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Mathai SC. Pulmonary Hypertension Associated with Connective Tissue Disease. Rheum Dis Clin North Am 2024; 50:359-379. [PMID: 38942575 DOI: 10.1016/j.rdc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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2
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Gerges C, Beurnier A, Jaïs X, Hervé P, Lau EMT, Girerd B, Günther S, Bouchachi A, Jevnikar M, Boucly A, Bogaard HJ, Simonneau G, Sitbon O, Savale L, Chemla D, Humbert M, Montani D. Exercise Hemodynamics Predict Pulmonary Arterial Hypertension in BMPR2 Mutation Carriers. Chest 2024:S0012-3692(24)04839-6. [PMID: 39059577 DOI: 10.1016/j.chest.2024.06.3808] [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: 03/08/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Exercise hemodynamics are recommended for early detection of pulmonary arterial hypertension (PAH) and have been suggested to be predictive of future development of PAH in high-risk populations such as BMPR2 mutation carriers. However, the optimal exercise hemodynamic screening parameter remains to be determined. Recent data suggest that pulmonary vascular distensibility coefficient (α) may serve as a useful parameter for early detection of PAH. RESEARCH QUESTION What is the value of exercise hemodynamics, including α, for predicting the occurrence of PAH during long-term follow-up in BMPR2 mutation carriers? STUDY DESIGN AND METHODS Fifty-two asymptomatic BMPR2 mutation carriers who underwent symptom-limited exercise hemodynamic assessment were followed up for a median of 10 years. The impact of hemodynamics at rest and exercise, presence of exercise pulmonary hypertension, and α on occurrence of PAH during long-term follow-up were assessed. RESULTS During long-term follow-up, five patients demonstrated PAH. Patients who demonstrated PAH showed a significantly lower α (0.8 ± 0.4%/mm Hg) than patients without PAH (1.8 ± 0.8%/mm Hg; P = .008). The only hemodynamic parameter that predicted the occurrence of PAH during long-term follow-up at regression analysis was α. Receiver operating characteristic analysis showed that α ≤ 1.5%/mm Hg predicted PAH occurrence with a specificity of 75% and sensitivity of 100%. INTERPRETATION Before development of PAH in BMPR2 mutation carriers, α is reduced markedly and may serve as a useful parameter in the setting of early disease detection. Given the low event rate, caution is warranted in interpreting these results, highlighting the need for validation studies.
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Affiliation(s)
- Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria; School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Antoine Beurnier
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Xavier Jaïs
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Philippe Hervé
- INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France; Service de Chirurgie Thoracique, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Edmund M T Lau
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Barbara Girerd
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Sven Günther
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Amir Bouchachi
- Service de Physiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; Service de Cardiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Mitja Jevnikar
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Athénaïs Boucly
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Gérald Simonneau
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Olivier Sitbon
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Laurent Savale
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Denis Chemla
- Service de Physiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - David Montani
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France.
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3
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Todesco A, Grynblat J, Akoumia KKF, Bonnet D, Mendes‐Ferreira P, Morisset S, Chemla D, Levy M, Méot M, Malekzadeh‐Milani S, Tielemans B, Decante B, Vastel‐Amzallag C, Habert P, Ghigna M, Humbert M, Montani D, Boulate D, Perros F. Pulmonary Hypertension Induced by Right Pulmonary Artery Occlusion: Hemodynamic Consequences of Bmpr2 Mutation. J Am Heart Assoc 2024; 13:e034621. [PMID: 38979789 PMCID: PMC11292755 DOI: 10.1161/jaha.124.034621] [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: 02/17/2024] [Accepted: 05/28/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND The primary genetic risk factor for heritable pulmonary arterial hypertension is the presence of monoallelic mutations in the BMPR2 gene. The incomplete penetrance of BMPR2 mutations implies that additional triggers are necessary for pulmonary arterial hypertension occurrence. Pulmonary artery stenosis directly raises pulmonary artery pressure, and the redirection of blood flow to unobstructed arteries leads to endothelial dysfunction and vascular remodeling. We hypothesized that right pulmonary artery occlusion (RPAO) triggers pulmonary hypertension (PH) in rats with Bmpr2 mutations. METHODS AND RESULTS Male and female rats with a 71 bp monoallelic deletion in exon 1 of Bmpr2 and their wild-type siblings underwent acute and chronic RPAO. They were subjected to full high-fidelity hemodynamic characterization. We also examined how chronic RPAO can mimic the pulmonary gene expression pattern associated with installed PH in unobstructed territories. RPAO induced precapillary PH in male and female rats, both acutely and chronically. Bmpr2 mutant and male rats manifested more severe PH compared with their counterparts. Although wild-type rats adapted to RPAO, Bmpr2 mutant rats experienced heightened mortality. RPAO induced a decline in cardiac contractility index, particularly pronounced in male Bmpr2 rats. Chronic RPAO resulted in elevated pulmonary IL-6 (interleukin-6) expression and decreased Gdf2 expression (corrected P value<0.05 and log2 fold change>1). In this context, male rats expressed higher pulmonary levels of endothelin-1 and IL-6 than females. CONCLUSIONS Our novel 2-hit rat model presents a promising avenue to explore the adaptation of the right ventricle and pulmonary vasculature to PH, shedding light on pertinent sex- and gene-related effects.
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MESH Headings
- Animals
- Bone Morphogenetic Protein Receptors, Type II/genetics
- Bone Morphogenetic Protein Receptors, Type II/metabolism
- Female
- Male
- Pulmonary Artery/physiopathology
- Pulmonary Artery/metabolism
- Hemodynamics
- Disease Models, Animal
- Mutation
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/metabolism
- Rats
- Rats, Sprague-Dawley
- Vascular Remodeling/genetics
- Pulmonary Arterial Hypertension/physiopathology
- Pulmonary Arterial Hypertension/genetics
- Pulmonary Arterial Hypertension/metabolism
- Pulmonary Arterial Hypertension/etiology
- Stenosis, Pulmonary Artery/genetics
- Stenosis, Pulmonary Artery/physiopathology
- Stenosis, Pulmonary Artery/metabolism
- Arterial Pressure
- Myocardial Contraction/physiology
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Affiliation(s)
- Alban Todesco
- Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, North HospitalAix Marseille University, Assistance Publique‐Hôpitaux de MarseilleMarseilleFrance
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Julien Grynblat
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
| | - Kouamé Kan Firmin Akoumia
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Damien Bonnet
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Pedro Mendes‐Ferreira
- Cardiovascular R&D Centre, UnIC@RISE, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
- Paris‐Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERMUniversité Paris‐SaclayParisFrance
| | | | - Denis Chemla
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
| | - Marilyne Levy
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Mathilde Méot
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Sophie‐Guiti Malekzadeh‐Milani
- M3C‐Necker, Hôpital Necker‐Enfants maladesAP‐HP Université de Paris Cité, Cardiologie Congénitale et PédiatriqueParisFrance
| | - Birger Tielemans
- Department of Imaging and Pathology, Biomedical MRI unit/MosaicKU LeuvenLeuvenBelgium
| | - Benoit Decante
- Preclinical Research Laboratory, Pulmonary Hypertension National Referral Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint JosephParis‐Saclay UniversityLe Plessis RobinsonFrance
| | - Carine Vastel‐Amzallag
- Paediatric Cardiology, Centre de Spécialités Pédiatriques de l’Est Parisien, CSPEPCréteilFrance
| | - Paul Habert
- Department of RadiologyNorth Hospital, Assistance Publique–Hôpitaux de MarseilleMarseilleFrance
- Aix Marseille Univ, LIIEMarseilleFrance
| | - Maria‐Rosa Ghigna
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Department of PathologyInstitut Gustave RoussyVillejuifFrance
| | - Marc Humbert
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
- AP‐HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral CentreDMU 5 Thorinno, Hôpital BicêtreLe Kremlin‐BicêtreFrance
| | - David Montani
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Faculty of Medicine Le Kremlin‐BicêtreUniversité Paris‐SaclayBures‐sur‐YvetteFrance
- AP‐HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral CentreDMU 5 Thorinno, Hôpital BicêtreLe Kremlin‐BicêtreFrance
| | - David Boulate
- Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, North HospitalAix Marseille University, Assistance Publique‐Hôpitaux de MarseilleMarseilleFrance
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- COMPutational Pharmacology and clinical Oncology (COMPO), INRIA‐INSERMAix Marseille UniversityMarseilleFrance
| | - Frédéric Perros
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel TherapiesLe Plessis RobinsonFrance
- Paris‐Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERMUniversité Paris‐SaclayParisFrance
- CarMeN Laboratory, INSERM U1060, INRAE U1397Université Claude Bernard Lyon1Pierre‐BéniteFrance
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Singh I, Waxman AB. The casting of invasive cardiopulmonary exercise testing: towards a common goal. Eur Respir J 2024; 64:2400783. [PMID: 38991723 DOI: 10.1183/13993003.00783-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine and Yale New Haven Hospital, New Haven, CT, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
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5
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Campedelli L, Nouraie SM, Risbano MG. Non-arterial line cardiac output calculation misclassifies exercise pulmonary hypertension and increases risk of data loss particularly in black, scleroderma and Raynaud's patients during invasive exercise testing. Eur Respir J 2024; 64:2302232. [PMID: 38782468 DOI: 10.1183/13993003.02232-2023] [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: 12/13/2023] [Accepted: 05/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The direct Fick principle is the standard for calculating cardiac output (CO) to detect CO-dependent conditions like exercise pulmonary hypertension (ePH). Fick COarterial incorporates arterial haemoglobin (Hba) and oxygen saturation (S aO2 ) with oxygen consumption from exercise testing, while Fick COnon-arterial substitutes mixed venous haemoglobin (Hbmv) and peripheral oxygen saturation (S pO2 ) in the absence of an arterial line. The decision to employ an arterial catheter for exercise testing varies, and discrepancies in oxygen saturation and haemoglobin between arterial and non-arterial methods may lead to differences in Fick CO, potentially affecting ePH classification. METHODS We performed a retrospective analysis of 296 consecutive invasive cardiopulmonary exercise testing (iCPET) studies comparing oxygen saturation from pulse oximetry (S pO2 ) and radial arterial (S aO2 ), Hba and Hbmv, and CO calculated with arterial (COarterial) and non-arterial (COnon-arterial) values. We assessed the risk of misclassification of pre- and post-capillary ePH and data loss due to inaccurate S pO2 . RESULTS When considering all stages from rest to peak exercise, Hba and Hbmv demonstrated high correlation, while S pO2 and S aO2 as well as COarterial and COnon-arterial demonstrated low correlation. Data loss was significantly higher across all stages of exercise for S pO2 (n=346/1926 (18%)) compared to S aO2 (n=17/1923 (0.88%)). We found that pre- and post-capillary ePH were misclassified as COnon-arterial data (n=7/41 (17.1%) and n=2/23 (8.7%), respectively). Patients with scleroderma and/or Raynaud's (n=11/33 (33.3%)) and black patients (n=6/19 (31.6%)) had more S pO2 data loss. CONCLUSION Reliance upon S pO2 during invasive exercise testing results in the misclassification of pre- and post-capillary ePH, and unmeasurable S pO2 for black, scleroderma and Raynaud's patients can preclude accurate exercise calculations, thus limiting the diagnostic and prognostic value of invasive exercise testing without an arterial line.
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Affiliation(s)
- Luiz Campedelli
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - S Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Michael G Risbano
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
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Naguib M, Aljwaid A, Marella D, Flores RJ, Singh A. Nitroprusside Combined with Leg Raise at the Time of Right Heart Catheterization to Differentiate Precapillary from Other Hemodynamic Forms of Pulmonary Hypertension: A Single-Center Pilot Study. J Cardiovasc Dev Dis 2024; 11:124. [PMID: 38667742 PMCID: PMC11050046 DOI: 10.3390/jcdd11040124] [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: 01/23/2024] [Revised: 04/13/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Pulmonary hypertension (PH) can arise from several distinct disease processes, with a percentage presenting with combined pre- and postcapillary pulmonary hypertension (cpcPH). Patients with cpcPH are unsuitable candidates for PH-directed therapies due to elevated pulmonary capillary wedge pressures (PCWPs); however, the PCWP is dynamic and is affected by both preload and afterload. Many patients that are diagnosed with cpcPH are hypertensive at the time of right heart catheterization which has the potential to increase the PCWP and, therefore, mimic a more postcapillary-predominant phenotype. In this small pilot study, we examine the effect of nitroprusside combined with dynamic preload augmentation with a passive leg raise maneuver in hypertensive cpcPH patients at the time of right heart catheterization to identify a more precapillary-dominant PH phenotype. Patients that met the criteria of PCWP ≤ 15 mmHg with nitroprusside infusion and PCWP ≤ 18 mmHg with nitroprusside infusion and simultaneous leg raise were started on pulmonary vascular-targeted therapy. Long-term PH therapy was well tolerated, with increased six-minute walk distance, improved WHO functional class, decreased NT-proBNP, and improved REVEAL 2.0 Lite Risk Score in this precapillary-dominant PH phenotype. This small study highlights the importance of characterizing patient physiology beyond resting conditions at the time of right heart catheterization.
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Affiliation(s)
- Mostafa Naguib
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Ahmed Aljwaid
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Dean Marella
- Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Raul J. Flores
- Heart Success Program (Advanced Heart Failure Program), Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Abhishek Singh
- Heart Success Program (Advanced Heart Failure Program), Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
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7
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Panagiotidou E, Βoutou A, Fouka E, Papakosta D, Chatzopoulos E, Sourla E, Markopoulou A, Kioumis I, Stanopoulos I, Pitsiou G. Phenotyping exercise limitation of patients with Interstitial Fibrosing Lung Disease: the importance of exercise hemodynamics. Pulmonology 2024; 30:104-112. [PMID: 35568651 DOI: 10.1016/j.pulmoe.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Left-heart dysfunction and pulmonary vasculopathy are increasingly recognized as contributing factors of exercise capacity limitation in interstitial fibrosing lung disease (IFLD). Moreover, the clinical significance of exercise pulmonary hypertension (ePH) in pulmonary and cardiac diseases has been documented, representing a risk factor for decreased exercise capacity and survival, progression to resting pulmonary hypertension (PH) and overall clinical worsening. We conducted a prospective study aiming at: (a) assessing the prevalence of PH and ePH in a cohort of 40 functionally limited patients with IFLD, (b) determining the post-capillary (postC) or pre-capillary (preC) etiology of either PH or ePH in this cohort, and (c) examining the correlations between invasively and non-invasively measured exercise variables among hemodynamic groups. PATIENTS AND METHODS 40 IFLD patients underwent cardiopulmonary evaluation, including: clinical examination, lung function tests, 6-minute walking test, heart ultrasonography, cardiopulmonary exercise test and, finally, right heart catheterization (RHC). Resting hemodynamic evaluation was followed by the exercise protocol proposed by Herve et al, using a bedside cycle ergometer in the supine position. Abnormal elevation of mean pulmonary artery pressure (mPAP) above 30mmHg during exercise, with respect to abnormal elevation of cardiac output (CO) below 10 L/min (mPAP-CO ratio ⩾3 mmHg·min·L-1) was used to define ePH (Herve et al, 2015). Secondary hemodynamic evaluation involved detection of abnormal pulmonary arterial wedge pressure (PAWP) increase at peak exercise in relation to CO. Specifically, ΔPAWP/ΔCO >2 mmHg/L per minute determined an abnormal PAWP elevation (Bentley et al, 2020). RESULTS Among the 40-patient cohort, 25% presented postC PH, 37.5% preC PH, 27.5% ePH, with the remaining 10% recording normal hemodynamics. PAWP evaluation during exercise revealed a postC etiology in 4 out of the 11 patients presenting ePH, and a postC etiology in 6 out of the 15 patients presenting resting preC PH. Mean values of non-invasive variables did not display statistically significant differences among hemodynamic groups, except for: diffusing capacity for carbon monoxide (DLCO), carbon monoxide transfer coefficient (KCO) and the ratio of functional vital capacity to DLCO (FVC%/DLCO%), which were lower in both ePH and PH groups (p < 0.05). Resting values of CO, cardiac index (CI), stroke volume (SV) and pulmonary vascular compliance (PVC) were significantly impaired in ePH, preC-PH and postC-PH groups when compared to the normal group. CONCLUSIONS Both PH and ePH were highly prevalent within the IFLD patient group, suggesting that RHC should be offered more frequently in functionally limited patients. Diffusion capacity markers must thus guide decision making, in parallel to clinical evaluation. ePH was associated to lower resting CO and PVC, in a similar way to resting PH, indicating the relevance of cardiopulmonary function to exercise limitation. Finally, the use of the ΔPAWP/ΔCO>2 criterion further uncovered PH of postcapillary etiology, highlighting the complexity of hemodynamics in IFLD. CLINICALTRIALS gov ID: NCT03706820.
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Affiliation(s)
- E Panagiotidou
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - A Βoutou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - E Fouka
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Papakosta
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Chatzopoulos
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Sourla
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Markopoulou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - I Kioumis
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - I Stanopoulos
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - G Pitsiou
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
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Vaidy A, Vahdatpour CA, Mazurek J. Exercise Testing in Patients with Pulmonary Hypertension. J Clin Med 2024; 13:795. [PMID: 38337493 PMCID: PMC10855991 DOI: 10.3390/jcm13030795] [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: 12/21/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Pulmonary hypertension (PH), defined by a mean pulmonary artery pressure of >20 mm Hg, often presents with non-specific symptoms such as dyspnea and exercise intolerance, making it difficult to diagnose early before the onset of right heart dysfunction. Therefore, exercise testing can be of great utility for clinicians who are evaluating patients with an unclear etiology of exercise intolerance by helping identify the underlying mechanisms of their disease. The presence of PH is associated with adverse clinical outcomes, with distinct differences and patterns in the cardiovascular and ventilatory responses to exercise across various PH phenotypes. We discuss the role of exercise-invasive hemodynamic testing, cardiopulmonary exercise testing, and exercise stress echocardiography modalities across the spectrum of PH.
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Affiliation(s)
- Anika Vaidy
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Cyrus A. Vahdatpour
- Division of Pulmonary Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Jeremy Mazurek
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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9
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Singh N, Eickhoff C, Garcia-Agundez A, Bertone P, Paudel SS, Tambe DT, Litzky LA, Cox-Flaherty K, Klinger JR, Monaghan SF, Mullin CJ, Pereira M, Walsh T, Whittenhall M, Stevens T, Harrington EO, Ventetuolo CE. Transcriptional profiles of pulmonary artery endothelial cells in pulmonary hypertension. Sci Rep 2023; 13:22534. [PMID: 38110438 PMCID: PMC10728171 DOI: 10.1038/s41598-023-48077-6] [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: 08/11/2023] [Accepted: 11/22/2023] [Indexed: 12/20/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by endothelial cell (EC) dysfunction. There are no data from living patients to inform whether differential gene expression of pulmonary artery ECs (PAECs) can discern disease subtypes, progression and pathogenesis. We aimed to further validate our previously described method to propagate ECs from right heart catheter (RHC) balloon tips and to perform additional PAEC phenotyping. We performed bulk RNA sequencing of PAECs from RHC balloons. Using unsupervised dimensionality reduction and clustering we compared transcriptional signatures from PAH to controls and other forms of pulmonary hypertension. Select PAEC samples underwent single cell and population growth characterization and anoikis quantification. Fifty-four specimens were analyzed from 49 subjects. The transcriptome appeared stable over limited passages. Six genes involved in sex steroid signaling, metabolism, and oncogenesis were significantly upregulated in PAH subjects as compared to controls. Genes regulating BMP and Wnt signaling, oxidative stress and cellular metabolism were differentially expressed in PAH subjects. Changes in gene expression tracked with clinical events in PAH subjects with serial samples over time. Functional assays demonstrated enhanced replication competency and anoikis resistance. Our findings recapitulate fundamental biological processes of PAH and provide new evidence of a cancer-like phenotype in ECs from the central vasculature of PAH patients. This "cell biopsy" method may provide insight into patient and lung EC heterogeneity to advance precision medicine approaches in PAH.
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Affiliation(s)
- Navneet Singh
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Carsten Eickhoff
- Department of Computer Science, Brown University, Providence, RI, USA
| | | | - Paul Bertone
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sunita S Paudel
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, AL, USA
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Dhananjay T Tambe
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, AL, USA
- Department of Pharmacology, College of Medicine, University of South Alabama, Mobile, AL, USA
- Department of Mechanical Aerospace and Biomedical Engineering, College of Engineering, University of South Alabama, Mobile, AL, USA
| | - Leslie A Litzky
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - James R Klinger
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sean F Monaghan
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher J Mullin
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Mary Whittenhall
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, AL, USA
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Elizabeth O Harrington
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
- Vascular Research Laboratory, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Corey E Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA.
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10
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Lechartier B, Kularatne M, Jaïs X, Humbert M, Montani D. Updated Hemodynamic Definition and Classification of Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:721-727. [PMID: 37595614 DOI: 10.1055/s-0043-1770115] [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: 08/20/2023]
Abstract
Pulmonary hypertension (PH) is a pathophysiological manifestation of a heterogeneous group of diseases characterized by abnormally elevated pulmonary arterial pressures diagnosed on right heart catheterization. The 2022 European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the diagnosis and treatment of PH provides a new hemodynamic definition to define PH by lowering the threshold of the mean pulmonary artery pressure (mPAP) to 20 mm Hg. Precapillary PH is thus now defined as a mPAP >20 mm Hg together with a normal pulmonary artery wedge pressure (<15 mm Hg) and an increased pulmonary vascular resistance (>2 Wood Units). The ESC/ERS 2022 Guidelines also introduce a revised clinical classification of PH while retaining its previous distinction between the five groups according to the underlying pathophysiology.
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Affiliation(s)
- Benoit Lechartier
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Respiratory Division, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Mithum Kularatne
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Canada
| | - Xavier Jaïs
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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11
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Boucly A, Gerges C, Savale L, Jaïs X, Jevnikar M, Montani D, Sitbon O, Humbert M. Pulmonary arterial hypertension. Presse Med 2023; 52:104168. [PMID: 37516248 DOI: 10.1016/j.lpm.2023.104168] [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: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laurent Savale
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
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12
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Baratto C, Caravita S, Dewachter C, Faini A, Perego GB, Bondue A, Senni M, Muraru D, Badano LP, Parati G, Vachiéry JL. Right Heart Adaptation to Exercise in Pulmonary Hypertension: An Invasive Hemodynamic Study. J Card Fail 2023; 29:1261-1272. [PMID: 37150503 DOI: 10.1016/j.cardfail.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Right heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise. METHODS AND RESULTS We analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16-24 mm Hg] vs 12 mm Hg [9-19 mm Hg] and 3.47 mm Hg/L/min [2.02-6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01-4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation. CONCLUSIONS Patients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy.
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | | | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
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13
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Sánchez-Aguilera Sánchez-Paulete P, Lázaro Salvador M, Berenguel Senén A, Méndez Perles C, Rodríguez Padial L. Role of cardiopulmonary exercise test in early diagnosis of pulmonary hypertension in scleroderma patients. Med Clin (Barc) 2023; 160:283-288. [PMID: 36049974 DOI: 10.1016/j.medcli.2022.07.012] [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: 03/15/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, high mortality and progressive disease. Early diagnosis and treatment improves the prognosis. Patients with scleroderma disease presents high risk of developing PAH. Established screening strategies - echocardiogram and DETECT algorithm - recognize the disease when it is already advanced. Cardiopulmonary exercise testing (CPET) detects pulmonary vascular injury in earlier stages. METHODS Prospective study of 52 consecutive patients diagnosed of scleroderma in our health area, during 2 years (2018 and 2019). All of them undergo CPET, in addition to the annual systematic screening. Sensitivity of current PAH screening is compared to CPET. To confirm the presence of PAH, right heart catheterization (RHC) is performed. In case of suspected PAH in CPET, but non-confirmatory right heart catheterization at rest, patients carried out exercise RHC. RESULTS Fifty-two CPET were performed, of which 16 suggested PAH. Resting RHC confirmed PAH in 5 patients and exercise RHC in 7 (diagnostic sensitivity of CPET together with rest and exercise catheterization of 100%). Of these 16 patients, DETECT had identified 10, of whom resting RHC confirmed PAH in 3 and exercise RHC in 2 (guideline-based diagnostic algorithm sensitivity 70%). CONCLUSIONS CPET and exercise RHC could detect PAH earlier than established screening in patients with scleroderma disease, allowing early diagnosis.
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14
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Guo W, Zhang M, Li H, Wang Y, Zhang W, Chen Y, Duan S, Guo X, Yin A, Peng J, An C, Xiao Y, Wan J. A comparative study on the diagnostic efficacy of different diagnostic criteria for exercise pulmonary hypertension. Int J Cardiol 2023; 381:94-100. [PMID: 37019218 DOI: 10.1016/j.ijcard.2023.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Exercise pulmonary hypertension (ePH) has three common diagnostic criteria: the mean pulmonary artery pressure (mPAP) > 30 mmHg and total pulmonary resistance (TPR) at peak exercise >3 Wood units ("Joint criteria"), the mPAP/cardiac output (CO) slope of the two-point measurement (ΔmPAP/ΔCO) > 3 mmHg/L/min ("Two-point criteria"), and the mPAP/CO slope of the multi-point data >3 mmHg/L/min ("Multi-point criteria"). We compared the diagnostic efficacy of these criteria, which remain controversial. METHODS Following resting right heart catheterization (RHC), all patients underwent exercise RHC (eRHC). The patients were divided into different ePH and non-exercise pulmonary hypertension (nPH) groups according to the above criteria. Joint criteria were used as the reference to compare the other two, namely diagnostic concordance, sensitivity and specificity. We conducted further analysis to determine the correlation between different diagnostic criteria grouping and the clinical severity of PH. RESULTS Thirty-three patients with mPAPrest ≤ 20 mmHg were enrolled. a) Diagnostic concordance, sensitivity and specificity: compared with Joint criteria, the diagnostic concordances of Two-point criteria and Multi-point criteria were 78.8% (κ = 0.570, P < 0.01) and 90.9% (κ = 0.818, P < 0.01), respectively; the sensitivity of Two-point criteria was high (100%), but the specificity was poor (56.3%); however, Multi-point criteria exhibited higher sensitivity (94.1%) and specificity (87.5%). b) Clinically relevant analysis: a significant difference was observed in several clinical severity indicators between ePH and nPH patients according to Multi-point criteria grouping(all P < 0.05). CONCLUSION Multi-point criteria are more clinically relevant and provide better diagnostic efficiency.
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Affiliation(s)
- Wei Guo
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Meng Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Hui Li
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yan Wang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Wenmei Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yong Chen
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Shengchen Duan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Xueran Guo
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Ao Yin
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Jiafei Peng
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Chunrong An
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yao Xiao
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China.
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15
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Kagami K, Obokata M, Harada T, Sorimachi H, Yuasa N, Saito Y, Kato T, Wada N, Adachi T, Ishii H. Incremental diagnostic value of post-exercise lung congestion in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2023; 24:553-561. [PMID: 36691846 DOI: 10.1093/ehjci/jead007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS Lung ultrasound (LUS) may unmask occult heart failure with preserved ejection fraction (HFpEF) by demonstrating an increase in extravascular lung water (EVLW) during exercise. Here, we sought to examine the dynamic changes in ultrasound B-lines during exercise to identify the optimal timeframe for HFpEF diagnosis. METHODS AND RESULTS Patients with HFpEF (n = 134) and those without HF (controls, n = 121) underwent a combination of exercise stress echocardiography and LUS with simultaneous expired gas analysis to identify exercise EVLW. Exercise EVLW was defined by B-lines that were newly developed or increased during exercise. The E/e' ratio peaked during maximal exercise and immediately decreased during the recovery period in patients with HFpEF. Exercise EVLW was most prominent during the recovery period in patients with HFpEF, while its prevalence did not increase from peak exercise to the recovery period in controls. Exercise EVLW was associated with a higher E/e' ratio and pulmonary artery pressure, lower right ventricular systolic function, and elevated minute ventilation to carbon dioxide production (VE vs. VCO2) slope during peak exercise. Increases in B-lines from rest to the recovery period provided an incremental diagnostic value to identify HFpEF over the H2FPEF score and resting left atrial reservoir strain. CONCLUSION Exercise EVLW was most prominent early during the recovery period; this may be the optimal timeframe for imaging ultrasound B-lines. Exercise stress echocardiography with assessments of recovery EVLW may enhance the diagnosis of HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.,Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Abstract
Rationale: Current guidelines recognize the utility of provocative maneuvers during right heart catheterization to aid the diagnosis of pulmonary hypertension. Few studies have compared the performance of different provocation maneuvers. Objectives: To assess the hemodynamic correlation among three provocative maneuvers, including their effect on pulmonary hypertension classification. Methods: This prospective trial was conducted between October 2016 and May 2018. Adult patients underwent three provocative maneuvers during right heart catheterization: passive leg raise (PLR), load-targeted supine bicycle exercise, and rapid crystalloid fluid infusion. Patients were classified as follows: no pulmonary hypertension, precapillary pulmonary hypertension, isolated postcapillary pulmonary hypertension, combined pre- and postcapillary pulmonary hypertension, and uncategorized pulmonary hypertension. We assessed the hemodynamic changes associated with each maneuver. We also assessed whether provocative maneuvers led to hemodynamic reclassification of the patient to either postcapillary pulmonary hypertension with provocation or exercise pulmonary hypertension. Results: Eighty-five patients (mean age 62 ± 12 years, 53% women) were included. Correlation between exercise and fluid challenge was moderate to strong (0.49-0.82; P < 0.001) for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, and cardiac index from baseline. Correlation between PLR and exercise (0.4-0.65; P < 0.001) and between PLR and fluid challenge (0.45-0.6; P < 0.001) was moderate for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, pulmonary vascular resistance, and cardiac index. Hemodynamic correlation between other provocative maneuvers was poor. Depending on provocative maneuver and classification criteria, there was significant variation in the number of patients reclassified as having exercise pulmonary hypertension (3-50%) or postcapillary pulmonary hypertension with provocation (11-48%). Conclusions: Hemodynamic determinations during exercise and fluid challenge showed moderate to strong hemodynamic correlation. Moderate hemodynamic correlation was seen between PLR and exercise or fluid challenge. Although some provocative maneuvers demonstrate good hemodynamic correlation, there is inconsistency when using these maneuvers to identify patients with postcapillary or exercise pulmonary hypertension.
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Douschan P, Avian A, Foris V, Sassmann T, Bachmaier G, Rosenstock P, Zeder K, Olschewski H, Kovacs G. Prognostic Value of Exercise as Compared to Resting Pulmonary Hypertension in Patients with Normal or Mildly Elevated Pulmonary Arterial Pressure. Am J Respir Crit Care Med 2022; 206:1418-1423. [PMID: 35925022 PMCID: PMC9746857 DOI: 10.1164/rccm.202112-2856le] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Philipp Douschan
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria,Corresponding author (e-mail: )
| | | | - Vasile Foris
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Teresa Sassmann
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | | | - Piet Rosenstock
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Katarina Zeder
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Horst Olschewski
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Gabor Kovacs
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
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18
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Montani D, Jutant EM, Simonneau G, Humbert M. Nouvelles définitions et classification de l’hypertension pulmonaire. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Douschan P, Kovacs G, Sassmann T, Stadlbauer V, Avian A, Foris V, Tatscher E, Durchschein F, Rainer F, Spindelboeck W, Wagner M, Kniepeiss D, Zollner G, Bachmaier G, Fickert P, Olschewski H, Stauber RE. Pulmonary vascular disease and exercise hemodynamics in chronic liver disease. Respir Med 2022; 202:106987. [PMID: 36115317 DOI: 10.1016/j.rmed.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are severe pulmonary vascular complications of chronic liver disease and strongly associated with morbidity and mortality. The prevalence of these complications is relatively high in patients evaluated for liver transplantation, however it is virtually unknown in patients with stable chronic liver disease. METHODS We assessed the pulmonary hypertension (PH) and HPS prevalence in a prospective registry study of our liver out-patient clinic in a tertiary center. Between 2011 and 2016, consecutive patients with cirrhosis or non-cirrhotic portal hypertension were prospectively enrolled after written informed consent. We excluded patients with acute decompensation of liver disease and other causes of PH like severe chronic heart or lung diseases and chronic thromboembolic PH. HPS was diagnosed using contrast enhanced echocardiography and blood gas analysis. Patients were screened for PH using an algorithm implementing severity of dyspnea, echocardiography, cardiopulmonary exercise testing and exercise echocardiography employing a threshold of systolic pulmonary arterial pressure (SPAP) = 50 mmHg at peak exercise. If the algorithm indicated an increased PH risk, patients were invited for invasive investigations by means of right heart and hepatic vein catheter. We defined POPH as resting mPAP≥21 mmHg and PVR>3WU and PAWP<15 mmHg, mild PH as resting mPAP = 21-24 mmHg, and exercise PH as mPAP>30 mmHg and TPR >3 WU at peak exercise. RESULTS Two-hundred-five patients were enrolled (male 75%; cirrhosis 96%; median age 57 yrs). Sixty-seven patients (33%) fulfilled HPS criteria but only two (1.0%) for severe (PaO2:50-60 mmHg) or very severe HPS (PaO2<50 mmHg). In 18/77 patients (23%) undergoing exercise echocardiography, SPAP at peak exercise exceeded 50 mmHg. Finally, n = 3 (1.5%) patients were invasively diagnosed with POPH, n = 4 (2.9%) with mild PH and n = 2 with exercise PH. CONCLUSION In chronic liver disease, excluding acute decompensation and other causes of PH, POPH and severe HPS are rare findings while mild to moderate HPS and mild PH or exercise PH are more frequent.
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Affiliation(s)
- Philipp Douschan
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elisabeth Tatscher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Franziska Durchschein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
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20
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Lee MH, Menezes TCF, Reisz JA, Ferreira EVM, Graham BB, Oliveira RKF. Exercise metabolomics in pulmonary arterial hypertension: Where pulmonary vascular metabolism meets exercise physiology. Front Physiol 2022; 13:963881. [PMID: 36171971 PMCID: PMC9510894 DOI: 10.3389/fphys.2022.963881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arterial hypertension is an incurable disease marked by dysregulated metabolism, both at the cellular level in the pulmonary vasculature, and at the whole-body level characterized by impaired exercise oxygen consumption. Though both altered pulmonary vascular metabolism and abnormal exercise physiology are key markers of disease severity and pulmonary arterial remodeling, their precise interactions are relatively unknown. Herein we review normal pulmonary vascular physiology and the current understanding of pulmonary vascular cell metabolism and cardiopulmonary response to exercise in Pulmonary arterial hypertension. We additionally introduce a newly developed international collaborative effort aimed at quantifying exercise-induced changes in pulmonary vascular metabolism, which will inform about underlying pathophysiology and clinical management. We support our investigative approach by presenting preliminary data and discuss potential future applications of our research platform.
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Affiliation(s)
- Michael H. Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Thaís C. F. Menezes
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eloara V. M. Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Brian B. Graham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil,*Correspondence: Rudolf K. F. Oliveira,
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21
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension (PH) is a common complication of chronic obstructive lung disease (COPD), but clinical presentation is variable and not always 'proportional' to the severity of the obstructive disease. This review aims to analyze heterogeneity in clinical features of PH-COPD, providing a guide for diagnosis and management according to phenotypes. RECENT FINDINGS Recent works have focused on severe PH in COPD, providing insights into the characteristics of patients with predominantly vascular disease. The recently recognized 'pulmonary vascular phenotype', characterized by severe PH and mild airflow obstruction with severe hypoxemia, has markedly worse prognosis and may be a candidate for large trials with pulmonary vasodilators. In severe PH, which might be best described by a pulmonary vascular resistance threshold, there may also be a need to distinguish patients with mild COPD (pulmonary vascular phenotype) from those with severe COPD ('Severe COPD-Severe PH' phenotype). SUMMARY Correct phenotyping is key to appropriate management of PH associated with COPD. The lack of evidence regarding the use of pulmonary vasodilators in PH-COPD may be due to the existence of previously unrecognized phenotypes with different responses to therapy. This review offers the clinician caring for patients with COPD and PH a phenotype-focused approach to diagnosis and management, aimed at personalized care.
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Affiliation(s)
| | - Lucilla Piccari
- Department of Pulmonary Medicine, Hospital del Mar, Barcelona, Spain
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22
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Brittain EL, Thenappan T, Huston JH, Agrawal V, Lai YC, Dixon D, Ryan JJ, Lewis EF, Redfield MM, Shah SJ, Maron BA. Elucidating the Clinical Implications and Pathophysiology of Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction: A Call to Action: A Science Advisory From the American Heart Association. Circulation 2022; 146:e73-e88. [PMID: 35862198 PMCID: PMC9901193 DOI: 10.1161/cir.0000000000001079] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This science advisory focuses on the need to better understand the epidemiology, pathophysiology, and treatment of pulmonary hypertension in patients with heart failure with preserved ejection fraction. This clinical phenotype is important because it is common, is strongly associated with adverse outcomes, and lacks evidence-based therapies. Our goal is to clarify key knowledge gaps in pulmonary hypertension attributable to heart failure with preserved ejection fraction and to suggest specific, actionable scientific directions for addressing such gaps. Areas in need of additional investigation include refined disease definitions and interpretation of hemodynamics, as well as greater insights into noncardiac contributors to pulmonary hypertension risk, optimized animal models, and further molecular studies in patients with combined precapillary and postcapillary pulmonary hypertension. We highlight translational approaches that may provide important biological insight into pathophysiology and reveal new therapeutic targets. Last, we discuss the current and future landscape of potential therapies for patients with heart failure with preserved ejection fraction and pulmonary vascular dysfunction, including considerations of precision medicine, novel trial design, and device-based therapies, among other considerations. This science advisory provides a synthesis of important knowledge gaps, culminating in a collection of specific research priorities that we argue warrant investment from the scientific community.
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23
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Douschan P, Tello K, Rieth AJ, Wiedenroth CB, Sassmann T, Kovacs G, Ghofrani HA, Seeger W, Richter M, Guth S. Right ventricular-pulmonary arterial coupling and its relationship to exercise haemodynamics in a continuum of patients with pulmonary vascular disease due to chronic thromboembolism. Eur Respir J 2022; 60:13993003.00450-2022. [PMID: 35953102 DOI: 10.1183/13993003.00450-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Philipp Douschan
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,These two authors contributed equally to this article
| | - Khodr Tello
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Werner Seeger
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany
| | - Manuel Richter
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany .,These two authors contributed equally to this article
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24
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Right Heart Catheterization (RHC): A comprehensive review of provocation tests and hepatic hemodynamics in patients with pulmonary hypertension (PH). Curr Probl Cardiol 2022; 47:101351. [DOI: 10.1016/j.cpcardiol.2022.101351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 12/26/2022]
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25
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Desole S, Obst A, Habedank D, Opitz CF, Knaack C, Hortien F, Heine A, Stubbe B, Ewert R. Comparison between thermodilution and Fick methods for resting and exercise-induced cardiac output measurement in patients with chronic dyspnea. Pulm Circ 2022; 12:e12128. [PMID: 36051350 PMCID: PMC9425001 DOI: 10.1002/pul2.12128] [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: 07/07/2021] [Revised: 06/07/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Studies comparing thermodilution (TD) and the direct Fick method (dFM) for cardiac output (CO) measurement are rare. We compared CO measurements between TD (2-5 cold water injections), the dFM, and indirect Fick method (iFM) at rest and during exercise, and assessed the effect of averaging different numbers of TD measurements during exercise. This retrospective study included 300 patients (52.3% women, mean age 66 ± 11 years) having pulmonary hypertension (76.0%) or unexplained dyspnea. Invasive hemodynamic and gas exchange parameters were measured at rest (supine; n = 300) and during unloaded cycling (semi-supine; n = 275) and 25-W exercise (semi-supine; n = 240). All three methods showed significant differences in CO measurement (ΔCO) at rest (p ≤ 0.001; ΔCO > 1 L/min: 45.0% [iFM vs. dFM], 42.0% [iFM vs. TD], and 45.7% [TD vs. dFM]). ΔCO (TD vs. dFM) was significant during unloaded cycling (p < 0.001; ΔCO > 1 L/min: 56.6%) but not during 25-W exercise (p = 0.137; ΔCO > 1 L/min: 52.8%). ΔCO (TD vs. dFM) during 25-W exercise was significant when using one or two (p ≤ 0.01) but not three (p = 0.06) TD measurements. Mean ΔCO (TD [≥3 measurements] vs. dFM) was -0.43 ± 1.98 and -0.06 ± 2.29 L/min during unloaded and 25-W exercise, respectively. Thus, TD and dFM CO measurements are comparable during 25-W exercise (averaging ≥3 TD measurements), but not during unloaded cycling or at rest. Individual ΔCOs vary substantially and require critical interpretation to avoid CO misclassification.
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Affiliation(s)
- Susanna Desole
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Anne Obst
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Dirk Habedank
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christian F. Opitz
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christine Knaack
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Franziska Hortien
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Alexander Heine
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Beate Stubbe
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Ralf Ewert
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
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26
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Raza F, Dharmavaram N, Hess T, Dhingra R, Runo J, Chybowski A, Kozitza C, Batra S, Horn EM, Chesler N, Eldridge M. Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E /VCO 2 and ETCO 2 identify pulmonary vascular disease. Clin Cardiol 2022; 45:742-751. [PMID: 35419844 PMCID: PMC9286332 DOI: 10.1002/clc.23831] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management. HYPOTHESIS Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH. METHODS We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant. RESULTS The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2 = 0.70* and ETCO2 = 0.73*. Based on this, optimal thresholds of rest VE /VCO2 > 40 mm Hg and rest ETCO2 < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group. CONCLUSIONS In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2 > 40 mm Hg and ETCO2 < 30 mm Hg) identify PVD.
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Affiliation(s)
- Farhan Raza
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Naga Dharmavaram
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Timothy Hess
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Ravi Dhingra
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - James Runo
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Amy Chybowski
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Callyn Kozitza
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Supria Batra
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Evelyn M. Horn
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Naomi Chesler
- University of California‐Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringIrvineCaliforniaUSA
| | - Marlowe Eldridge
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of PediatricsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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27
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Kagami K, Obokata M, Harada T, Kato T, Wada N, Adachi T, Ishii H. Diastolic Filling Time, Chronotropic Response, and Exercise Capacity in Heart Failure and Preserved Ejection Fraction With Sinus Rhythm. J Am Heart Assoc 2022; 11:e026009. [PMID: 35766289 PMCID: PMC9333393 DOI: 10.1161/jaha.121.026009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Exercise‐induced high heart rate may impair exercise tolerance by reducing diastolic filling time and ventricular filling in heart failure with preserved ejection fraction (HFpEF). Given the importance of chronotropic response, we hypothesized that reduction in diastolic filling time because of exercise‐induced increased heart rate would not impair cardiac output reserve and exercise capacity. We sought to determine the association between heart rate, diastolic filling time, hemodynamics, and exercise capacity in HFpEF. Methods and Results Patients with HFpEF (n=66) and controls without HF (n=107) underwent bicycle exercise echocardiography with simultaneous expired gas analysis to measure oxygen consumption. Diastolic filling time was assessed by the overlap time between mitral E‐ and A‐waves (longer overlap time indicates shorter diastolic filling duration). Overlap time increased (ie, diastolic filling time shortened) in HFpEF and controls as heart rate increased with exercise, and the relationship was similar between the groups. Greater heart rate response correlated with higher cardiac output (r=0.51, P<0.0001) and oxygen consumption (r=0.50, P<0.0001) during peak exercise. Shorter diastolic filling time, as assessed by longer overlap time, was correlated with higher cardiac output (r=0.47, P<0.0001) and peak oxygen consumption (r=0.38, P=0.007), not with E/e′ or right ventricular‐pulmonary artery uncoupling. Longer overlap time was associated with mitral A velocity (r=0.53, P<0.0001) and left atrial booster pump strain (r=0.42, P<0.0001). Conclusions Shortening of diastolic filling interval in tandem with increased heart rate during exercise does not limit cardiac output reserve or exercise capacity in HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan.,Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
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28
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Kusunose K, Hirata Y, Yamaguchi N, Kosaka Y, Tsuji T, Kotoku J, Sata M. Deep Learning for Detection of Exercise-Induced Pulmonary Hypertension Using Chest X-Ray Images. Front Cardiovasc Med 2022; 9:891703. [PMID: 35783826 PMCID: PMC9240342 DOI: 10.3389/fcvm.2022.891703] [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: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background Stress echocardiography is an emerging tool used to detect exercise-induced pulmonary hypertension (EIPH). However, facilities that can perform stress echocardiography are limited by issues such as cost and equipment. Objective We evaluated the usefulness of a deep learning (DL) approach based on a chest X-ray (CXR) to predict EIPH in 6-min walk stress echocardiography. Methods The study enrolled 142 patients with scleroderma or mixed connective tissue disease with scleroderma features who performed a 6-min walk stress echocardiographic test. EIPH was defined by abnormal cardiac output (CO) responses that involved an increase in mean pulmonary artery pressure (mPAP). We used the previously developed AI model to predict PH and calculated PH probability in this cohort. Results EIPH defined as ΔmPAP/ΔCO >3.3 and exercise mPAP >25 mmHg was observed in 52 patients, while non-EIPH was observed in 90 patients. The patients with EIPH had a higher mPAP at rest than those without EIPH. The probability of PH based on the DL model was significantly higher in patients with EIPH than in those without EIPH. Multivariate analysis showed that gender, mean PAP at rest, and the probability of PH based on the DL model were independent predictors of EIPH. A model based on baseline parameters (age, gender, and mPAP at rest) was improved by adding the probability of PH predicted by the DL model (AUC: from 0.65 to 0.74; p = 0.046). Conclusion Applying the DL model based on a CXR may have a potential for detection of EIPH in the clinical setting.
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Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
- *Correspondence: Kenya Kusunose,
| | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Natsumi Yamaguchi
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitaka Kosaka
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Takumasa Tsuji
- Department of Radiological Technology, Graduate School of Medical Care and Technology, Teikyo University, Tokyo, Japan
| | - Jun’ichi Kotoku
- Department of Radiological Technology, Graduate School of Medical Care and Technology, Teikyo University, Tokyo, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
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Pugliese NR, Mazzola M, Madonna R, Gargani L, De Biase N, Dini FL, Taddei S, De Caterina R, Masi S. Exercise-induced pulmonary hypertension in HFpEF and HFrEF: Different pathophysiologic mechanism behind similar functional impairment. Vascul Pharmacol 2022; 144:106978. [PMID: 35301117 DOI: 10.1016/j.vph.2022.106978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 12/27/2022]
Abstract
AIMS Pathophysiological mechanisms behind cardio-pulmonary impairment in heart failure (HF) with reduced (HFrEF) and preserved (HFpEF) ejection fraction are likely different. We analysed them using combined cardiopulmonary-exercise stress echocardiography (CPET-ESE). METHODS We matched 1:1 subjects with HFrEF (n = 90) and HFpEF (n = 90) for age, sex, body mass index (BMI), peak oxygen consumption, and minute ventilation/carbon dioxide production slope. All patients underwent a symptom-limited graded ramp bicycle CPET-ESE compared with 40 age-, sex- and BMI-matched healthy controls. RESULTS During a median follow-up of 25 months, we observed 22 deaths and 80 HF hospitalisations, with similar distribution between HFpEF and HFrEF. Compared with HFrEF, HFpEF had a higher prevalence of metabolic syndrome (p = 0.02) with higher levels of high-sensitivity C-reactive protein and uric acid (p < 0.01). The multipoint mean pulmonary artery pressure/cardiac output (mPAP/CO) slope showed equally increased values in HFrEF and HFpEF (3.5 ± 1.8 and 3.7 ± 1.5 mmHg/L/min) compared with controls (1.8 ± 1.1 mmHg/L/min; p < 0.0001). During exercise, HFpEF displayed more adverse interaction of right ventricle-pulmonary artery (RV-PA; tricuspid annular plane systolic excursion/systolic pulmonary artery pressure: 0.40 ± 0.2 vs 0.47 ± 0.2 mm/mmHg in HFrEF; p < 0.01) and left atrium-left ventricle (LA-LV; LA reservoir strain/LV global longitudinal strain: 1.5 ± 0.8 vs 2.2 ± 1.1 in HFrEF; p < 0.01). The latter were independent predictors of mPAP/CO slope, along with hs-CRP (adjusted R2: 0.21; p < 0.0001). CONCLUSION Despite similar disease severity, HFpEF and HFrEF show different pathophysiological mechanisms. HFpEF is characterised by a worse LA-LV and RV-PA interaction than HFrEF, with more prevalent low-grade systemic inflammation. In HFpEF, these features may have a role in exercise-induced pulmonary hypertension.
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Affiliation(s)
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Raffale De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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30
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Kagami K, Harada T, Yoshida K, Amanai S, Kato T, Wada N, Adachi T, Obokata M. Impaired Right Atrial Reserve Function in Heart Failure with Preserved Ejection Fraction. J Am Soc Echocardiogr 2022; 35:836-845. [DOI: 10.1016/j.echo.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
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31
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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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32
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Yang JH, Harada T, Choi KH, Kato T, Kim D, Takama N, Park TK, Kurabayashi M, Chang SA, Obokata M. Peripheral Venous Pressure-Assisted Exercise Stress Echocardiography in the Evaluation of Pulmonary Hypertension During Exercise in Patients With Suspected Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2022; 15:e009028. [PMID: 35189688 DOI: 10.1161/circheartfailure.121.009028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. METHODS In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. RESULTS In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise (r=0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14±5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6±4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. CONCLUSIONS PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction.
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Affiliation(s)
- Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.(J.H.Y.).,Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Ki Hong Choi
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Darae Kim
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Taek Kyu Park
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Sung-A Chang
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
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33
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Berlier C, Saxer S, Lichtblau M, Schneider SR, Schwarz EI, Furian M, Bloch KE, Carta AF, Ulrich S. Influence of Upright Versus Supine Position on Resting and Exercise Hemodynamics in Patients Assessed for Pulmonary Hypertension. J Am Heart Assoc 2022; 11:e023839. [PMID: 35156392 PMCID: PMC9245795 DOI: 10.1161/jaha.121.023839] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The aim of the present work was to study the influence of body position on resting and exercise pulmonary hemodynamics in patients assessed for pulmonary hypertension (PH).
Methods and Results
Data from 483 patients with suspected PH undergoing right heart catheterization for clinical indications (62% women, age 61±15 years, 246 precapillary PH, 48 postcapillary PH, 106 exercise PH, 83 no PH) were analyzed; 213 patients (main cohort, years 2016–2018) were examined at rest in upright (45°) and supine position, such as under upright exercise. Upright exercise hemodynamics were compared with 270 patients (historical cohort) undergoing supine exercise with the same protocol. Upright versus supine resting data revealed a lower mean pulmonary artery pressure 31±14 versus 32±13 mm Hg, pulmonary artery wedge pressure 11±4 versus 12±5 mm Hg, and cardiac index 2.9±0.7 versus 3.1±0.8 L/min per m
2
, and higher pulmonary vascular resistance 4.1±3.1 versus 3.9±2.8 Wood
P
<0.001. Exercise data upright versus supine revealed higher work rates (53±26 versus 33±22 watt), and adjusting for differences in work rate and baseline values, higher end‐exercise mean pulmonary artery pressure (52±19 versus 45±16 mm Hg,
P
=0.001), similar pulmonary artery wedge pressure and cardiac index, higher pulmonary vascular resistance (5.4±3.7 versus 4.5±3.4 Wood units,
P
=0.002), and higher mean pulmonary artery pressure/cardiac output (7.9±4.7 versus 7.1±4.1 Wood units,
P
=0.001).
Conclusions
Body position significantly affects resting and exercise pulmonary hemodynamics with a higher pulmonary vascular resistance of about 10% in upright versus supine position at rest and end‐exercise, and should be considered and reported when assessing PH.
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Affiliation(s)
- Charlotte Berlier
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Mona Lichtblau
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | | | - Esther I. Schwarz
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Michael Furian
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Konrad E. Bloch
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
- Centre for Integrative Human PhysiologyUniversity of Zürich Zürich Switzerland
| | | | - Silvia Ulrich
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
- Centre for Integrative Human PhysiologyUniversity of Zürich Zürich Switzerland
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34
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Kvaslerud AB, Gude E, Eriksen G, Andreassen AK, Gullestad L, Broch K. Diastolic Dysfunction Is Unmasked on Exercise in Patients With Asymptomatic, Severe Aortic Stenosis: An Invasive Hemodynamic Study. Circ Heart Fail 2022; 15:e009253. [PMID: 35137599 DOI: 10.1161/circheartfailure.121.009253] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal timing of aortic valve replacement remains difficult in patients with asymptomatic, severe aortic stenosis (AS). More accurate diagnostic methods are warranted for the detection of subtle ventricular impairment. We aimed to evaluate diastolic function in asymptomatic patients with severe AS. METHODS In this cross-sectional study, patients with asymptomatic, severe AS were evaluated with right heart catheterization at rest and during moderate exercise. The patients also underwent cardiopulmonary exercise testing to objectify functional capacity and confirm the absence of symptoms. RESULTS Between February 2019 and May 2021, we included 50 patients aged 70±12 years. The patients had severe AS with peak velocity 4.4±0.4 m/s, mean gradient 46±9 mm Hg, and an indexed valve area of 0.47±0.08 cm2 at rest. All patients were asymptomatic and had normal left ventricular ejection fraction. Five patients had postcapillary pulmonary hypertension at rest. During exercise, 44 patients (88%) had an increase in the mean pulmonary artery pressure per increase in cardiac output of >3 mm Hg/L per minute, of whom 93% had a concomitant increase in the pulmonary artery wedge pressure per increase in cardiac output >2 mm Hg/L per minute, suggesting exercise-induced pulmonary hypertension due to left heart disease. Female gender and increasing age were associated with a higher increase in the pulmonary artery wedge pressure per increase in cardiac output ratio. The catheterization was well tolerated, and there were no adverse events. CONCLUSIONS A large proportion of asymptomatic patients with severe, degenerative AS have exercise-induced postcapillary pulmonary hypertension.
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Affiliation(s)
- Anette B Kvaslerud
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
| | - Einar Gude
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Gunnar Eriksen
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Arne K Andreassen
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Lars Gullestad
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
| | - Kaspar Broch
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
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Duke JW, Lewandowski AJ, Abman SH, Lovering AT. Physiological aspects of cardiopulmonary dysanapsis on exercise in adults born preterm. J Physiol 2022; 600:463-482. [PMID: 34961925 PMCID: PMC9036864 DOI: 10.1113/jp281848] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023] Open
Abstract
Progressive improvements in perinatal care and respiratory management of preterm infants have resulted in increased survival of newborns of extremely low gestational age over the past few decades. However, the incidence of bronchopulmonary dysplasia, the chronic lung disease after preterm birth, has not changed. Studies of the long-term follow-up of adults born preterm have shown persistent abnormalities of respiratory, cardiovascular and cardiopulmonary function, possibly leading to a lower exercise capacity. The underlying causes of these abnormalities are incompletely known, but we hypothesize that dysanapsis, i.e. discordant growth and development, in the respiratory and cardiovascular systems is a central structural feature that leads to a lower exercise capacity in young adults born preterm than those born at term. We discuss how the hypothesized system dysanapsis underscores the observed respiratory, cardiovascular and cardiopulmonary limitations. Specifically, adults born preterm have: (1) normal lung volumes but smaller airways, which causes expiratory airflow limitation and abnormal respiratory mechanics but without impacts on pulmonary gas exchange efficiency; (2) normal total cardiac size but smaller cardiac chambers; and (3) in some cases, evidence of pulmonary hypertension, particularly during exercise, suggesting a reduced pulmonary vascular capacity despite reduced cardiac output. We speculate that these underlying developmental abnormalities may accelerate the normal age-associated decline in exercise capacity, via an accelerated decline in respiratory, cardiovascular and cardiopulmonary function. Finally, we suggest areas of future research, especially the need for longitudinal and interventional studies from infancy into adulthood to better understand how preterm birth alters exercise capacity across the lifespan.
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Affiliation(s)
- Joseph W. Duke
- Northern Arizona University, Department of Biological Sciences, Flagstaff, AZ, USA
| | - Adam J. Lewandowski
- University of Oxford, Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford, UK
| | - Steven H. Abman
- University of Colorado Anschutz School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Pediatric Heart Lung Center, Children’s Hospital Colorado, Aurora, CO, USA
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36
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Kovacs G, Olschewski H. The definition of pulmonary hypertension: history, practical implications and current controversies. Breathe (Sheff) 2022; 17:210076. [PMID: 35035548 PMCID: PMC8753640 DOI: 10.1183/20734735.0076-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/19/2021] [Indexed: 01/14/2023] Open
Abstract
The definition of pulmonary hypertension (PH) is based on a growing body of evidence and represents the result of ongoing discussions within the PH community over the past 50 years. In 2018, the most recent World Symposium on Pulmonary Hypertension introduced significant changes in the definition of PH by lowering the mean pulmonary arterial pressure threshold to >20 mmHg and (re)introducing the pulmonary vascular resistance ≥3 WU cut-off for all forms of pre-capillary PH. These changes and their potential clinical impact have been the subject of lively discussions in the community and some important questions and controversies have been identified. In this review we aim to present the development of the definition of PH over the past decades and discuss the main arguments that led to relevant modifications. In addition, we address the practical implications of the most recent changes and controversies that still exist. The definitions of PH and PAH reflect the upper limit of normal haemodynamic values, their prognostic relevance and practical considerations. With appropriate clinical context they represent the cornerstone of PH diagnosis and clinical decision making.https://bit.ly/3gRSyWz
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Affiliation(s)
- Gabor Kovacs
- Dept of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Horst Olschewski
- Dept of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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37
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Hillerson D, Charnigo R, Moon Kim S, Iyengar A, Lane M, Misumida N, Kolodziej AR, Ogunbayo GO, Abdel-Latif A, Gurley JC, Booth DC. Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circ Heart Fail 2022; 15:e008838. [PMID: 35026961 DOI: 10.1161/circheartfailure.121.008838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. METHODS We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. RESULTS Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P<0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P<0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes. CONCLUSIONS In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.
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Affiliation(s)
- Dustin Hillerson
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Richard Charnigo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,Department of Biostatistics, University of Kentucky, Lexington. (R.C.)
| | - Sun Moon Kim
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC (S.M.K.).,Department of Medicine, University of North Carolina at Chapel Hill (S.M.K.)
| | - Amrita Iyengar
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,College of Medicine, University of Kentucky, Lexington. (A.I.)
| | - Matthew Lane
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,College of Pharmacy, University of Kentucky, Lexington. (M.L.)
| | - Naoki Misumida
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Andrew R Kolodziej
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Gbolahan O Ogunbayo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Ahmed Abdel-Latif
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - John C Gurley
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - David C Booth
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
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38
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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39
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Duknic M, Lichtblau M, Saxer S, Berlier C, Schneider SR, Schwarz EI, Carta AF, Furian M, Bloch KE, Ulrich S. Comparison of Repetitive Cardiac Output Measurements at Rest and End-Exercise by Direct Fick Using Pulse Oximetry vs. Blood Gases in Patients With Pulmonary Hypertension. Front Med (Lausanne) 2021; 8:776956. [PMID: 34888330 PMCID: PMC8649780 DOI: 10.3389/fmed.2021.776956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Exact and simultaneous measurements of mean pulmonary artery pressure (mPAP) and cardiac output (CO) are crucial to calculate pulmonary vascular resistance (PVR), which is essential to define pulmonary hypertension (PH). Simultaneous measurements of mPAP and CO are not feasible using the direct Fick (DF) method, due to the necessity to sample blood from the catheter-tip. We evaluated a modified DF method, which allows simultaneous measurement of mPAP and CO without needing repetitive blood samples. Methods: Twenty-four patients with pulmonary arterial or chronic thromboembolic PH had repetitive measurements of CO at rest and end-exercise during three phases of a crossover trial. CO was assessed by the original DF method using oxygen uptake, measured by a metabolic unit, and arterial and mixed venous oxygen saturations from co-oximetry of respective blood gases served as reference. These CO measurements were then compared with a modified DF method using pulse oximetry at the catheter- and fingertip. Results: The bias among CO measurements by the two DF methods at rest was −0.26 L/min with limits of agreement of ±1.66 L/min. The percentage error was 28.6%. At the end-exercise, the bias between methods was 0.29 L/min with limits of agreement of ±1.54 L/min and percentage error of 16.1%. Conclusion: Direct Fick using a catheter- and fingertip pulse oximetry (DFp) is a practicable and reliable method for assessing CO in patients with PH. This method has the advantage of allowing simultaneous measurement of PAP and CO, and frequent repetitive measurements are needed during exercise. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT02755259, identifier: NCT02755259.
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Affiliation(s)
- Milos Duknic
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Simon R Schneider
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Arcangelo F Carta
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zürich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
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40
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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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41
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Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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42
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Harada T, Araki T, Sunaga H, Kagami K, Yoshida K, Kato T, Kawakami R, Tomono J, Wada N, Iso T, Kurabayashi M, Obokata M. Pathophysiological and diagnostic importance of fatty acid-binding protein 1 in heart failure with preserved ejection fraction. Sci Rep 2021; 11:21175. [PMID: 34707207 PMCID: PMC8551161 DOI: 10.1038/s41598-021-00760-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023] Open
Abstract
Elevated intracardiac pressure at rest and/or exercise is a fundamental abnormality in heart failure with preserved ejection fraction (HFpEF). Fatty acid-binding protein 1 (FABP1) is proposed to be a sensitive biomarker for liver injury. We sought to determine whether FABP1 at rest would be elevated in HFpEF and would correlate with echocardiographic markers of intracardiac pressures at rest and during exercise. In this prospective study, subjects with HFpEF (n = 22) and control subjects without HF (n = 23) underwent resting FABP1 measurements and supine bicycle exercise echocardiography. Although levels of conventional hepatic enzymes were similar between groups, FABP1 levels were elevated in HFpEF compared to controls (45 [25–68] vs. 18 [14–24] ng/mL, p = 0.0008). FABP1 levels were correlated with radiographic and blood-based markers of congestion, hemodynamic derangements during peak exercise (E/e’, r = 0.50; right atrial pressure, r = 0.35; pulmonary artery systolic pressure, r = 0.46), reduced exercise cardiac output (r = − 0.49), and poor exercise workload achieved (r = − 0.40, all p < 0.05). FABP1 distinguished HFpEF from controls with an area under the curve of 0.79 (p = 0.003) and had an incremental diagnostic value over the H2FPEF score (p = 0.007). In conclusion, FABP1 could be a novel hepatic biomarker that associates with hemodynamic derangements, reduced cardiac output, and poor exercise capacity in HFpEF.
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Affiliation(s)
- Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takeshi Araki
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hiroaki Sunaga
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.,Center for Liberal Arts and Sciences, Ashikaga University, Ashikaga, Tochigi, Japan
| | - Kazuki Kagami
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kuniko Yoshida
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Kawakami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Junichi Tomono
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tatsuya Iso
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
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43
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Haque A, Kiely DG, Kovacs G, Thompson AAR, Condliffe R. Pulmonary hypertension phenotypes in patients with systemic sclerosis. Eur Respir Rev 2021; 30:30/161/210053. [PMID: 34407977 DOI: 10.1183/16000617.0053-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/04/2021] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension (PH) commonly affects patients with systemic sclerosis (SSc) and is associated with significant morbidity and increased mortality. PH is a heterogenous condition and several different forms can be associated with SSc, including pulmonary arterial hypertension (PAH) resulting from a pulmonary arterial vasculopathy, PH due to left heart disease and PH due to interstitial lung disease. The incidence of pulmonary veno-occlusive disease is also increased. Accurate and early diagnosis to allow optimal treatment is, therefore, essential. Recent changes to diagnostic haemodynamic criteria at the 6th World Symposium on Pulmonary Hypertension have resulted in therapeutic uncertainty regarding patients with borderline pulmonary haemodynamics. Furthermore, the optimal pulmonary vascular resistance threshold for diagnosing PAH and the role of exercise in identifying early disease require further elucidation. In this article we review the epidemiology, diagnosis, outcomes and treatment of the spectrum of pulmonary vascular phenotypes associated with SSc.
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Affiliation(s)
- Ashraful Haque
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Dept of Rheumatology, Royal Hallamshire Hospital, Sheffield, UK.,Both authors contributed equally
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK .,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Both authors contributed equally
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44
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Ulrich S, Mathai SC. Performance Under Pressure: The Relevance of Pulmonary Vascular Response to Exercise Challenge in Scleroderma. Chest 2021; 159:481-483. [PMID: 33563435 DOI: 10.1016/j.chest.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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45
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Petit T, Claessen G, Claeys M, La Gerche A, Claus P, Ghysels S, Delcroix M, Ciarka A, Droogne W, Van Cleemput J, Willems R, Voigt JU, Bogaert J, Janssens S. Right ventricular and cyclic guanosine monophosphate signalling abnormalities in stages B and C of heart failure with preserved ejection fraction. ESC Heart Fail 2021; 8:4661-4673. [PMID: 34477327 PMCID: PMC8712894 DOI: 10.1002/ehf2.13514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 01/05/2023] Open
Abstract
Aims Identifying early right ventricular (RV) dysfunction and impaired vasodilator reserve is challenging in heart failure with preserved ejection fraction (HFpEF). We hypothesized that cardiac magnetic resonance (CMR)‐based exercise imaging and serial cyclic guanosine monophosphate (cGMP) measurements can identify dynamic RV‐arterial uncoupling and responsiveness to pulmonary vasodilators at early stages of the HFpEF syndrome. Methods and results Patients with HFpEF (n = 16), impaired left ventricular relaxation due to concentric remodelling (LVCR, n = 7), and healthy controls (n = 8) underwent CMR at rest and during supine bicycle exercise with simultaneous measurements of central haemodynamics and circulating cGMP levels, before and after oral administration of 50 mg sildenafil. At rest, mean pulmonary artery pressures (mPAP) were higher in HFpEF, compared with LVCR and controls (27 ± 2, 18 ± 1, and 11 ± 1, respectively; P = 0.01), whereas biventricular volumes, heart rate, and stroke volume were similar. During exercise, LVCR and HFpEF had a greater increase in the ratio of mPAP over cardiac output than controls (5.50 ± 0.77 and 6.34 ± 0.86 vs. 2.24 ± 0.55 in controls, P = 0.005). The ratio of peak exercise to rest RV end‐systolic pressure‐volume, a surrogate of RV contractility, was significantly reduced in LVCR and HFpEF (2.32 ± 0.17 and 1.56 ± 0.08 vs. 3.49 ± 0.35 in controls, P < 0.001) and correlated with peak exercise VO2 (R2 = 0.648, P < 0.001). cGMP levels increased with exercise across the HFpEF spectrum (P < 0.05 vs. baseline), except when postcapillary pulmonary hypertension was present at rest (P = 0.73 vs. baseline). A single sildenafil administration failed to increase circulating cGMP levels and did not improve RV performance. Conclusion Exercise CMR identifies impaired RV‐arterial coupling at an early stage of HFpEF. Circulating cGMP levels phenocopy the haemodynamic spectrum in HFpEF but fail to increase after phosphodiesterase type 5 inhibition, endorsing the need for alternative interventions to increase cGMP signalling in HFpEF.
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Affiliation(s)
- Thibault Petit
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Mathias Claeys
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Andre La Gerche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Piet Claus
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Stefan Ghysels
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Chronic Diseaes and Metabolism, KU Leuven, Leuven, Belgium
| | - Agnieszka Ciarka
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Walter Droogne
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Jan Bogaert
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
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46
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Tea I, Hussain I. Under Pressure: Right Heart Catheterization and Provocative Testing for Diagnosing Pulmonary Hypertension. Methodist Debakey Cardiovasc J 2021; 17:92-100. [PMID: 34326928 PMCID: PMC8298122 DOI: 10.14797/afui4711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is a heterogenous disorder involving multiple
pathophysiological processes that ultimately affect the vasculature within the
lungs. Right heart catheterization (RHC) continues to be the benchmark for
diagnosing PH. The use of provocation techniques during RHC can help
sub-characterize the type of PH and thus assist in developing appropriate
treatment strategies for the management of each PH subtype. This review examines
proven and novel approaches for evaluating the pulmonary vasculature during RHC
and aspires to provide an accurate, clinically relevant framework for using RHC
to diagnose and manage PH. Further improvement in standardized protocols will
help optimize the application of RHC in patients with PH.
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Affiliation(s)
- Isaac Tea
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Imad Hussain
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
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47
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Malenfant S, Lebret M, Breton-Gagnon É, Potus F, Paulin R, Bonnet S, Provencher S. Exercise intolerance in pulmonary arterial hypertension: insight into central and peripheral pathophysiological mechanisms. Eur Respir Rev 2021; 30:200284. [PMID: 33853885 PMCID: PMC9488698 DOI: 10.1183/16000617.0284-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/08/2020] [Indexed: 11/05/2022] Open
Abstract
Exercise intolerance is a cardinal symptom of pulmonary arterial hypertension (PAH) and strongly impacts patients' quality of life (QoL). Although central cardiopulmonary impairments limit peak oxygen consumption (V' O2peak ) in patients with PAH, several peripheral abnormalities have been described over the recent decade as key determinants in exercise intolerance, including impaired skeletal muscle (SKM) morphology, convective O2 transport, capillarity and metabolism indicating that peripheral abnormalities play a greater role in limiting exercise capacity than previously thought. More recently, cerebrovascular alterations potentially contributing to exercise intolerance in patients with PAH were also documented. Currently, only cardiopulmonary rehabilitation has been shown to efficiently improve the peripheral components of exercise intolerance in patients with PAH. However, more extensive studies are needed to identify targeted interventions that would ultimately improve patients' exercise tolerance and QoL. The present review offers a broad and comprehensive analysis of the present literature about the complex mechanisms and their interactions limiting exercise in patients and suggests several gaps in knowledge that need to be addressed in the future for a better understanding of exercise intolerance in patients with PAH.
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Affiliation(s)
- Simon Malenfant
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Marius Lebret
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Émilie Breton-Gagnon
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - François Potus
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
| | - Roxane Paulin
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Steeve Provencher
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
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48
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Kagami K, Harada T, Yamaguchi K, Kouno S, Ikoma T, Yoshida K, Kato T, Tomono J, Wada N, Adachi T, Kurabayashi M, Obokata M. Association between lung ultrasound B-lines and exercise-induced pulmonary hypertension in patients with connective tissue disease. Echocardiography 2021; 38:1297-1306. [PMID: 34184322 DOI: 10.1111/echo.15141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Identification of elevation in pulmonary pressures during exercise may provide prognostic and therapeutic implications in patients with connective tissue disease (CTD). Interstitial lung disease (ILD) is common in CTD patients and subtle interstitial abnormalities detected by lung ultrasound could predict exercise-induced pulmonary hypertension (PH). METHODS AND RESULTS Echocardiography and lung ultrasound were performed at rest and bicycle exercise in CTD patients (n = 41) and control subjects without CTD (n = 24). Ultrasound B-lines were quantified by scanning four intercostal spaces in the right hemithorax. We examined the association between total B-lines at rest and the development of exercise-induced PH during ergometry exercise. Compared to controls, the number of total B-lines at rest was higher in CTD patients (0 [0, 0] vs 2 [0, 9], P < .0001) and was correlated with radiological severity of ILD assessed by computed tomography (fibrosis score, r = .70, P < .0001). Pulmonary artery systolic pressure (PASP) was increased with ergometry exercise in CTD compared to controls (48 ± 14 vs 35 ± 13 mm Hg, P = .0006). The number of total B-lines at rest was highly correlated with higher PASP (r = .52, P < .0001) and poor right ventricular pulmonary artery coupling (tricuspid annular plane systolic excursion/PASP ratio, r = -.31, P = .01) during peak exercise. The number of resting B-lines predicted the development of exercise-induced PH with an area under the curve .79 (P = .0003). CONCLUSIONS These data may suggest the value of a simple resting assessment of lung ultrasound as a potential tool for assessing the risk of exercise-induced PH in CTD patients.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.,Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koichi Yamaguchi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shunichi Kouno
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takahiro Ikoma
- Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Kuniko Yoshida
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.,Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Junichi Tomono
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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High Right Ventricular Afterload during Exercise in Patients with Pulmonary Arterial Hypertension. J Clin Med 2021; 10:jcm10092024. [PMID: 34065097 PMCID: PMC8126033 DOI: 10.3390/jcm10092024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/30/2021] [Indexed: 12/17/2022] Open
Abstract
The right ventricle (RV) is more sensitive to an increase in afterload than the left ventricle (LV), and RV afterload during exercise increases more easily than LV afterload. Pulmonary arterial hypertension (PAH)-specific therapy has improved pulmonary hemodynamics at rest; however, the pulmonary hemodynamic response to exercise is still abnormal in most patients with PAH. In these patients, RV afterload during exercise could be higher, resulting in a greater increase in RV wall stress. Recently, an increasing number of studies have indicated the short-term efficacy of exercise training. However, considering the potential risk of promoting myocardial maladaptive remodeling, even low-intensity repetitive exercise training could lead to long-term clinical deterioration. Further studies investigating the long-term effects on the RV and pulmonary vasculature are warranted. Although the indications for exercise training for patients with PAH have been expanding, exercise training may be associated with various risks. Training programs along with risk stratification based on the pulmonary hemodynamic response to exercise may enhance the safety of patients with PAH.
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50
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Baratto C, Caravita S, Soranna D, Faini A, Dewachter C, Zambon A, Perego GB, Bondue A, Senni M, Badano LP, Parati G, Vachiéry JL. Current Limitations of Invasive Exercise Hemodynamics for the Diagnosis of Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2021; 14:e007555. [PMID: 33951935 DOI: 10.1161/circheartfailure.120.007555] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exercise hemodynamics can differentiate heart failure with preserved ejection fraction (HFpEF) from noncardiac dyspnea. However, respiratory pressure swings may impact hemodynamic measurements, potentially leading to misdiagnosis of HFpEF. Moreover, threshold values for abnormal hemodynamic response indicative of HFpEF are not universally accepted. Thus, we sought to evaluate the impact of respiratory pressure swings on hemodynamic data interpretation as well as the concordance among 3 proposed exercise hemodynamic criteria for HFpEF: (1) end-expiratory pulmonary artery wedge pressure (PAWPexp) ≥25 mm Hg; (2) PAWPexp/cardiac output slope >2 mm Hg/L per minute; and (3) respiratory-averaged (avg) mean pulmonary artery pressure >30 mm Hg, total pulmonary resistanceavg >3 WU, PAWPavg ≥20 mm Hg. METHODS Fifty-seven patients with unexplained dyspnea (70% women, 70±9 years) underwent exercise cardiac catheterization. The difference between end-expiratory and averaged hemodynamic values, as well as the concordance among the 3 hemodynamic definitions of HFpEF, were assessed. RESULTS End-expiratory hemodynamics measurements were higher than values averaged across the respiratory cycle. During exercise, a larger proportion of patients exceeded the threshold of 25 mm Hg for PAWPexp rather than for PAWPavg (70% versus 53%, P<0.01). The concordance of 3/3 HFpEF exercise hemodynamic criteria was recorded in 70% of patients. PAWPexp/cardiac output slope identified HFpEF more frequently than the other 2 criteria (81% versus 64% to 69%), incorporating over 97% of abnormal responses to the latter. Patients with 3/3 positive criteria had worse clinical, gas-exchange, and hemodynamic profiles. CONCLUSIONS Respiratory pressure swings impact on the exercise hemodynamic definitions of HFpEF that provide discordant results in 30% of patients. Equivocal diagnoses of HFpEF might be limited by adopting the most sensitive and inclusive criterion alone (ie, PAWPexp/cardiac output slope).
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery (C.B., L.P.B., G.P.), University of Milano-Bicocca, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.).,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy (S.C.)
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Biostatistics Unit, Milan, Italy (D.S., A.Z.)
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.)
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Belgium (C.D., A.B., J.-L.V.)
| | - Antonella Zambon
- Department of Statistic and Quantitative Methods (A.Z.), University of Milano-Bicocca, Italy.,IRCCS Istituto Auxologico Italiano, Biostatistics Unit, Milan, Italy (D.S., A.Z.)
| | - Giovanni Battista Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.)
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Belgium (C.D., A.B., J.-L.V.)
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy (M.S.)
| | - Luigi P Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery (C.B., L.P.B., G.P.), University of Milano-Bicocca, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., A.F., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery (C.B., L.P.B., G.P.), University of Milano-Bicocca, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Belgium (C.D., A.B., J.-L.V.)
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