
- Pulmonary Artery/metabolism
- Pulmonary Artery/drug effects
- Pulmonary Artery/physiopathology
- Pulmonary Artery/pathology
- Cell Proliferation/drug effects
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/pathology
- Signal Transduction
- Hypertrophy, Right Ventricular/metabolism
- Hypertrophy, Right Ventricular/physiopathology
- Hypertrophy, Right Ventricular/chemically induced
- Inflammation Mediators/metabolism
- Rats
- Cell Movement/drug effects
Collapse
Affiliation(s)
- Hui Meng
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Yan Deng
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China.
- Department of Echocardiography of Cardiovascular Disease Institute, First Affiliated Hospital of Guangxi Medical University, 6 Shuang Yong Road, Nanning, 530021, People's Republic of China.
| | - Juan Liao
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Dan-Dan Wu
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Li-Xiang Li
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Xing Chen
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Wei-Fang Lan
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| |
Collapse
|
3
|
Brownstein AJ, Wilkinson JD, Liang LL, Channick RN, Saggar R, Kim A. Immature reticulocyte fraction: A novel biomarker of hemodynamic severity in pulmonary arterial hypertension. Pulm Circ 2024; 14:e12421. [PMID: 39105130 PMCID: PMC11298897 DOI: 10.1002/pul2.12421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 08/07/2024] Open
Abstract
Various erythropoietic abnormalities are highly prevalent among patients with pulmonary arterial hypertension (PAH) and associated with worse disease severity. Given the poorly understood yet important roles of dysregulated erythropoiesis and iron metabolism in PAH, we sought to further characterize the hematologic and iron profiles in PAH and their relationship to PAH severity. We recruited 67 patients with PAH and 13 healthy controls. Hemodynamics attained within 1 year of blood sample collection were available for 36 patients. Multiple hematologic, iron, and inflammatory parameters were evaluated for their association with hemodynamics. The subset with hemodynamic data consisted of 29 females (81%). The most common etiologies were idiopathic PAH (47%) and connective tissue disease-related PAH (33%). 19 (53%) had functional class 3 or 4 symptomatology, and 12 (33%) were on triple pulmonary vasodilator therapy. Immature reticulocyte fraction (IRF) had significant positive correlations with mean pulmonary artery (PA) pressure (mPAP) (0.59, p < 0.001), pulmonary vascular resistance (0.52, p = 0.001), and right atrial pressure (0.46, p = 0.005), and significant negative correlations with cardiac index (-0.43, p = 0.009), PA compliance (PAC) (-0.60, p < 0.001), stroke volume index (SVI) (-0.57, p < 0.001), and mixed venous oxygen saturation (-0.51, p = 0.003). IRF correlated with markers of iron deficiency (ID) and erythropoiesis. On multivariable linear regression, IRF was associated with elevated mPAP and reduced SVI and PAC independent of EPO levels, transferrin saturation, and soluble transferrin receptor levels. We identified IRF as a novel and potent biomarker of PAH hemodynamic severity, possibly related to its associations with erythropoiesis, ID, and tissue hypoxia.
Collapse
Affiliation(s)
- Adam J. Brownstein
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Jared D. Wilkinson
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Lloyd L. Liang
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Richard N. Channick
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Rajan Saggar
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Airie Kim
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| |
Collapse
|
4
|
Dardi F, Guarino D, Ballerini A, Bertozzi R, Donato F, Cennerazzo F, Salvi M, Nardi E, Magnani I, Manes A, Galiè N, Palazzini M. Prognostic role of haemodynamics at follow-up in patients with pulmonary arterial hypertension: a challenge to current European Society of Cardiology/European Respiratory Society risk tools. ERJ Open Res 2024; 10:00225-2024. [PMID: 39104950 PMCID: PMC11298999 DOI: 10.1183/23120541.00225-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/08/2024] [Indexed: 08/07/2024] Open
Abstract
Background Haemodynamic variables like right atrial pressure (RAP), cardiac index (CI), stroke volume index (SVI) and mixed venous oxygen saturation (S vO2 ) predict survival in patients with pulmonary arterial hypertension (PAH). However, there is the need to identify further prognostic haemodynamic parameters as well as to redefine their role in PAH risk stratification compared to current risk tools and non-invasive parameters. Methods This cohort study includes treatment-naïve patients assessed at baseline and after first-line PAH therapy with clinical, functional, exercise, laboratory and haemodynamic evaluations. Using a stepwise multivariate Cox regression analysis, independent prognostic haemodynamic parameters were identified and stratified according to cut-offs already defined in the European Society of Cardiology (ESC)/European Respiratory Society (ERS) risk table or defined based on the highest Chi-squared of the log-rank test. Their discriminatory power was tested for all-cause death and a combined end-point of death, hospitalisation and need of treatment escalation. Results 794 patients with PAH were enrolled. At first follow-up, RAP and pulmonary artery elastance were independently associated with death. Because of high correlations between haemodynamic parameters, different multivariable analyses were done identifying six other variables (pulmonary arterial compliance, cardiac efficiency, pulmonary vascular resistance, S vO2 , CI and SVI). Haemodynamic parameters were of no added prognostic value compared to ESC/ERS risk tools for the all-cause death end-point but they showed additional value to non-invasive parameters for the combined end-point and, when taken alone, had a discriminatory capacity comparable to ESC/ERS risk tools. Conclusion Haemodynamics' discriminative ability for clinical worsening is comparable to current ESC/ERS risk tools and is of added value to non-invasive parameters.
Collapse
Affiliation(s)
- Fabio Dardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Guarino
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Alberto Ballerini
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Riccardo Bertozzi
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Federico Donato
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Francesco Cennerazzo
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Monica Salvi
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Elena Nardi
- Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ilenia Magnani
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| |
Collapse
|
5
|
Ghio S, Badagliacca R, D'Alto M, Scelsi L, Argiento P, Brunetti ND, Casu G, Cedrone N, Confalonieri M, Corda M, Correale M, D'Agostino C, De Tommasi E, Filomena D, Galgano G, Greco A, Grimaldi M, Lombardi C, Madonna R, Manzi G, Mercurio V, Mihai A, Mulè M, Paciocco G, Papa S, Recchioni T, Romaniello A, Romeo E, Stolfo D, Vitulo P, Benza RL, Vizza CD. Right ventricular phenotyping in incident patients with idiopathic pulmonary arterial hypertension. J Heart Lung Transplant 2024:S1053-2498(24)01698-X. [PMID: 38942159 DOI: 10.1016/j.healun.2024.06.003] [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: 04/12/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Right ventricular (RV) imaging has not a definite role in risk stratification of pulmonary arterial hypertension (PAH) patients. We tested the hypothesis that echocardiography-derived phenotypes, depicting different degrees of RV remodeling and dysfunction, may provide additional prognostic information to current risk stratification tools. METHODS Consecutive incident PAH patients aged ≥18 years, diagnosed between January 2005 and December 2021, underwent clinical assessment, right heart catheterization, standard echocardiography. Simple echocardiographic variables were combined in order to define a priori four phenotypes representing different degrees of RV dilatation and RV-pulmonary arterial (PA) coupling: Phenotype 1 with mildy dilated right ventricle and preserved RV-PA coupling (n = 152 patients); phenotype 2 with mildly dilated right ventricle and poor RV-PA coupling (n = 143 patients); phenotype 3 with severely dilated right ventricle and preserved RV-PA coupling (n = 201 patients); phenotype 4 with severely dilated right ventricle and poor RV-PA coupling, with or without severe tricuspid regurgitation (n = 519 patients). Risk stratification was based on the European Society of Cardiology/European Respiratory Society (ESC/ERS) 3-strata model and Registry to Evaluate Early and Long-Term PAH disease Management (REVEAL) 2.0 score. RESULTS These phenotypes were present in all risk groups. Notably, regardless of the ESC/ERS risk stratum assigned to the patient, phenotype 4 was associated with a 2-fold increase of the odds of death (HR 2.1, 95% CI 1.6-2.8, p < 0.001), while phenotype 1 was associated with a 71% reduction in the odds of dying (HR 0.29, 95% CI 0.18-0.47, p < 0.001). CONCLUSIONS Echocardiography-derived phenotypes describing RV remodeling and dysfunction may provide prognostic information which is independent of and additional to the clinically defined risk in incident PAH patients.
Collapse
Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy.
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
| | - Paola Argiento
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Natale D Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gavino Casu
- Division of Cardiology, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Nadia Cedrone
- Unità di Medicina Interna, Ospedale S. Pertini., Rome, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Heart-Thorax-Vessels Dept., University Hospital of Cattinara, Trieste, Italy
| | - Marco Corda
- Cardiology Unit, Azienda Ospedaliera "G. Brotzu" San Michele, Cagliari, Italy
| | - Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Carlo D'Agostino
- Cardiology Department - University Hospital Policlinico Consorziale, Bari, Italy
| | | | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Giuseppe Galgano
- Department of Cardiology, "F.Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
| | - Massimo Grimaldi
- Department of Cardiology, "F.Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Carlo Lombardi
- Cardiologia, Università degli studi di Brescia, Brescia, Italy
| | - Rosalinda Madonna
- Cardiology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area Medicine, University of Pisa - UNIPI, Pisa, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences - Federico II University of Naples, Naples, Italy
| | - Alexandra Mihai
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Massimiliano Mulè
- Cardiology Unit, IRCCS, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Giuseppe Paciocco
- Dipartimento Cardio-Toraco-Vascolare, Clinica Pneumologica, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | | | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Patrizio Vitulo
- Pulmonology Unit, IRCCS - Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Raymond L Benza
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Carmine D Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| |
Collapse
|
6
|
Kramer T, Nattmann P, Gerhardt F, Stafiej P, Dumitrescu D, ten Freyhaus H, Wißmüller M, Hohmann C, Baldus S, Rosenkranz S. Impact of rapid sequential combination therapy on distinct haemodynamic measures in newly diagnosed pulmonary arterial hypertension. ESC Heart Fail 2024; 11:1540-1552. [PMID: 38224960 PMCID: PMC11098663 DOI: 10.1002/ehf2.14611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/16/2023] [Accepted: 11/16/2023] [Indexed: 01/17/2024] Open
Abstract
AIMS In pulmonary arterial hypertension (PAH), upfront combination therapy with ERA and PDE5i is associated with a reduction in morbidity and mortality events and improves standard haemodynamics, but data remain limited. Aims of this study were (i) to capture detailed haemodynamic effects of rapid sequential dual combination therapy in patients with newly diagnosed PAH; (ii) to monitor the impact of treatment initiation on clinical variables and patients' risk status, and (iii) to compare the treatment effect in patients with 'classical PAH' and 'PAH with co-morbidities'. METHODS Fifty patients (median age 57 [42-71] years, 66% female) with newly diagnosed PAH (76% idiopathic) were treated with a PD5i/sGC-S or ERA, followed by addition of the respective other drug class within 4 weeks. All patients underwent repeat right heart catheterization (RHC) during early follow-up. RESULTS At early repeat RHC (7 ± 2 months), there were substantial reductions in mean pulmonary artery pressure (mPAP: 52.2 ± 13.5 to 39.0 ± 10.6 mmHg; -25.3%), and pulmonary vascular resistance (PVR: 12.1 ± 5.7 to 5.8 ± 3.1 WU; -52.1%), and an increase in cardiac index (2.1 ± 0.4 to 2.7 ± 0.7 mL/min/m2; +32.2%) (all P < 0.05). Haemodynamic improvements correlated with improved clinical parameters including 6-min walking distance (336 ± 315 to 389 ± 120 m), NTproBNP levels (1.712 ± 2.024 to 506 ± 550 ng/L, both P < 0.05) and WHO-FC at 12 months, resulting in improved risk status, and were found in patients with few (n = 37) or multiple cardiovascular co-morbidities (BMI > 30 kg/m2, hypertension, diabetes, coronary artery disease [≥3]; n = 13), albeit baseline PVR in PAH patients with multiple co-morbidities was lower (9.3 ± 4.4 vs. 13.1 ± 5.9 WU) and PVR reduction less pronounced compared with those with few co-morbidities (-42.7% vs. -54.7%). However, comprehensive haemodynamic assessment considering further variables of prognostic relevance such as stroke volume index and pulmonary artery compliance showed similar improvements among the two groups (SVI: +50.0% vs. +49.2%; PAC: 91.7% vs. 100.0%). Finally, the 4-strata risk assessment approach was better able to capture treatment response as compared with other approaches, particularly in patients with co-morbidities. CONCLUSIONS Rapid sequential combination therapy with PDE5i/sGC-S and ERA substantially ameliorates cardiopulmonary haemodynamics at early follow-up in patients without, and to a lesser extent, with cardiovascular co-morbidities. This occurs in line with improvements of clinical parameters and risk status.
Collapse
Affiliation(s)
- Tilmann Kramer
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Phillip Nattmann
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Felix Gerhardt
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Patrycja Stafiej
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Daniel Dumitrescu
- Klinik für Allgemeine und Interventionelle KardiologieHerz‐ und Diabeteszentrum NRWBad OeynhausenGermany
| | - Henrik ten Freyhaus
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
| | - Max Wißmüller
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Christopher Hohmann
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Stephan Baldus
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
| | - Stephan Rosenkranz
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
| |
Collapse
|
7
|
Yang L, Luo D, Huang T, Li X, Zhang C, Fei H. New risk model by right ventricle - pulmonary arterial coupling and inferior vena cava from echocardiography in patients with conventional low-intermediate risk pulmonary artery hypertension under targeted treatment. Echocardiography 2024; 41:e15850. [PMID: 38818775 DOI: 10.1111/echo.15850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Accurately stratifying patients with pulmonary arterial hypertension (PAH) is very important, and traditional risk scores still have internal heterogeneity. This study aimed to construct a risk stratification model that can accurately identify clinical worsening (CW) events in conventional low-intermediate risk patients with pulmonary hypertension under targeted drug treatment by using echocardiographic parameters. METHODS This study is a single-center, prospective study, including 105 PAH patients who underwent regular follow-up at Guangdong Provincial People's Hospital from October 2021 to April 2023. The primary endpoint was the occurrence of CW, including death, hospitalization due to pulmonary hypertension, escalation of targeted drug therapy, and worsening of PAH. The predictive value of the echocardiography-based three-strata risk model was assessed using Kaplan-Meier curves and COX regression analysis. RESULTS A total of 98 PAH patients were ultimately included in this study. The median follow-up duration was 26 months (range 7-28 months). The echocardiography-based three-strata model included the ratio of tricuspid annular plane systolic excursion and pulmonary artery systolic pressure (TAPSE/PASP) and inferior vena cava (IVC). The echocardiography-based three-strata model had higher diagnostic value (C-index = .76) compared to the 2022 ESC/ERS three-strata model and four-strata model (C-index = .66 and C-index = .61, respectively). PAH patients with lower TAPSE/PASP and wider IVC showed a higher CW rate compared to patients with higher TAPSE/PASP and normal IVC (HR = 15.1, 95%CI:4.4-51.9, p < .001). CONCLUSION The echocardiography-based three-strata model based on TAPSE/PASP and IVC can effectively improve the stratification of low-intermediate risk PAH patients under targeted treatment.
Collapse
Affiliation(s)
- Lifang Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Dongling Luo
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Taoran Huang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
- Shantou University Medical College, Shantou, Guangdong Province, China
| | - Xiaoshan Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
- Guangdong Medical University, Zhanjiang, Guangdong Province, China
| | - Caojin Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Hongwen Fei
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| |
Collapse
|
8
|
Turquier S, Huot L, Lamkhioued M, Subtil F, Traclet J, Ahmad K, Lestelle F, Chauvelot L, Cottin V, Mornex JF. Bioreactance assessment of cardiac output lacks reliability for the follow-up of patients with pulmonary hypertension. PLoS One 2024; 19:e0298727. [PMID: 38768104 PMCID: PMC11104646 DOI: 10.1371/journal.pone.0298727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/27/2024] [Indexed: 05/22/2024] Open
Abstract
Cardiac output (CO) is one of the primary prognostic factors evaluated during the follow-up of patients treated for pulmonary hypertension (PH). It is recommended that it be measured using the thermodilution technique during right heart catheterization. The difficulty to perform iterative invasive measurements on the same individual led us to consider a non-invasive option. The aims of the present study were to assess the agreement between CO values obtained using bioreactance (Starling™ SV) and thermodilution, and to evaluate the ability of the bioreactance monitor to detect patients whose CO decreased by more than 15% during follow-up and, accordingly, its usefulness for patient monitoring. A prospective cohort study evaluating the performance of the Starling™ SV monitor was conducted in patients with clinically stable PH. Sixty patients referred for hemodynamic assessment were included. CO was measured using both the thermodilution technique and bioreactance during two follow-up visits. A total of 60 PH patients were included. All datasets were available at the baseline visit (V0) and 50 of them were usable during the follow-up visit (V1). Median [IQR] CO was 4.20 l/min [3.60-4.70] when assessed by bioreactance, and 5.30 l/min [4.57-6.20] by thermodilution (p<0.001). The Spearman correlation coefficient was 0.51 [0.36-0.64], and the average deviation on Bland-Altman plot was -1.25 l/min (95% CI [-1.48-1.01], p<0.001). The ability of the monitor to detect a variation in CO of more than 15% between two follow-up measurements, when such variation existed using thermodilution, was insufficient for clinical practice (AUC = 0.54, 95% CI [0.33-0.75]).
Collapse
Affiliation(s)
- Ségolène Turquier
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- Lung Physiology Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Huot
- Innovation Department, Health Economic Evaluation Service, Public Health Centre, Hospices Civils de Lyon, Lyon, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Claude Bernard University, Lyon, France
| | - Medhi Lamkhioued
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- Lung Physiology Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Fabien Subtil
- Biostatistics and Bioinformatics Department, Public Health Centre, Hospices Civils de Lyon, Lyon, France
| | - Julie Traclet
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Kais Ahmad
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - François Lestelle
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Louis Chauvelot
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR754, INRAE, Claude Bernard University, Lyon, France
| | - Jean-François Mornex
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR754, INRAE, Claude Bernard University, Lyon, France
| |
Collapse
|
9
|
Rubin LJ. Is There a Role for Calcium Channel Blockers in the Contemporary Treatment Paradigm for Pulmonary Arterial Hypertension? Circulation 2024; 149:1565-1567. [PMID: 38739700 DOI: 10.1161/circulationaha.124.069124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Lewis J Rubin
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. Department of Medicine, School of Medicine, University of California, San Diego, La Jolla
| |
Collapse
|
10
|
Gerhardt F, Fiessler E, Olsson KM, Kayser MZ, Kovacs G, Gall H, Ghofrani HA, Badr Eslam R, Lang IM, Benjamin N, Grünig E, Halank M, Lange TJ, Ulrich S, Leuchte H, Held M, Klose H, Ewert R, Wilkens H, Pizarro C, Skowasch D, Wissmüller M, Hellmich M, Olschewski H, Hoeper MM, Rosenkranz S. Positive Vasoreactivity Testing in Pulmonary Arterial Hypertension: Therapeutic Consequences, Treatment Patterns, and Outcomes in the Modern Management Era. Circulation 2024; 149:1549-1564. [PMID: 38606558 DOI: 10.1161/circulationaha.122.063821] [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: 12/31/2022] [Accepted: 02/21/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Among patients with pulmonary arterial hypertension (PAH), acute vasoreactivity testing during right heart catheterization may identify acute vasoresponders, for whom treatment with high-dose calcium channel blockers (CCBs) is recommended. However, long-term outcomes in the current era remain largely unknown. We sought to evaluate the implications of acute vasoreactivity response for long-term response to CCBs and other outcomes. METHODS Patients diagnosed with PAH between January 1999 and December 2018 at 15 pulmonary hypertension centers were included and analyzed retrospectively. In accordance with current guidelines, acute vasoreactivity response was defined by a decrease of mean pulmonary artery pressure by ≥10 mm Hg to reach <40 mm Hg, without a decrease in cardiac output. Long-term response to CCBs was defined as alive with unchanged initial CCB therapy with or without other initial PAH therapy and World Health Organization functional class I/II and/or low European Society of Cardiology/European Respiratory Society risk status at 12 months after initiation of CCBs. Patients were followed for up to 5 years; clinical measures, outcome, and subsequent treatment patterns were captured. RESULTS Of 3702 patients undergoing right heart catheterization for PAH diagnosis, 2051 had idiopathic, heritable, or drug-induced PAH, of whom 1904 (92.8%) underwent acute vasoreactivity testing. A total of 162 patients fulfilled acute vasoreactivity response criteria and received an initial CCB alone (n=123) or in combination with another PAH therapy (n=39). The median follow-up time was 60.0 months (interquartile range, 30.8-60.0), during which overall survival was 86.7%. At 12 months, 53.2% remained on CCB monotherapy, 14.7% on initial CCB plus another initial PAH therapy, and the remaining patients had the CCB withdrawn and/or PAH therapy added. CCB long-term response was found in 54.3% of patients. Five-year survival was 98.5% in long-term responders versus 73.0% in nonresponders. In addition to established vasodilator responder criteria, pulmonary artery compliance at acute vasoreactivity testing, low risk status and NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels at early follow-up correlated with long-term response and predicted survival. CONCLUSIONS Our data display heterogeneity within the group of vasoresponders, with a large subset failing to show a sustained satisfactory clinical response to CCBs. This highlights the necessity for comprehensive reassessment during early follow-up. The use of pulmonary artery compliance in addition to current measures may better identify those likely to have a good long-term response.
Collapse
Affiliation(s)
- Felix Gerhardt
- Department of Cardiology, Heart Center at the University Hospital Cologne, Germany (F.G., E.F., M.W., S.R.)
- Cologne Cardiovascular Research Center, University of Cologne, Germany (F.G., E.F., M.W., S.R.)
| | - Eva Fiessler
- Department of Cardiology, Heart Center at the University Hospital Cologne, Germany (F.G., E.F., M.W., S.R.)
- Cologne Cardiovascular Research Center, University of Cologne, Germany (F.G., E.F., M.W., S.R.)
| | - Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Germany (K.M.O., M.Z.K., M.M.H.)
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
| | - Moritz Z Kayser
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Germany (K.M.O., M.Z.K., M.M.H.)
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
| | - Gabor Kovacs
- Klinische Abteilung für Lungenkrankheiten, Klinik für Innere Medizin, Medizinische Universität Graz, Austria (G.K., H.O.)
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Austria (G.K., H.O.)
| | - Henning Gall
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
- Abteilung Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Gießen & Marburg Lung Center, Standort Gießen, Germany (H.G., H.A.G.)
| | - H Ardeschir Ghofrani
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
- Abteilung Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Gießen & Marburg Lung Center, Standort Gießen, Germany (H.G., H.A.G.)
| | - Roza Badr Eslam
- Klinik für Innere Medizin II, Abteilung Kardiologie, Medizinische Universität Wien, Austria (R.B.E., I.M.L.)
| | - Irene M Lang
- Klinik für Innere Medizin II, Abteilung Kardiologie, Medizinische Universität Wien, Austria (R.B.E., I.M.L.)
| | - Nicola Benjamin
- Zentrum für Pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg, Germany (N.B., E.G.)
| | - Ekkehard Grünig
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
- Zentrum für Pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg, Germany (N.B., E.G.)
| | - Michael Halank
- Medizinische Klinik I, Universitätsklinik Carl Gustav Carus, TU Dresden, Germany (M. Halank)
| | - Tobias J Lange
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Germany (T.J.L.)
| | - Silvia Ulrich
- Klinik für Pneumologie, Universitätsspital Zürich, Switzerland (S.U.)
| | - Hanno Leuchte
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
- Klinik der barmherzigen Schwestern, Krhs Neuwittelsbach, LMU München, Germany (H.L.)
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie, Missioklinik Würzburg, Germany (M. Held)
| | - Hans Klose
- Centrum für Pulmonale Hypertonie Hamburg, Sektion Pneumologie, Universitätsklinikum Hamburg-Eppendorf, Germany (H.K.)
| | - Ralf Ewert
- Klinik für Innere Medizin, Pneumologie/Infektiologie, Universitätsklinik Greifswald, Germany (R.E.)
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg, Germany (H.W.)
| | - Carmen Pizarro
- Medizinische Klinik II, Universitätsklinikum Bonn, Germany (C.P., D.S.)
| | - Dirk Skowasch
- Medizinische Klinik II, Universitätsklinikum Bonn, Germany (C.P., D.S.)
| | - Max Wissmüller
- Department of Cardiology, Heart Center at the University Hospital Cologne, Germany (F.G., E.F., M.W., S.R.)
- Cologne Cardiovascular Research Center, University of Cologne, Germany (F.G., E.F., M.W., S.R.)
| | - Martin Hellmich
- Institut für Medizinische Statistik und Bioinformatik, Medizinische Fakultät und Uniklinik Köln, Universität zu Köln, Germany (M. Hellmich)
| | - Horst Olschewski
- Klinische Abteilung für Lungenkrankheiten, Klinik für Innere Medizin, Medizinische Universität Graz, Austria (G.K., H.O.)
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Austria (G.K., H.O.)
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Germany (K.M.O., M.Z.K., M.M.H.)
- German Center for Lung Research, Neuherberg, Germany (K.M.O., M.Z.K., H.G., H.A.G., E.G., H.L., M.M.H.)
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, Germany (F.G., E.F., M.W., S.R.)
- Cologne Cardiovascular Research Center, University of Cologne, Germany (F.G., E.F., M.W., S.R.)
| |
Collapse
|
11
|
Zhang X, Qin H, Ma Q, Zhang J, Tian H, Meng Y. CircST6GAL1 knockdown alleviates pulmonary arterial hypertension by regulating miR-509-5p/multiple C2 and transmembrane domain containing 2 axis. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13771. [PMID: 38747117 PMCID: PMC11094577 DOI: 10.1111/crj.13771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/07/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Hypertension is a main contributing factor of cardiovascular diseases; deregulated circular RNAs are involved in the pathogenesis of pulmonary arterial hypertension (PAH). Herein, we evaluated the function and mechanism of circST6GAL1 in PAH process. METHODS Human pulmonary artery smooth muscle cells (HPASMCs) were cultured in hypoxic environment for functional analysis. The cell counting kit-8, 5-ethynyl-2'-deoxyuridine, wound healing, and flow cytometry assays were used to investigate cell proliferation, migration, and apoptosis. qRT-PCR and Western blotting analyses were used for level measurement of genes and proteins. The binding between miR-509-5p and circST6GAL1 or multiple C2 and transmembrane domain containing 2 (MCTP2) was analyzed by dual-luciferase reporter, RNA immunoprecipitation, and pull-down assays. The monocrotaline (MCT)-induced PAH mouse models were established for in vivo assay. RESULTS CircST6GAL1 was highly expressed in PAH patients and hypoxia-induced HPASMCs. Functionally, circST6GAL1 deficiency reversed hypoxia-induced proliferation and migration, as well as apoptosis arrest in HPASMCs. Mechanistically, circST6GAL1 directly targeted miR-509-5p, and MCTP2 was a target of miR-509-5p. Rescue assays showed that the regulatory effects of circST6GAL1 deficiency on hypoxia-induced HPASMCs were abolished. Moreover, forced expression of miR-509-5p suppressed HPASMC proliferation and migration and induced cell apoptosis under hypoxia stimulation, while these effects were abolished by MCTP2 overexpression. Moreover, circST6GAL1 silencing improved MCT-induced pulmonary vascular remodeling and PAH. CONCLUSION CircST6GAL1 deficiency reversed hypoxia-induced proliferation and migration, as well as apoptosis arrest in HPASMCs, and alleviated pulmonary vascular remodeling in MCT-induced PAH mouse models through the miR-509-5p/MCTP2 axis, indicating a potential therapeutic target for PAH.
Collapse
Affiliation(s)
- Xing Zhang
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Hao Qin
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Qiang Ma
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Junbo Zhang
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Hongyan Tian
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Yan Meng
- Department of Peripheral Vascular DiseasesThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| |
Collapse
|
12
|
Waxman AB, Systrom DM, Manimaran S, de Oliveira Pena J, Lu J, Rischard FP. SPECTRA Phase 2b Study: Impact of Sotatercept on Exercise Tolerance and Right Ventricular Function in Pulmonary Arterial Hypertension. Circ Heart Fail 2024; 17:e011227. [PMID: 38572639 DOI: 10.1161/circheartfailure.123.011227] [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: 12/07/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND This study aims to assess the impact of sotatercept on exercise tolerance, exercise capacity, and right ventricular function in pulmonary arterial hypertension. METHODS SPECTRA (Sotatercept Phase 2 Exploratory Clinical Trial in PAH) was a phase 2a, single-arm, open-label, multicenter exploratory study that evaluated the effects of sotatercept by invasive cardiopulmonary exercise testing in participants with pulmonary arterial hypertension and World Health Organization functional class III on combination background therapy. The primary end point was the change in peak oxygen uptake from baseline to week 24. Cardiac magnetic resonance imaging was performed to assess right ventricular function. RESULTS Among the 21 participants completing 24 weeks of treatment, there was a significant improvement from baseline in peak oxygen uptake, with a mean change of 102.74 mL/min ([95% CIs, 27.72-177.76]; P=0.0097). Sotatercept demonstrated improvements in secondary end points, including resting and peak exercise hemodynamics, and 6-minute walk distance versus baseline measures. Cardiac magnetic resonance imaging showed improvements from baseline at week 24 in right ventricular function. CONCLUSIONS The clinical efficacy and safety of sotatercept demonstrated in the SPECTRA study emphasize the potential of this therapy as a new treatment option for patients with pulmonary arterial hypertension. Improvements in right ventricular structure and function underscore the potential for sotatercept as a disease-modifying agent with reverse-remodeling capabilities. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03738150.
Collapse
Affiliation(s)
- Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - Solaiappan Manimaran
- Acceleron Pharma, a wholly owned subsidiary of Merck & Co Inc, Rahway, NJ (S.M.)
| | | | | | - Franz P Rischard
- Department of Medicine, Division of Pulmonary and Critical Care (F.P.R.), University of Arizona, Tucson
- Sarver Heart Center (F.R.), University of Arizona, Tucson
| |
Collapse
|
13
|
Lachant DJ, Lachant MD, Haight D, White RJ. Cardiac effort and 6-min walk distance correlate with stroke volume measured by cardiac magnetic resonance imaging. Pulm Circ 2024; 14:e12355. [PMID: 38572082 PMCID: PMC10985409 DOI: 10.1002/pul2.12355] [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: 10/06/2023] [Revised: 01/18/2024] [Accepted: 03/05/2024] [Indexed: 04/05/2024] Open
Abstract
Right ventricular (RV) dysfunction in pulmonary arterial hypertension (PAH) is associated with poor outcomes. Cardiac magnetic resonance imaging (cMRI) is the gold standard for volumetric assessment, and few reports have correlated 6-min walk distance (6MWD) and cMRI parameters in PAH. Cardiac Effort, (the number of heart beats used during 6-min walk test)/(6MWD), incorporates physiologic changes into walk distance and has been associated with stroke volume (SV) measured by nuclear imaging and indirect Fick. Here, we aimed to interrogate the relationship of Cardiac Effort and 6MWD with SV measured by the gold standard, cMRI. This was a single-center, observational, prospective study in Group 1 PAH patients. Subjects completed 6-min walk with heart rate monitoring (Cardiac Effort) and cMRI within 24 h. cMRI was correlated to Cardiac Effort and 6MWD using Spearman Correlation Coefficient. Twenty-five participants with a wide range of RV function completed both cMRI and Cardiac Effort. There was a strong correlation between left ventricle SV index and both Cardiac Effort (r = -0.70, p = 0.0001) and 6MWD (r = 0.67, p = 0.0002). Cardiac Effort and 6MWD were statistically separated in patients at prognostically significant thresholds of left ventricle SV index (>31 ml/m2), RV Ejection Fraction (>35%), and SV/End Systolic Volume ( > 0.53). Cardiac Effort and 6MWD are noninvasive ways to gain insight into those with impaired SV. 6MWD may correlate better with SV than previously thought and heart rate monitoring provides physiologic context to the walk distance obtained.
Collapse
Affiliation(s)
- Daniel J. Lachant
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Rochester Medical CenterRocesterNYUSA
| | - Michael D. Lachant
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Rochester Medical CenterRocesterNYUSA
| | - Deborah Haight
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Rochester Medical CenterRocesterNYUSA
| | - R. James White
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Rochester Medical CenterRocesterNYUSA
| |
Collapse
|
14
|
Weatherald J, Sitbon O. POINT: Should the Use of Upfront Triple Combination Therapy Be Standard of Care in Pulmonary Arterial Hypertension? Yes. Chest 2024; 165:492-494. [PMID: 38461011 DOI: 10.1016/j.chest.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine University of Alberta, Edmonton, AB, Canada
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
| |
Collapse
|
15
|
Kiely DG, Channick R, Flores D, Galiè N, MacDonald G, Marcus JT, Mitchell L, Peacock A, Rosenkranz S, Tawakol A, Torbicki A, Vonk Noordegraaf A, Swift AJ. Comparison of cardiac magnetic resonance imaging, functional and haemodynamic variables in pulmonary arterial hypertension: insights from REPAIR. ERJ Open Res 2024; 10:00547-2023. [PMID: 38348238 PMCID: PMC10860210 DOI: 10.1183/23120541.00547-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/11/2023] [Indexed: 02/15/2024] Open
Abstract
Background Measures that can detect large treatment effects are important for monitoring therapeutic effectiveness. The 2022 European Society of Cardiology/European Respiratory Society guidelines highlight the importance of imaging in monitoring disease status and treatment response in pulmonary arterial hypertension (PAH). Are the standardised treatment effect sizes (STES) of cardiac magnetic resonance imaging (cMRI) comparable with functional and haemodynamic variables? Methods REPAIR (ClinicalTrials.gov: NCT02310672) was a prospective, multicentre, single-arm, open-label, 52-week phase 4 study evaluating the effect of macitentan 10 mg, with or without a phosphodiesterase 5 inhibitor (PDE5i), on right ventricular (RV) remodelling, cardiac function and cardiopulmonary haemodynamics. Both cMRI and functional assessments were performed at screening and at weeks 26 and 52; haemodynamic measurements were conducted at screening and week 26. In this post hoc analysis, STES were estimated using the parametric Cohen's d and non-parametric Cliff's delta tests. Results At week 26, large STES (Cohen's d) were observed for 10 of the 20 cMRI variables assessed, including the prognostic measures of RV and left ventricular stroke volume and RV ejection fraction and the haemodynamic trial end-point, pulmonary vascular resistance; medium STES were observed for 6-min walk distance (6MWD). The STES were consistent in treatment-naïve patients and those escalating therapy and maintained at week 52. Similar results were obtained using the non-parametric Cliff's delta method. Conclusions The treatment effect of macitentan, alone or in combination with a PDE5i, was comparable for several cMRI and haemodynamic variables with prognostic value in PAH, and greater than that of 6MWD in patients with PAH, highlighting the emerging relevance of cMRI in PAH.
Collapse
Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit and NIHR Biomedical Research Centre, Royal Hallamshire Hospital and University of Sheffield, Sheffield, UK
- Department of Clinical Medicine, University of Sheffield, Sheffield, UK
| | | | - Dayana Flores
- Global Medical Affairs, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Allschwil, Switzerland
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Università di Bologna, Bologna, Italy
| | - Gwen MacDonald
- Global Medical Affairs, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Allschwil, Switzerland
| | - J. Tim Marcus
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lada Mitchell
- Statistical Decision Science, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Allschwil, Switzerland
| | - Andrew Peacock
- Statistical Decision Science, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Allschwil, Switzerland
| | | | - Ahmed Tawakol
- Department of Cardiology, Heart Center, University Hospital Cologne and Cologne Cardiovascular Research Center, University of Cologne, Cologne, Germany
| | - Adam Torbicki
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Andrew J. Swift
- Department of Clinical Medicine, University of Sheffield, Sheffield, UK
| |
Collapse
|
16
|
Varian F, Dick J, Battersby C, Roman S, Ablott J, Watson L, Binmahfooz S, Zafar H, Colgan G, Cannon J, Suntharalingam J, Lordan J, Howard L, McCabe C, Wort J, Price L, Church C, Hamilton N, Armstrong I, Hameed A, Hurdman J, Elliot C, Condliffe R, Wilkins M, Webb A, Adlam D, Benza RL, Rahimi K, Shojaei‐Shahrokhabadi M, Lin NX, Wason JMS, McIntosh A, McConnachie A, Middleton JT, Thompson R, Kiely DG, Toshner M, Rothman A. Pulmonary Hypertension: Intensification and Personalization of Combination Rx (PHoenix): A phase IV randomized trial for the evaluation of dose-response and clinical efficacy of riociguat and selexipag using implanted technologies. Pulm Circ 2024; 14:e12337. [PMID: 38500737 PMCID: PMC10945040 DOI: 10.1002/pul2.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 03/20/2024] Open
Abstract
Approved therapies for the treatment of patients with pulmonary arterial hypertension (PAH) mediate pulmonary vascular vasodilatation by targeting distinct biological pathways. International guidelines recommend that patients with an inadequate response to dual therapy with a phosphodiesterase type-5 inhibitor (PDE5i) and endothelin receptor antagonist (ERA), are recommended to either intensify oral therapy by adding a selective prostacyclin receptor (IP) agonist (selexipag), or switching from PDE5i to a soluble guanylate-cyclase stimulator (sGCS; riociguat). The clinical equipoise between these therapeutic choices provides the opportunity for evaluation of individualized therapeutic effects. Traditionally, invasive/hospital-based investigations are required to comprehensively assess disease severity and demonstrate treatment benefits. Regulatory-approved, minimally invasive monitors enable equivalent measurements to be obtained while patients are at home. In this 2 × 2 randomized crossover trial, patients with PAH established on guideline-recommended dual therapy and implanted with CardioMEMS™ (a wireless pulmonary artery sensor) and ConfirmRx™ (an insertable cardiac rhythm monitor), will receive ERA + sGCS, or PDEi + ERA + IP agonist. The study will evaluate clinical efficacy via established clinical investigations and remote monitoring technologies, with remote data relayed through regulatory-approved online clinical portals. The primary aim will be the change in right ventricular systolic volume measured by magnetic resonance imaging (MRI) from baseline to maximal tolerated dose with each therapy. Using data from MRI and other outcomes, including hemodynamics, physical activity, physiological measurements, quality of life, and side effect reporting, we will determine whether remote technology facilitates early evaluation of clinical efficacy, and investigate intra-patient efficacy of the two treatment approaches.
Collapse
Affiliation(s)
- Frances Varian
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Jennifer Dick
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
| | | | - Stefan Roman
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Jenna Ablott
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - Hamza Zafar
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - John Cannon
- Royal Papworth Hospital NHS Foundation TrustCambridgeUK
| | | | - Jim Lordan
- Newcastle Hospitals NHS Foundation TrustNewcastleUK
| | - Luke Howard
- Imperial College Healthcare NHS TrustLondonUK
| | - Colm McCabe
- Royal Brompton and HarefieldGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - John Wort
- NHS Greater Glasgow and ClydeGlasgowUK
| | | | - Colin Church
- National Heart and Lung Institute, Faculty of Medicine, Imperial College LondonLondonUK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Iain Armstrong
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Judith Hurdman
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Martin Wilkins
- National Heart and Lung Institute, Faculty of Medicine, Imperial College LondonLondonUK
| | - Alastair Webb
- Wolfson Centre for Prevention of Stroke and DementiaUniversity of OxfordOxfordUK
| | - David Adlam
- Cardiovascular Research Unit of LeicesterLeicesterUK
| | - Ray L. Benza
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women's and Reproductive HealthUniversity of OxfordOxfordUK
| | | | - Nan X. Lin
- Biostatistics Research Group, Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - James M. S. Wason
- Biostatistics Research Group, Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Alasdair McIntosh
- Robertson Centre for Biostatistics, School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Jennifer T. Middleton
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Roger Thompson
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - David G. Kiely
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Mark Toshner
- Department of Medicine, Heart and Lung Research InstituteUniversity of CambridgeCambridgeUK
| | - Alexander Rothman
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| |
Collapse
|
17
|
Ghio S, Badagliacca R, Acquaro M, Filomena D, Recchioni T, Papa S, Colombo D, Ditali V, Carrozzi C, Greco A, Turco A, Breviario F, Benza R, Vizza D, Scelsi L. Prognostic value of deep echocardiographic phenotyping in pulmonary arterial hypertension. ERJ Open Res 2024; 10:00587-2023. [PMID: 38196894 PMCID: PMC10772897 DOI: 10.1183/23120541.00587-2023] [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: 08/12/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background A novel approach to derive prognostic information from echocardiography in pulmonary arterial hypertension (PAH) is to define a phenotype of right heart function combining standard echocardiographic parameters which describe right ventricular pump function and systemic venous congestion. We tested the hypothesis that the combination of advanced strain imaging parameters could yield high prognostic accuracy. Methods This was a prospective observational study with a single centre derivation cohort and a second centre validation cohort. The derivation cohort included 49 naive PAH patients who underwent right heart catheterisation and echocardiographic evaluation at baseline and 4-12 months after diagnosis. The validation cohort included 83 prevalent PAH patients who underwent the same examinations at 12 months after diagnosis. We stratified the risk of the derivation cohort according to three models: Model 1, based on haemodynamic parameters; Model 2, based on standard echocardiographic parameters; and Model 3, based on advanced echocardiographic parameters. The median follow-up period was 21 months; the end point of the analysis was clinical worsening. Results In the derivation cohort, haemodynamic and echocardiographic parameters obtained at diagnosis were not associated with outcome, whereas a significant association was observed at first reassessment. Model 3 yielded a better predictive accuracy (Harrell's C index 0.832) as compared to Model 2 (Harrell's C index 0.667), and to Model 1 (Harrell's C index 0.713). The validation cohort confirmed the accuracy of Model 3. Conclusions A comprehensive assessment of right heart function using right ventricular strain, right atrial reservoir strain and degree of tricuspid regurgitation provides accurate prognostic information in prevalent PAH patients.
Collapse
Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- These authors contributed equally
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
- These authors contributed equally
| | - Mauro Acquaro
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- These authors contributed equally
| | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Davide Colombo
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Ditali
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Carrozzi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Annalisa Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Breviario
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raymond Benza
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
18
|
Klose H, Harbaum L, Richter MJ, Lichtblau M, Marra AM, Kabitz HJ, Harutyunova S, Milger-Kneidinger K, Lange TJ. [Targeted therapy for pulmonary arterial hypertension in patients without comorbidities]. Pneumologie 2023; 77:890-900. [PMID: 37963478 DOI: 10.1055/a-2145-4711] [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: 11/16/2023]
Abstract
The 2022 guidelines on pulmonary hypertension from the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) provide therapeutic strategies that account for the variability in the clinical presentation of newly diagnosed patients. We summarize treatment recommendations for pulmonary arterial hypertension (PAH) in patients without significant comorbidities, particularly for idiopathic, hereditary, drug/toxin-induced, or connective tissue disease-associated PAH. In this group of patients, multidimensional assessments for short-term mortality risk guide initial treatment decisions and treatment decisions during follow-up. Upfront dual combination therapy (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) is recommended for low- and intermediate-risk patients, and triple therapy including a parenteral prostacyclin should be considered in high- or intermediate-high-risk patients. If a low or intermediate-low-risk profile cannot be achieved during therapy, sequential add-on therapy escalation with parenteral prostacyclin or a prostacyclin receptor agonist should be considered, and switching from a phosphodiesterase type-5 inhibitor to a guanylate cyclase stimulator may also be considered.
Collapse
Affiliation(s)
- Hans Klose
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Lars Harbaum
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, zzt. Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Mona Lichtblau
- Klinik für Pneumologie, Zentrum für Pulmonale Hypertonie, Universitätsspital Zürich, Zürich, Schweiz
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University of Naples, Napoli, Italy
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Aarau, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik an der Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Katrin Milger-Kneidinger
- Medizinische Klinik und Poliklinik V, Ludwig-Maximilians-Universität (LMU) Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Bad Reichenhall, Deutschland
- Fakultät für Medizin, Lehrstuhl für Innere Medizin II, Universität Regensburg, Regensburg, Deutschland
| |
Collapse
|
19
|
Humbert M, Sitbon O, Guignabert C, Savale L, Boucly A, Gallant-Dewavrin M, McLaughlin V, Hoeper MM, Weatherald J. Treatment of pulmonary arterial hypertension: recent progress and a look to the future. THE LANCET. RESPIRATORY MEDICINE 2023; 11:804-819. [PMID: 37591298 DOI: 10.1016/s2213-2600(23)00264-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe but treatable form of pre-capillary pulmonary hypertension caused by pulmonary vascular remodelling. As a result of basic science discoveries, randomised controlled trials, studies of real-world data, and the development of clinical practice guidelines, considerable progress has been made in the treatment options and outcomes for patients with PAH, underscoring the importance of seamless translation of information from bench to bedside and, ultimately, to patients. However, PAH still carries a high mortality rate, which emphasises the urgent need for transformative innovations in the field. In this Series paper, written by a group of clinicians, researchers, and a patient with PAH, we review therapeutic approaches and treatment options for PAH. We summarise current knowledge of the cellular and molecular mechanisms of PAH, with an emphasis on emerging treatable pathways and optimisation of current management strategies. In considering future directions for the field, our ambition is to identify therapies with the potential to stall or reverse pulmonary vascular remodelling. We highlight novel therapeutic approaches, the important role of patients as partners in research, and innovative approaches to PAH clinical trials.
Collapse
Affiliation(s)
- Marc Humbert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France.
| | - Olivier Sitbon
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | | | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), Hannover, Germany
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
20
|
Weatherald J, Zanini U, Humbert M. Illuminating the Importance of Pulmonary Arterial Compliance in Pulmonary Hypertension. Am J Respir Crit Care Med 2023; 208:231-233. [PMID: 37348119 PMCID: PMC10395725 DOI: 10.1164/rccm.202306-0990ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/22/2023] [Indexed: 06/24/2023] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine University of Alberta Edmonton, Alberta, Canada
| | - Umberto Zanini
- Department of Medicine University of Alberta Edmonton, Alberta, Canada
- Department of Medicine and Surgery University of Milan-Bicocca Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo Monza, Italy
| | - Marc Humbert
- Faculty of Medicine Paris-Saclay University Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Le Kremlin-Bicêtre, France
- Department of Respiratory and Intensive Care Medicine Hôpital Bicêtre Le Kremlin-Bicêtre, France
| |
Collapse
|
21
|
Lange TJ. Refined risk stratification, current treatment, and new therapeutic approaches in pulmonary arterial hypertension. Herz 2023; 48:259-265. [PMID: 37085727 DOI: 10.1007/s00059-023-05179-1] [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] [Accepted: 03/15/2023] [Indexed: 04/23/2023]
Abstract
The 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines for pulmonary hypertension have introduced a refined risk stratification to guide both initial and subsequent treatment of pulmonary arterial hypertension (PAH). The risk stratification at PAH diagnosis still comprises three risk categories (low, intermediate, high) and lists some new parameters. As the estimated 1‑year mortality is more than 20% in high-risk patients after diagnosis, an initial triple-combination therapy including parenteral prostacyclin analogues is recommended for this group. All other patients should receive a dual-combination therapy with an endothelin receptor antagonist and a phosphodiesterase‑5 inhibitor. However, this approach of initial combination therapy is only recommended for classic PAH, while monotherapy followed by regular follow-up and individualized therapy should be used for patients with cardiopulmonary comorbidities. For PAH patients without cardiopulmonary comorbidities, it is recommended to assess their risk at follow-up with a new 4‑strata classification, where the intermediate-risk group is split on the basis of three noninvasive parameters. Importantly, changes from intermediate-high to intermediate-low risk have been shown to be associated with a better prognosis. In addition, the recommendations on treatment escalation became more precise with the addition of a prostacyclin receptor agonist or switching a phosphodiesterase‑5 inhibitor to a soluble guanylate cyclase stimulator for intermediate-low risk and proceeding to triple-combination therapy with parenteral prostacyclin analogues already for intermediate-high risk. With sotatercept, the first non-vasodilator PAH treatment will become available in the near future to further enrich our treatment options for this chronic and still severe disease.
Collapse
Affiliation(s)
- Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Riedelstr. 5, 83435, Bad Reichenhall, Germany.
- Medizinische Fakultät, Universität Regensburg, Regensburg, Germany.
| |
Collapse
|
22
|
Dayer N, Ltaief Z, Liaudet L, Lechartier B, Aubert JD, Yerly P. Pressure Overload and Right Ventricular Failure: From Pathophysiology to Treatment. J Clin Med 2023; 12:4722. [PMID: 37510837 PMCID: PMC10380537 DOI: 10.3390/jcm12144722] [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: 06/05/2023] [Revised: 07/01/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Right ventricular failure (RVF) is often caused by increased afterload and disrupted coupling between the right ventricle (RV) and the pulmonary arteries (PAs). After a phase of adaptive hypertrophy, pressure-overloaded RVs evolve towards maladaptive hypertrophy and finally ventricular dilatation, with reduced stroke volume and systemic congestion. In this article, we review the concept of RV-PA coupling, which depicts the interaction between RV contractility and afterload, as well as the invasive and non-invasive techniques for its assessment. The current principles of RVF management based on pathophysiology and underlying etiology are subsequently discussed. Treatment strategies remain a challenge and range from fluid management and afterload reduction in moderate RVF to vasopressor therapy, inotropic support and, occasionally, mechanical circulatory support in severe RVF.
Collapse
Affiliation(s)
- Nicolas Dayer
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Benoit Lechartier
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - John-David Aubert
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - Patrick Yerly
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
| |
Collapse
|
23
|
Jansa P, Kopeć G, Torbicki A, Sadushi‐Kolici R, Campean I, Halank M, Simkova I, Steringer‐Mascherbauer R, Salobir B, Klepetko W, Lindner J, Lang IM. The risk profile change in patients with severe chronic thromboembolic pulmonary hypertension treated with subcutaneous treprostinil. Pulm Circ 2023; 13:e12274. [PMID: 37609358 PMCID: PMC10440840 DOI: 10.1002/pul2.12274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is successfully treatable with pulmonary endarterectomy (PEA), balloon pulmonary angioplasty, and medical therapy. Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management risk score (RRS) is able to predict long-term outcome in inoperable patients or in patients with residual PH after surgery. We performed a post hoc analysis of RRS in patients who were enrolled in the CTREPH study (NCT01416636), a randomized, double-blind clinical trial comparing high-dose and low-dose subcutaneous (SC) treprostinil in patients with severe CTEPH that was classified by an interdisciplinary CTEPH team as nonoperable, or as persistent or recurrent pulmonary hypertension after PEA. Baseline mean RRS was similar in both treatment groups (8.7 in high-dose arm vs. 8.6 in low-dose arm), but mean RRS change from baseline to Week 24 was greater in the high-dose treprostinil group than in the low-dose treprostinil group (-0.88 vs. -0.17). The difference in RRS change from baseline to Week 24 between high dose versus low dose was statistically significant with mean difference of -0.70 (95% confidence interval: -1.36 to -0.05, p = 0.0352), and was driven mainly by improvement of World Health Organization functional class and N-terminal pro-brain natriuretic peptide concentration. SC treprostinil therapy administered in standard dose had positive effect on the risk profile measured by RRS in patients with inoperable or persistent/recurrent severe CTEPH. Although our study was limited by the small sample size and post hoc nature, assessment of risk profile is of great importance to this particular patient population with very poor prognosis.
Collapse
Affiliation(s)
- Pavel Jansa
- Clinical Department of Cardiology and Angiology of the 2nd Department of MedicineGeneral University HospitalPragueCzech Republic
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Pulmonary Circulation CentreJagiellonian University Medical College and John Paul II Hospital in KrakowKrakowPoland
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic DiseasesEuropean Health CenterOtwockPoland
| | - Roela Sadushi‐Kolici
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Ioana‐Alexandra Campean
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Michael Halank
- Department of Internal Medicine I, University Hospital Carl Gustav CarusTechnische Universität DresdenDresdenGermany
| | - Iveta Simkova
- Department of Cardiology and Angiology of Medical FacultySlovak Medical University and National Institute of Cardiovascular DiseasesBratislavaSlovakia
| | | | - Barbara Salobir
- Department of Pulmonary Diseases and AllergyLjubljana University Medical CentreLjubljanaSlovenia
| | - Walter Klepetko
- Department of Cardiothoracic SurgeryMedical University of ViennaViennaAustria
| | - Jaroslav Lindner
- 2nd Department of Surgery—Department of Cardiovascular SurgeryGeneral University HospitalPragueCzech Republic
| | - Irene M. Lang
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| |
Collapse
|
24
|
Nakashima M, Akagi S, Ejiri K, Nakamura K, Ito H. Impact of malnutrition on prognosis in patients with pulmonary arterial hypertension. Pulm Circ 2023; 13:e12286. [PMID: 37705961 PMCID: PMC10496044 DOI: 10.1002/pul2.12286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023] Open
Abstract
Pulmonary arterial hypertension is a life-threatening disease that coexists with right heart failure. We evaluated the relationship between malnutrition and prognosis in patients with pulmonary arterial hypertension, as malnutrition is known as a prognosis determinant in chronic heart failure. We retrospectively reviewed data of patients with pulmonary arterial hypertension before treatment. The Geriatric Nutritional Risk Index, Prognostic Nutritional Index, and Controlling Nutritional Status scores on the day of diagnosis were calculated to assess the nutritional status. Clinical endpoints were defined as composite outcomes of all-cause death or lung transplantation. Eighty patients were enrolled (mean age, 50 years; 23 men). The mean pulmonary arterial pressure was 47 ± 19 mmHg, Geriatric Nutritional Risk Index was 99.9 ± 12.0, and Prognostic Nutritional Index was 46.3 ± 10.0. The median Controlling Nutritional Status score was 2 (1-4). During the median 5.5-year follow-up period, 28 composite events occurred. Kaplan-Meier analysis demonstrated significant differences in the incidence of clinical endpoints between groups divided by each median Geriatric Nutritional Risk Index, Prognostic Nutritional Index, and Controlling Nutritional Status score (p = 0.007, 0.039, and 0.010, respectively). In multivariate Cox regression analysis, clinical endpoints were significantly associated with Geriatric Nutritional Risk Index (hazard ratio: 0.953, 95% confidence interval: 0.918-0.990), Prognostic Nutritional Index (hazard ratio: 0.942, 95% confidence interval: 0.892-0.996), and Controlling Nutritional Status score (hazard ratio: 1.230, 95% confidence interval: 1.056-1.433) after adjustment for factors associated in univariate Cox regression analysis. Malnutrition at diagnosis is a useful prognostic predictor for patients with pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Mitsutaka Nakashima
- Department of Cardiovascular Medicine, Okayama University Graduate School of MedicineDentistry and Pharmaceutical SciencesOkayamaJapan
| | - Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of MedicineDentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of MedicineDentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of MedicineDentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of MedicineDentistry and Pharmaceutical SciencesOkayamaJapan
| |
Collapse
|
25
|
Ostad S, Sugarman J, Alkhodair A, Liang J, Mielniczuk LM, Hambly N, Helmersen D, Hirani N, Thakrar M, Varughese R, Norena M, Kularatne M, Swiston JR, Kapasi A, Weatherald J, Brunner NW. Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study. CJC Open 2023; 5:545-553. [PMID: 37496788 PMCID: PMC10366663 DOI: 10.1016/j.cjco.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.
Collapse
Affiliation(s)
- Sam Ostad
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Sugarman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Alkhodair
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jiaming Liang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Mielniczuk
- Department of Medicine, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathan Hambly
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naushad Hirani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mitesh Thakrar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John R. Swiston
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan W. Brunner
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
26
|
Miles KG, Critser PJ, Evers PD, Cash M, Magness M, Geers E, O'Neil M, Gao Z, Ollberding NJ, Hirsch R. Factors leading to supranormal cardiac index in pediatric pulmonary hypertension patients treated with parenteral prostanoid therapy. Pulm Circ 2023; 13:e12264. [PMID: 37427091 PMCID: PMC10323166 DOI: 10.1002/pul2.12264] [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: 12/13/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
Parenteral prostanoid therapy (PPT) can result in supranormal cardiac index (SCI; >4 L/min/m2) in pediatric pulmonary hypertension (PPH) patients. We evaluated the incidence, hemodynamic factors, and outcomes associated with SCI in PPH. This retrospective cohort study included 22 PPH patients on PPT from 2005 to 2020. Hemodynamic profiles were compared between the baseline and 3-6 month follow-up catheterization in the SCI and non-SCI cohorts. Cox regression analysis examined time to composite adverse outcome (CAO; Potts shunt, lung transplant, or death) controlling for initial disease severity. SCI developed in 17 (77%) patients, of whom 11 (65%) developed SCI within 6 months. The SCI cohort was characterized by significant augmentation of cardiac index (CI) and stroke volume (SV) as well as reductions in systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). Conversely, the non-SCI cohort had unchanged SV despite a modest rise in CI as well as persistent vasoconstriction. After median follow-up of 4.3 years (range 0.2-13 years), non-SCI patients were at significantly increased risk for the CAO (5/5: three deaths, two Potts shunts) compared with SCI patients (5/17: two deaths, three lung transplants; adjusted hazard ratio 14.0 [95% confidence interval: 2.1-91.3], p < 0.001). A majority of PPH patients developed SCI within 6-12 months of starting PPT and demonstrated lower risk of adverse outcomes compared with non-SCI patients. These data suggest that change in SVR and SV after 3-6 months of PPT may be early markers of therapeutic response and prognosis.
Collapse
Affiliation(s)
- Kimberley G. Miles
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Paul J. Critser
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Patrick D. Evers
- Division of Pediatric CardiologyOregon Health and Sciences UniversityPortlandOregonUSA
| | - Michelle Cash
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Melissa Magness
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Elizabeth Geers
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Meredith O'Neil
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nicholas J. Ollberding
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| |
Collapse
|
27
|
Vraka A, Diamanti E, Kularatne M, Yerly P, Lador F, Aubert JD, Lechartier B. Risk Stratification in Pulmonary Arterial Hypertension, Update and Perspectives. J Clin Med 2023; 12:4349. [PMID: 37445381 DOI: 10.3390/jcm12134349] [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: 06/01/2023] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Risk stratification in pulmonary arterial hypertension (PAH) is crucial in assessing patient prognosis. It serves a prominent role in everyday patient care and can be determined using several validated risk assessment scores worldwide. The recently published 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines underline the importance of risk stratification not only at baseline but also during follow-up. Achieving a low-risk status has now become the therapeutic goal, emphasising the importance of personalised therapy. The application of these guidelines is also important in determining the timing for lung transplantation referral. In this review, we summarise the most relevant prognostic factors of PAH as well as the parameters used in PAH risk scores and their evolution in the guidelines over the last decade. Finally, we describe the central role that risk stratification plays in the current guidelines not only in European countries but also in Asian countries.
Collapse
Affiliation(s)
- Argyro Vraka
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Eleni Diamanti
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Patrick Yerly
- Division of Cardiology, Cardiovascular Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Division, Geneva University Hospital, 1211 Geneva, Switzerland
| | - John-David Aubert
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Benoit Lechartier
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| |
Collapse
|
28
|
Hameed A, Condliffe R, Swift AJ, Alabed S, Kiely DG, Charalampopoulos A. Assessment of Right Ventricular Function-a State of the Art. Curr Heart Fail Rep 2023; 20:194-207. [PMID: 37271771 PMCID: PMC10256637 DOI: 10.1007/s11897-023-00600-6] [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] [Accepted: 04/17/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE OF REVIEW The right ventricle (RV) has a complex geometry and physiology which is distinct from the left. RV dysfunction and failure can be the aftermath of volume- and/or pressure-loading conditions, as well as myocardial and pericardial diseases. RECENT FINDINGS Echocardiography, magnetic resonance imaging and right heart catheterisation can assess RV function by using several qualitative and quantitative parameters. In pulmonary hypertension (PH) in particular, RV function can be impaired and is related to survival. An accurate assessment of RV function is crucial for the early diagnosis and management of these patients. This review focuses on the different modalities and indices used for the evaluation of RV function with an emphasis on PH.
Collapse
Affiliation(s)
- Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andrew J Swift
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
| |
Collapse
|
29
|
Kearney K, Lau EM. Pulmonary arterial compliance: a physiological variable still searching for clinical relevance? Heart 2023:heartjnl-2022-322222. [PMID: 36963819 DOI: 10.1136/heartjnl-2022-322222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Affiliation(s)
- Katherine Kearney
- Cardiology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Edmund M Lau
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| |
Collapse
|
30
|
The ratio of TAPSE to PASP predicts prognosis in lung transplant candidates with pulmonary arterial hypertension. Sci Rep 2023; 13:3758. [PMID: 36882461 PMCID: PMC9992363 DOI: 10.1038/s41598-023-30924-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023] Open
Abstract
Lung transplantation (LT) is the only option for patients with pulmonary arterial hypertension (PAH) refractory to maximal medical therapy. However, some patients referred for LT could survive without LT, and its determinants remain unclear. This study aimed to elucidate prognostic factors of severe PAH at the referral time. We retrospectively analyzed 34 patients referred for LT evaluation. The primary outcome was a composite of death or LT. Over a median follow-up period of 2.56 years, eight patients received LT and eight died. Compared with LT-free survival group, pulmonary arterial systolic pressure (PASP) was higher (p = 0.042), and the ratio of tricuspid annular plane systolic excursion (TAPSE) to PASP (TAPSE/PASP) was lower (p = 0.01) in LT or death group. In receiver operating characteristic analysis, the area under the curve was 0.759 (95% confidence interval 0.589-0.929) for TAPSE/PASP to predict primary outcome, and the optimal cut-off value was 0.30 mm/mmHg (sensitivity 0.875 and specificity 0.667). In a multivariate analysis, TAPSE/PASP was independently associated with death or LT. Kaplan-Meier analysis showed a better LT-free survival in patients with TAPSE/PASP ≧0.30 mm/mmHg than in those with < 0.30 mm/mmHg (p = 0.001). Low-level TAPSE/PASP could be a poor prognostic factor in PAH patients referred for LT evaluation.
Collapse
|
31
|
Kumar P, Arendt C, Martin S, Al Soufi S, DeLeuw P, Nagel E, Puntmann VO. Multimodality Imaging in HIV-Associated Cardiovascular Complications: A Comprehensive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2201. [PMID: 36767567 PMCID: PMC9915416 DOI: 10.3390/ijerph20032201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 06/18/2023]
Abstract
Human immunodeficiency virus (HIV) infection is a leading cause of mortality and morbidity worldwide. The introduction of antiretroviral therapy (ART) has significantly reduced the risk of developing acquired immune deficiency syndrome and increased life expectancy, approaching that of the general population. However, people living with HIV have a substantially increased risk of cardiovascular diseases despite long-term viral suppression using ART. HIV-associated cardiovascular complications encompass a broad spectrum of diseases that involve the myocardium, pericardium, coronary arteries, valves, and systemic and pulmonary vasculature. Traditional risk stratification tools do not accurately predict cardiovascular risk in this population. Multimodality imaging plays an essential role in the evaluation of various HIV-related cardiovascular complications. Here, we emphasize the role of multimodality imaging in establishing the diagnosis and aetiopathogenesis of various cardiovascular manifestations related to chronic HIV disease. This review also provides a critical appraisal of contemporary data and illustrative cases.
Collapse
Affiliation(s)
- Parveen Kumar
- Institute of Experimental and Translational Cardiac Imaging, DZHK, Centre for Cardiovascular Imaging, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Christophe Arendt
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Simon Martin
- Institute of Experimental and Translational Cardiac Imaging, DZHK, Centre for Cardiovascular Imaging, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Safaa Al Soufi
- Institute of Experimental and Translational Cardiac Imaging, DZHK, Centre for Cardiovascular Imaging, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | | | - Eike Nagel
- Institute of Experimental and Translational Cardiac Imaging, DZHK, Centre for Cardiovascular Imaging, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Valentina O. Puntmann
- Institute of Experimental and Translational Cardiac Imaging, DZHK, Centre for Cardiovascular Imaging, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| |
Collapse
|
32
|
Ishii S, Hatano M, Maki H, Minatsuki S, Saito A, Yagi H, Shimbo M, Soma K, Numata G, Fujiwara T, Takeda N, Komuro I. Prognostic value of follow-up vasoreactivity test in pulmonary arterial hypertension. J Cardiol 2023:S0914-5087(23)00005-9. [PMID: 36682710 DOI: 10.1016/j.jjcc.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Acute vasoreactivity test with inhaled nitric oxide (NO) is performed during diagnostic right heart catheterization (RHC) to identify patients with pulmonary arterial hypertension (PAH) who respond to calcium channel blockers. Our purpose was to investigate the prognostic importance of follow-up vasoreactivity test after treatment. METHODS We retrospectively analyzed 36 PAH patients (mean age, 47 years; 61 % treatment-naïve), who underwent diagnostic and follow-up RHC and vasoreactivity tests at our center. The primary outcome was all-cause mortality. RESULTS The median time between baseline and follow-up RHC was 9.7 months. Absolute change in mean pulmonary arterial pressure (ΔmPAP) during NO challenge was less pronounced after treatment, but there was great variability among patients. Overall cohort was dichotomized into two groups: preserved vasoreactivity (ΔmPAP ≤ -1 mmHg) and less vasoreactivity (ΔmPAP ≥0 mmHg) at follow-up RHC. Less vasoreactivity group had higher usage rate of endothelin receptor antagonists and parenteral prostacyclin analogues. During a median observation period of 6.3 years after follow-up RHC, 7 patients died, of which 6 showed less vasoreactivity at follow-up. Absolute ΔmPAP ≥0 at follow-up RHC was associated with all-cause mortality in univariable Cox regression analysis (hazard ratio, 8.728; 95 % confidence interval, 1.045-72.887; p = 0.045), whereas other hemodynamic parameters were not. Absolute ΔmPAP ≥0 at follow-up RHC was associated with all-cause mortality in multivariable Cox analysis adjusted for age and known PAH prognostic factors (HR, 12.814; 95 % CI, 1.088-150.891; p = 0.043). Kaplan-Meier survival analysis revealed a significantly worse survival of less vasoreactivity group compared to preserved vasoreactivity group (log-rank test, p = 0.016). CONCLUSIONS Follow-up vasoreactivity test after treatment could contribute to the detection of high-risk subgroups who might need careful monitoring and referral for lung transplantation.
Collapse
Affiliation(s)
- Satoshi Ishii
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Advanced Medical Center for Heart Failure, The University of Tokyo Hospital, Tokyo, Japan.
| | - Hisataka Maki
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Cardiovascular Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shun Minatsuki
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Mai Shimbo
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Katsura Soma
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Genri Numata
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takayuki Fujiwara
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
33
|
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 461] [Impact Index Per Article: 461.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | | |
Collapse
|
34
|
Rubin LJ, Naeije R. Sotatercept for pulmonary arterial hypertension: something old and something new. Eur Respir J 2023; 61:61/1/2201972. [PMID: 36609525 DOI: 10.1183/13993003.01972-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Lewis J Rubin
- University of California San Diego School of Medicine, San Diego, CA, USA
| | | |
Collapse
|
35
|
Benza RL, Langleben D, Hemnes AR, Vonk Noordegraaf A, Rosenkranz S, Thenappan T, Hassoun PM, Preston IR, Ghio S, Badagliacca R, Vizza CD, Lang IM, Meier C, Grünig E. Riociguat and the right ventricle in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2022; 31:31/166/220061. [PMID: 36198418 DOI: 10.1183/16000617.0061-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are progressive diseases that can lead to right heart failure and death. Right ventricular dysfunction, hypertrophy and maladaptive remodelling are consequences of increased right ventricular (RV) afterload in PAH and CTEPH and are indicative of long-term outcomes. Because RV failure is the main cause of morbidity and mortality in PAH and CTEPH, successful treatments should lead to improvements in RV parameters. Riociguat is a soluble guanylate cyclase stimulator approved for the treatment of PAH and inoperable or persistent/recurrent CTEPH after pulmonary endarterectomy. This review examines the current evidence showing the effect of riociguat on the right ventricle, with particular focus on remodelling, function and structural parameters in preclinical models and patients with PAH or CTEPH.
Collapse
Affiliation(s)
- Raymond L Benza
- Dept of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Stephan Rosenkranz
- Dept of Cardiology and Cologne Cardiovascular Research Center, Cologne University Heart Center, Cologne, Germany
| | - Thenappan Thenappan
- Cardiovascular Division, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Paul M Hassoun
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Irene M Lang
- Division of Cardiology, Dept of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| |
Collapse
|
36
|
Cajigas HR, Burger CD, Cartin-Ceba R, DuBrock H, Swanson K, Vargas HE, Keaveny AP, Watt KD, Krowka M. Portopulmonary Hypertension in Nontransplanted Patients: Results of the Largest US Single-Institution Registry. Mayo Clin Proc 2022; 97:2236-2247. [PMID: 36336515 DOI: 10.1016/j.mayocp.2022.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore clinical characteristics, risk profiles, and outcomes of patients with portopulmonary hypertension (PoPH) who have contraindications to liver transplant (LT). METHODS From the largest US single-institution registry of patients with PoPH, we analyzed 160 patients who did not receive LT between 1988 to 2019. Pulmonary arterial hypertension (PAH)-pertinent characteristics, hemodynamic features, treatments, and risk stratification were compared at baseline, first follow-up visit, and censor/death time. RESULTS Median survival for the entire cohort was 27.5 months from the diagnosis of PoPH. Overall survival was 89%, 77%, 51%, and 38% at 6 months, 1 year, 3 years, and 5 years, respectively. Survival was significantly affected by the severity of liver disease (P<.001). Most patients received PAH-specific therapies (136 [85%]), predominantly monotherapy (123 [77%)]. With treatment, significant improvements were noted in World Health Organization functional class (P=.04), 6-minute walk distance (P<.001), right ventricular function (P<.001), pulmonary vascular resistance (P<.001), and Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL) Lite 2 score (P=.02) univariately. Per European Society of Cardiology risk stratification, no patient met full criteria for low risk at baseline or at follow-up. In a multivariate Cox risk model, 6-minute walk distance, right atrial pressure, pulmonary capillary wedge pressure, bilirubin level, and Model for End-Stage Liver Disease-sodium score of 15 or higher were associated with increased risk of death. CONCLUSION Patients with PoPH who did not undergo LT had a poor prognosis. This persisted despite use of PAH-specific therapies and significant improvements in hemodynamics, echocardiography parameters of right ventricle function, 6-minute walk distance, and World Health Organization functional class.
Collapse
Affiliation(s)
- Hector R Cajigas
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Charles D Burger
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hilary DuBrock
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen Swanson
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Andrew P Keaveny
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Krowka
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
37
|
Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
Collapse
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
| |
Collapse
|
38
|
Comments on the 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 76:294-300. [PMID: 36379365 DOI: 10.1016/j.rec.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/27/2022] [Indexed: 11/14/2022]
|
39
|
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1082] [Impact Index Per Article: 541.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
|
40
|
Nakata T, Shindo T, Ito K, Eguchi K, Monma Y, Ichijo S, Ryoke R, Satoh W, Kumasaka K, Sato H, Kurosawa R, Satoh K, Kawashima R, Miura M, Kanai H, Yasuda S, Shimokawa H. Beneficial Effects of Low-Intensity Pulsed Ultrasound Therapy on Right Ventricular Dysfunction in Animal Models. JACC Basic Transl Sci 2022; 8:283-297. [PMID: 37034290 PMCID: PMC10077125 DOI: 10.1016/j.jacbts.2022.08.010] [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: 06/16/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/05/2022]
Abstract
Right ventricular failure (RVF) is a leading cause of death in patients with pulmonary hypertension; however, effective treatment remains to be developed. We have developed low-intensity pulsed ultrasound therapy for cardiovascular diseases. In this study, we demonstrated that the expression of endothelial nitric oxide synthase (eNOS) in RVF patients was downregulated and that eNOS expression and its downstream pathway were ameliorated through eNOS activation in 2 animal models of RVF. These results indicate that eNOS is an important therapeutic target of RVF, for which low-intensity pulsed ultrasound therapy is a promising therapy for patients with RVF.
Collapse
Affiliation(s)
- Takashi Nakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenta Ito
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kumiko Eguchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuto Monma
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sadamitsu Ichijo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rie Ryoke
- Institute of Development, Aging and Cancer, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Wakako Satoh
- Department of Clinical Physiology, Health Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazunori Kumasaka
- Department of Clinical Physiology, Health Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Haruka Sato
- Department of Clinical Physiology, Health Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryo Kurosawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kimio Satoh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuta Kawashima
- Institute of Development, Aging and Cancer, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masahito Miura
- Department of Clinical Physiology, Health Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Kanai
- Department of Electronic Engineering, Graduate School of Engineering, Tohoku University, Sendai, Japan
- Division of Biomedical Measurements and Diagnostics, Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- International University of Health and Welfare, Narita, Japan
- Address for correspondence: Dr Hiroaki Shimokawa, International University of Health and Welfare, Narita 286-8686, Japan.
| |
Collapse
|
41
|
Badagliacca R, Benza RL, Manzi G, Tello K, Naeije R. Phenotypes of idiopathic pulmonary arterial hypertension. THE LANCET. RESPIRATORY MEDICINE 2022; 10:e89. [PMID: 36179742 DOI: 10.1016/s2213-2600(22)00308-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy.
| | - Raymond L Benza
- Division of Cardiovascular Diseases, Ohio State University, Columbus, OH, USA
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Khodr Tello
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392 Giessen, Germany
| | - Robert Naeije
- Department of Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| |
Collapse
|
42
|
Montani D, Certain MC, Weatherald J, Jaïs X, Bulifon S, Noel-Savina E, Nieves A, Renard S, Traclet J, Bouvaist H, Riou M, de Groote P, Moceri P, Bertoletti L, Favrolt N, Guillaumot A, Jutant EM, Beurnier A, Boucly A, Ebstein N, Jevnikar M, Pichon J, Keddache S, Preda M, Roche A, Solinas S, Seferian A, Reynaud-Gaubert M, Cottin V, Savale L, Humbert M, Sitbon O. COVID-19 in Patients with Pulmonary Hypertension: A National Prospective Cohort Study. Am J Respir Crit Care Med 2022; 206:573-583. [PMID: 35549842 PMCID: PMC9716894 DOI: 10.1164/rccm.202112-2761oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with pulmonary endothelial dysfunction. There are limited data available on the outcomes of coronavirus disease (COVID-19) in patients with pulmonary hypertension (PH), a disease characterized by pulmonary endothelial dysfunction. Objectives: To describe characteristics and outcomes of patients with precapillary PH and COVID-19. Methods: We prospectively collected characteristics, management, and outcomes of adult patients with precapillary PH in the French PH network who had COVID-19 between February 1, 2020, and April 30, 2021. Clinical, functional, and hemodynamic characteristics of PH before COVID-19 were collected from the French PH registry. Measurements and Main Results: A total of 211 patients with PH (including 123 with pulmonary arterial hypertension, 47 with chronic thromboembolic PH, and 41 with other types of PH) experienced COVID-19, and 40.3% of them were outpatients, 32.2% were hospitalized in a conventional ward, and 27.5% were in an ICU. Among hospitalized patients (n = 126), 54.0% received corticosteroids, 37.3% high-flow oxygen, and 11.1% invasive ventilation. Right ventricular and acute renal failure occurred in 30.2% and 19.8% of patients, respectively. Fifty-two patients (all hospitalized) died from COVID-19. Overall mortality was 24.6% (95% CI [confidence interval], 18.8-30.5) and in-hospital mortality 41.3% (95% CI, 32.7-49.9). Nonsurvivors were significantly older, more frequently male and suffering comorbidities (diabetes, chronic respiratory diseases, systemic hypertension, chronic cardiac diseases, and/or chronic renal failure), and had more severe PH at their most recent evaluation preceding COVID-19 diagnosis (in terms of functional class and 6-minute-walk distance; all P < 0.05). Use of pulmonary arterial hypertension therapy was similar between survivors and nonsurvivors. Conclusions: COVID-19 in patients with precapillary PH was associated with a high in-hospital mortality. The typical risk factors for severe COVID-19 and severity of PH were associated with mortality in this population.
Collapse
Affiliation(s)
- David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Marie-Caroline Certain
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada;,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sophie Bulifon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | | | - Ana Nieves
- Service de Pneumologie Centre Hospitalier Universitaire Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Sébastien Renard
- Service de Cardiologie, Centre Régional de Compétences de l'Hypertension Pulmonaire, Hôpital La Timone, Marseille, France
| | - Julie Traclet
- Université Lyon-1, Hospices Civils de Lyon, Centre de Référence des Maladies Pulmonaires Rares, Centre de Compétences de l'Hypertension Pulmonaire, Hôpital Louis Pradel, Lyon, France
| | - Hélène Bouvaist
- Service de Cardiologie, Hôpital Universitaire Grenoble-Alpes, Grenoble, France
| | - Marianne Riou
- Département de Pneumologie, Nouvel Hôpital Civil, Strasbourg, France
| | - Pascal de Groote
- Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Pamela Moceri
- Unité de Recherche Clinique Côte d'Azur, Service de Cardiologie, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Institut National de la Santé et de la Recherche Médicale Unité 1059 et Centre d'Investigation Clinique 1408, Centre Hospitalier Universitaire de Saint-Etienne, Université Jean-Monnet, Saint-Etienne, France
| | - Nicolas Favrolt
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Anne Guillaumot
- Université de Lorraine, Centre Hospitalo-Universitaire Nancy, Pôle des Spécialités Médicales, Département de Pneumologie, Vandoeuvre-lès-Nancy, France; and
| | - Etienne-Marie Jutant
- Université de Poitiers, Centre Hospitalo-Universitaire de Poitiers, Service de pneumologie, Institut National de la Santé et de la Recherche Médicale Centre d'Investigation Clinique 1402, Poitiers, France
| | - Antoine Beurnier
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Physiology – Pulmonary Function Testing, Assistance Publique – Hôpitaux de Paris, Hôpital Bicêtre, Département Médico-Universitaire 5 Thorinno, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Nathan Ebstein
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Jérémie Pichon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sophia Keddache
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Mariana Preda
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Andrei Seferian
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Martine Reynaud-Gaubert
- Service de Pneumologie Centre Hospitalier Universitaire Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Vincent Cottin
- Université Lyon-1, Hospices Civils de Lyon, Centre de Référence des Maladies Pulmonaires Rares, Centre de Compétences de l'Hypertension Pulmonaire, Hôpital Louis Pradel, Lyon, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | | |
Collapse
|
43
|
Hassan HJ, Naranjo M, Kazzi B, Housten-Harris T, Hsu S, Balasubramanian A, Simpson CE, Damico RL, Kolb TM, Mathai SC, Hassoun PM. Risk assessment of systemic sclerosis-associated pulmonary arterial hypertension: cardiac index versus stroke volume index. Eur Respir J 2022; 60:2200801. [PMID: 35896206 DOI: 10.1183/13993003.00801-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/06/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Hussein J Hassan
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mario Naranjo
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brigitte Kazzi
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Traci Housten-Harris
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
44
|
Hoeper MM, Pausch C, Olsson KM, Huscher D, Pittrow D, Grünig E, Staehler G, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Park DH, Ewert R, Kaemmerer H, Kabitz HJ, Skowasch D, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H, Claussen M, Lange TJ, Rosenkranz S. COMPERA 2.0: a refined four-stratum risk assessment model for pulmonary arterial hypertension. Eur Respir J 2022. [PMID: 34737226 PMCID: PMC9260123 DOI: 10.1183/13993003.02311-2021,] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). The current European guidelines propose a three-stratum model to categorise risk as low, intermediate or high, based on the expected 1-year mortality. However, with this model, most patients are categorised as intermediate risk. We investigated a modified approach based on four risk categories, with intermediate risk subdivided into intermediate-low and intermediate-high risk. METHODS We analysed data from the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA), a European pulmonary hypertension registry, and calculated risk at diagnosis and first follow-up based on World Health Organization functional class, 6-min walk distance (6MWD) and serum levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), using refined cut-off values. Survival was assessed using Kaplan-Meier analyses, log-rank testing and Cox proportional hazards models. RESULTS Data from 1655 patients with PAH were analysed. Using the three-stratum model, most patients were classified as intermediate risk (76.0% at baseline and 63.9% at first follow-up). The refined four-stratum risk model yielded a more nuanced separation and predicted long-term survival, especially at follow-up assessment. Changes in risk from baseline to follow-up were observed in 31.1% of the patients with the three-stratum model and in 49.2% with the four-stratum model. These changes, including those between the intermediate-low and intermediate-high strata, were associated with changes in long-term mortality risk. CONCLUSIONS Modified risk stratification using a four-stratum model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically relevant changes in risk than the original three-stratum model.
Collapse
Affiliation(s)
- Marius M. Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany,Corresponding author: Marius M. Hoeper ()
| | | | - Karen M. Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany,Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Dept of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Dept of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J. Simon R. Gibbs
- Dept of Cardiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven – University of Leuven, Leuven, Belgium
| | - H. Ardeschir Ghofrani
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany,Dept of Medicine, Imperial College London, London, UK
| | - Da-Hee Park
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Dept of Respiratory Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für angeborene Herzfehler und Kinderkardiologie, TU München, Munich, Germany
| | - Hans-Joachim Kabitz
- Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Medizinische Klinik II, Konstanz, Germany
| | - Dirk Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik II, Innere Medizin – Kardiologie/Pneumologie, Bonn, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungenforschungsambulanz, Helmholtz Zentrum, München, Germany,Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Universitätsklinikum Leipzig, Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Leipzig, Germany
| | - Matthias Held
- Dept of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- Attikon University Hospital, 2nd Critical Care Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Dept of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Martin Claussen
- LungenClinic Grosshansdorf, Fachabteilung Pneumologie, Großhansdorf, Germany
| | - Tobias J. Lange
- Dept of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| |
Collapse
|
45
|
Liu L, Wei Y, Giunta S, He Q, Xia S. Potential Role of Cellular Senescence in Pulmonary Arterial Hypertension. Clin Exp Pharmacol Physiol 2022; 49:1042-1049. [PMID: 35748218 DOI: 10.1111/1440-1681.13696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare and chronic lung vasculature disease characterized by pulmonary vasculature remodeling, including abnormal proliferation of pulmonary artery smooth muscle cells (PASMCs) and dysfunctional endothelial cells (ECs). Remodeling of the pulmonary vasculature occurs from maturity to senescence, and it has become apparent that cellular senescence plays a central role in the pathogenesis of various degenerative vascular diseases and pulmonary pathologies. Cellular senescence represents a state of stable proliferative arrest accompanied by the senescence-associated secretory phenotype (SASP), which entails the copious secretion of proinflammatory signals in the tissue microenvironment. Evidences show that in PAH patients, higher levels of cytokines, chemokines, and inflammatory mediators can be detected and correlate with clinical outcome. Moreover, senescent cells accrue with age in epithelial, endothelial, fibroblastic, and immunological compartments within human lungs, and evidence showed that ECs and PASMCs in lungs from patients with chronic obstructive pulmonary disease were characterized by a higher number of senescent cells. However, there is little evidence uncovering the molecular pulmonary vasculature senescence in PAH. Herein, we review the cellular senescence in pulmonary vascular remodeling, and emphasize its importance in PAH. We further introduce some signaling pathways which might be involved in vasculature senescence and PAH, with the intent to discuss the possibility of the PAH therapy via targeting cellular senescence and reduce PAH progression and mortality.
Collapse
Affiliation(s)
- Lumei Liu
- College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, PR China
| | - Yaqin Wei
- Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, PR China
| | - Sergio Giunta
- Casa di Cura Prof. Nobili-GHC Garofalo Health Care, Bologna, Italy
| | - Qinghu He
- College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, PR China.,Hunan University of Medicine, Huaihua, PR China
| | - Shijin Xia
- Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, PR China
| |
Collapse
|
46
|
Wissmüller M, Xanthouli P, Benjamin N, Grünig E, Richter MJ, Gall H, Ghofrani HA, Herkenrath S, Skowasch D, Pizarro C, Halank M, Hohmann C, Hellmich M, Gerhardt F, Rosenkranz S. Profiles and treatment patterns of patients with pulmonary arterial hypertension on monotherapy at experienced centres. ESC Heart Fail 2022; 9:2873-2885. [PMID: 35706353 DOI: 10.1002/ehf2.13804] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Guideline recommendations highlight the critical role of combination therapy for the treatment of pulmonary arterial hypertension (PAH). Conversely, registry data demonstrate that a considerable number of PAH patients remain on monotherapy. The reasons for this discrepancy remain elusive. The aim of this study was to assess the patient profiles, treatment patterns, and disease characteristics of patients diagnosed with PAH who were kept on monotherapy at experienced pulmonary hypertension (PH) centres and to capture potential reasons for monotherapy. METHODS AND RESULTS We analysed the patient profiles of 182 patients on monotherapy with PAH-targeted drugs, managed at experienced PH expert centres (Cologne, Giessen, Heidelberg, and Dresden). Patients were identified based on their latest follow-up visit and analysed retrospectively from the time of PAH diagnosis to last follow-up. Patients were dichotomized by age, and patient characteristics, treatment patterns, response to therapy, change in risk status, and drug tolerability were recorded during the course of their disease. Patients' mean age was 69.1 ± 13.1 years at the most recent follow-up (Key Time Point 1) and 64.5 ± 14.9 years at the time of diagnosis (Key Time Point 2). The mean time on monotherapy was 60.7 ± 53.8 months; 35.7/64.3% of patients were male/female. The majority (66.5%) had idiopathic PAH, followed by PAH associated with connective tissue disease (17.0%) and portopulmonary PH (8.2%). Among patients on monotherapy, there were five main clusters: (i) patients with failed escalation attempts mostly because of intolerability (26.9%); (ii) low risk on monotherapy, favourable response, and no reason for escalation (24.2%); (iii) patients with mild PAH (36.3%); (iv) elderly patients with PAH and multiple co-morbidities (38.5%); and (v) patients with associated forms of PAH where the level of evidence for combination therapies is considered low (16.5%). There were substantial differences between patients above or below the median age (68 years). The most frequently used monotherapy for PAH was phosphodiesterase type 5 inhibitors (75.3%). CONCLUSIONS A considerable number of PAH patients are on monotherapy at large PH expert centres, characterized by specific reasons that justify this kind of treatment. Nevertheless, as comprehensive treatment strategies have shown improved long-term outcomes even in mildly symptomatic patients, each case of monotherapy should be justified.
Collapse
Affiliation(s)
- Max Wissmüller
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Manuel J Richter
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Henning Gall
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Simon Herkenrath
- Institute for Pneumology, University of Cologne, Solingen, Germany
- Bethanien Hospital, Clinic of Pneumology and Allergology Center for Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Dirk Skowasch
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Carmen Pizarro
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Michael Halank
- Medizinische Klinik I, Universitätsklinik Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Christopher Hohmann
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Martin Hellmich
- Institut für Medizinische Statistik, Informatik und Epidemiologie (IMSIE), Universität zu Köln, Cologne, Germany
| | - Felix Gerhardt
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Stephan Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Universität zu Köln, Cologne, Germany
| |
Collapse
|
47
|
Butcher SC, Feloukidis C, Kamperidis V, Yedidya I, Stassen J, Fortuni F, Vrana E, Mouratoglou SA, Boutou A, Giannakoulas G, Playford D, Ajmone Marsan N, Bax JJ, Delgado V. Right Ventricular Myocardial Work Characterization in Patients With Pulmonary Hypertension and Relation to Invasive Hemodynamic Parameters and Outcomes. Am J Cardiol 2022; 177:151-161. [PMID: 35691706 DOI: 10.1016/j.amjcard.2022.04.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
Abstract
Noninvasive evaluation of indexes of right ventricular (RV) myocardial work (RVMW) derived from RV pressure-strain loops may provide novel insights into RV function in precapillary pulmonary hypertension. This study was designed to evaluate the association between the indexes of RVMW and invasive parameters of right heart catheterization and all-cause mortality. Noninvasive analysis of RVMW was completed in 51 patients (mean age 58.1 ± 12.7 years, 31% men) with group I or group IV pulmonary hypertension. RV global work index (RVGWI), RV global constructive work (RVGCW), RV global wasted work (RVGWW), and RV global work efficiency (RVGWE) were compared with parameters derived invasively during right heart catheterization. Patients were followed-up for the occurrence of all-cause death. The median RVGWI, RVGCW, RVGWW, and RVGWE were 620 mm Hg%, 830 mm Hg%, 105 mm Hg% and 87%, respectively. Compared with conventional echocardiographic parameters of RV systolic function, RVGCW and RVGWI correlated more closely with invasively derived RV stroke work index (R = 0.63, p <0.001 and R = 0.60, p <0.001, respectively). Invasively derived pulmonary vascular resistance correlated with RVGWW (R = 0.63, p <0.001), RVGWE (R = 0.48, p <0.001), and RV global longitudinal strain (R = 0.58, p <0.001). RVGCW (hazard ratio 1.42 per 100 mm Hg% <900 mm Hg%, 95% confidence interval 1.12 to 1.81, p = 0.004) and RVGWI (hazard ratio 1.46 per 100 mm Hg% <650 mm Hg%, 95% confidence interval 1.09 to 1.94, p = 0.010) were significantly associated with all-cause mortality, whereas RV global longitudinal strain, RVGWE, and RVGWW were not. In conclusion, indexes of RVMW were more closely correlated with invasively derived RV stroke work index and peripheral vascular resistance than conventional echocardiographic parameters of RV systolic function. Decreased values of RVGCW and RVGWI were associated with all-cause mortality, whereas conventional echocardiographic parameters of RV function were not.
Collapse
Affiliation(s)
- Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Christos Feloukidis
- Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - Vasileios Kamperidis
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - Idit Yedidya
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Division of Cardiology, "Città della Salute della Scienza" University Hospital, Turin, Italy
| | - Elena Vrana
- Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - Sophia A Mouratoglou
- Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - Afroditi Boutou
- Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University, Thessaloniki, Greece
| | - David Playford
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
48
|
Suzuki S, Asano R, Aoki T, Nakayama S, Ueda J, Tsuji A, Noguchi T, Ogo T. Prognostic impact of follow-up pulmonary vascular resistance in pulmonary arterial hypertension. Open Heart 2022; 9:openhrt-2022-002054. [PMID: 35675988 PMCID: PMC9185661 DOI: 10.1136/openhrt-2022-002054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Pulmonary arterial hypertension (PAH), caused by pulmonary artery remodelling and increased pulmonary vascular resistance (PVR) due to an unknown mechanism, is an intractable disease with a poor prognosis. The recent development of PAH-specific treatment medications may allow for higher PVR reduction than previously achieved. This study aimed to identify the prognostic significance of follow-up PVR levels achieved shortly after the initiation of targeted treatment in patients with idiopathic/heritable pulmonary arterial hypertension (I/H-PAH). Methods We analysed the data of all patients with I/H-PAH admitted to our hospital between 1998 and 2019. We collected data at baseline and during the first invasive haemodynamic evaluation. The primary outcome was death or lung transplantation. Results Of the 133 treatment-naïve patients enrolled in this study, 47 experienced adverse events during a median follow-up period of 6.4 (IQR 3.5–11.5) years. The median time interval to first follow-up from diagnosis was 162 (IQR 117–253) days. Incidence of the primary outcome was significantly lower in patients who achieved low PVR at follow-up. Of risk factors evaluated at follow-up, the multivariate Cox regression analysis revealed PVR as an independent predictor of the primary outcome (HR 1.103, 95% CI 1.029 to 1.183; p=0.006). The results were consistent across risk profiles according to the simplified risk stratification recommended by the European Society of Cardiology and European Respiratory Society guidelines. Conclusion Follow-up PVR was an independent predictor of transplant-free survival in patients with I/H-PAH. Evaluation of haemodynamic status shortly after initiating treatment may help predict long-term prognosis.
Collapse
Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sayuri Nakayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
49
|
Vicenzi M, Caravita S, Rota I, Casella R, Deboeck G, Beretta L, Lombi A, Vachiery JL. The added value of right ventricular function normalized for afterload to improve risk stratification of patients with pulmonary arterial hypertension. PLoS One 2022; 17:e0265059. [PMID: 35587927 PMCID: PMC9119555 DOI: 10.1371/journal.pone.0265059] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Risk stratification is central to the management of pulmonary arterial hypertension (PAH). For this purpose, multiparametric tools have been developed, including the ESC/ERS risk score and its simplified versions derived from large database analysis such as the COMPERA and the French Pulmonary Hypertension Network (FPHN) registries. However, the distinction between high and intermediate-risk profiles may be difficult as the latter lacks granularity. In addition, neither COMPERA or FPHN strategies included imaging-derived markers. We thus aimed at investigating whether surrogate echocardiographic markers of right ventricular (RV) to pulmonary artery (PA) coupling could improve risk stratification in patients at intermediate-risk. Material and methods A single-center retrospective analysis including 102 patients with a diagnosis of PAH was performed. COMPERA and FPHN strategies were applied to stratify clinical risk. The univariate linear regression was used to test the influence of the echo-derived parameters qualifying the right heart (right ventricle basal diameter, right atrial area, and pressure, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion -TAPSE-). Among these, the TAPSE and tricuspid regurgitation velocity ratio (TAPSE/TRV) as well as the TAPSE and systolic pulmonary artery pressure ratio (TAPSE/sPAP) were considered as surrogate of RV-PA coupling. Results TAPSE/TRV and TAPSE/sPAP resulted the more powerful markers of prognosis. Once added to COMPERA, TAPSE/TRV or TAPSE/sPAP significantly dichotomized intermediate-risk group in intermediate-to-low-risk (TAPSE/TRV≥3.74 mm∙nm/s)-1 or TAPSE/sPAP≥0.24 mm/mmHg) and in intermediate-to-high-risk subgroups (TAPSE/TRV<3.74 mm∙(m/s)-1 or TAPSE/sPAP<0.24 mm/mmHg). In the same way, TAPSE/TRV or TAPSE/sPAP was able to select patients at lower risk among those with 2, 1, and 0 low-risk criteria of both invasive and non-invasive FPHN registries. Conclusions Our results suggest that adopting functional-hemodynamic echo-derived parameters may provide a more accurate risk stratification in patients with PAH. In particular, TAPSE/TRV or TAPSE/sPAP improved risk stratification in patients at intermediate-risk, that otherwise would have remained less characterized.
Collapse
Affiliation(s)
- Marco Vicenzi
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
| | - Irene Rota
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Rosa Casella
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gael Deboeck
- Faculty of Motricity Sciences, Department of Physiotherapy, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Lombi
- Department of Health Science, Pulmonology Unit, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| |
Collapse
|
50
|
Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
Collapse
Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
| |
Collapse
|