1
|
Khattab E, Velidakis N, Gkougkoudi E, Kadoglou NP. Exercise-Induced Pulmonary Hypertension: A Valid Entity or Another Factor of Confusion? LIFE (BASEL, SWITZERLAND) 2023; 13:life13010128. [PMID: 36676077 PMCID: PMC9860538 DOI: 10.3390/life13010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023]
Abstract
Exercise-induced pulmonary hypertension EIPH has been defined as an increase in mean pulmonary arterial pressure (mPAP) during exercise in otherwise normal values at rest. EIPH reflects heart and/or lung dysfunction and may precede the development of manifest pulmonary hypertension (PH) in a proportion of patients. It is also associated with decreased life expectancy in patients with heart failure with reduced ejection fraction (HFrEF) or left ventricle (LV) valvular diseases. Diastolic dysfunction exacerbated during exercise relates to increased LV filling pressure and left atrial pressure (LAP). In this context backward, transmitted pressure alone or accompanied with backward blood flow promotes EIPH. The gold standard of EIPH assessment remains the right heart catheterization during exercise, which is an accurate but invasive method. Alternatively, non-invasive diagnostic modalities include exercise stress echocardiography (ESE) and cardiopulmonary exercise testing (CPET). Both diagnostic tests are performed under gradually increasing physical stress using treadmill and ergo-cycling protocols. Escalating workload during the exercise is analogous to the physiological response to real exercise. The results of the latter techniques show good correlation with invasive measurements, but they suffer from lack of validation and cut-off value determination. Although it is not officially recommended, there are accumulated data supporting the importance of EIPH diagnosis in the assessment of other mild/subclinical or probably fatal diseases in patients with latent PH or heart failure or LV valvular disease, respectively. Nevertheless, larger, prospective studies are required to ensure its role in clinical practice.
Collapse
|
2
|
Qutrio Baloch Z, Abbas SA, Prasad RM, Elamin AM, Ali A. Potential Role of Cardiopulmonary Exercise Testing as an Early Screening Tool for Patients With Suspected Pulmonary Hypertension Including Exercise-Induced Pulmonary Hypertension: Results From a Retrospective Analysis. Perm J 2021; 25. [PMID: 35348085 DOI: 10.7812/tpp/20.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary goal of our retrospective case-control study was to evaluate the ability of cardiopulmonary exercise testing to screen for underlying exercise-induced pulmonary hypertension (EIPH) in symptomatic patients who had a negative stress test and elevated right ventricular systolic pressure on echocardiogram. We also evaluated long-acting nitrates and ranolazine as medication challenges. SETTING Performed at a single, tertiary-care medical center in the United States. PARTICIPANTS Based on the inclusion and exclusion criteria, 81 patients were included in this study. The primary outcome of the study was to measure mean pulmonary arterial pressure at rest and exertion, as well as Wasserman curves. We also recorded patient demographics and risk factors, left ventricular ejection fraction, and mean oxygen consumption. Additionally, patients were monitored symptomatically after receiving long-acting nitrates and ranolazine. RESULTS A total of 61 patients had resting pulmonary arterial hypertension, and 27 had EIPH. The EIPH group had a significantly higher mean age of 71.67 years. Wasserman curves calculated from the cardiopulmonary exercise testing data revealed 3 subgroups of EIPH patients: cardiac restriction, chronotropic incompetence, and combination of both patterns. The EIPH group showed significant improvement in symptoms after receiving long-acting nitrate therapy. CONCLUSIONS Many patients with symptoms of angina, dyspnea, and/or fatigue on exertion with negative cardiac stress testing may have underlying pulmonary arterial hypertension, including EIPH. Therefore, these patients require adequate treatment and follow-up to prevent worsening of symptoms and pathology.
Collapse
Affiliation(s)
| | | | - Rohan Madhu Prasad
- Department of Internal Medicine, Michigan State University - Sparrow Hospital, Lansing, MI
| | - Amin M Elamin
- Department of Pulmonary and Critical Care, University of South Florida, Tampa, FL
| | - Abbas Ali
- Department of Cardiology, West Virginia University, Morgantown, WV
| |
Collapse
|
3
|
Baratto C, Caravita S, Faini A, Perego GB, Senni M, Badano LP, Parati G. Impact of COVID-19 on exercise pathophysiology: a combined cardiopulmonary and echocardiographic exercise study. J Appl Physiol (1985) 2021; 130:1470-1478. [PMID: 33764166 PMCID: PMC8143785 DOI: 10.1152/japplphysiol.00710.2020] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Survivors from COVID-19 pneumonia can present with persisting multisystem involvement (lung, pulmonary vessels, heart, muscle, red blood cells) that may negatively affect exercise capacity. We sought to determine the extent and the determinants of exercise limitation in patients with COVID-19 at the time of hospital discharge. Eighteen consecutive patients with COVID-19 and 1:1 age-, sex-, and body mass index-matched controls underwent: spirometry, echocardiography, cardiopulmonary exercise test and exercise echocardiography for the study of pulmonary circulation. Arterial blood was sampled at rest and during exercise in patients with COVID-19. Patients with COVID-19 lie roughly on the same oxygen consumption isophlets than controls both at rest and during submaximal exercise, thanks to supernormal cardiac output (P < 0.05). Oxygen consumption at peak exercise was reduced by 30% in COVID-19 (P < 0.001), due to a peripheral extraction limit. In addition, within COVID-19 patients, hemoglobin content was associated with peak oxygen consumption (R2 = 0.46, P = 0.002). Respiratory reserve was not exhausted (median [IRQ], 0.59 [0.15]) in spite of moderate reduction of forced vital capacity (79 ± 40%). Pulmonary artery pressure increase during exercise was not different between patients and controls. Ventilatory equivalents for carbon dioxide were higher in patients with COVID-19 than in controls (39.5 [8.5] vs. 29.5 [8.8], P < 0.001), and such an increase was mainly explained by increased chemosensitivity. When recovering from COVID-19, patients present with reduced exercise capacity and augmented exercise hyperventilation. Peripheral factors, including anemia and reduced oxygen extraction by peripheral muscles were the major determinants of deranged exercise physiology. Pulmonary vascular function seemed unaffected, despite restrictive lung changes.NEW & NOTEWORTHY At the time of hospital discharge, patients with COVID-19 present with reduced functional capacity and exercise hyperventilation. Peripheral factors, namely reduced oxygen extraction (myopathy) and anemia, which are not fully compensated by a supernormal cardiac output response, account for exercise limitation before exhaustion of the respiratory reserve. Enhanced chemoreflex sensitivity, rather increased dead space, mainly accounts for exercise hyperventilation. The pulmonary vascular response to exercise circulation of survived patients with COVID-19 does not present major pathological changes.
Collapse
Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Giovanni Battista Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| |
Collapse
|
4
|
Li A, Zhu Z, He Y, Dong Q, Tang D, Chen Z, Huang W. DDCI-01, a novel long acting phospdiesterase-5 inhibitor, attenuated monocrotaline-induced pulmonary hypertension in rats. Pulm Circ 2020; 10:2045894020939842. [PMID: 33240482 PMCID: PMC7672744 DOI: 10.1177/2045894020939842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/09/2020] [Indexed: 11/29/2022] Open
Abstract
Pulmonary arterial hypertension is a progressive, malignant heart disease, characterized by pulmonary arteriole remodeling and increased pulmonary vascular resistance, which eventually leads to right heart failure. This study sought to evaluate the effects of a novel long-acting phospdiesterase-5 inhibitor, namely DDCI-01, as an early intervention for monocrotaline-induced pulmonary hypertensive rats. To establish this model, 50 mg/kg of monocrotaline was intraperitoneally injected into rats. At Day 7 after monocrotaline injection, two doses of DDCI-01 (3 or 9 mg/kg/day) or tadalafil (at 3 or 9 mg/kg/day) were intragastrically administered. The rats were anesthetized with pentobarbital for hemodynamic and echocardiographic measurements, at Day 21 after monocrotaline injection. Compared to the monocrotaline group, DDCI-01 at 3 and 9 mg/kg/day (P) reduced the mean pulmonary arterial pressure (mPAP), right ventricular systolic pressure, right ventricular transverse diameter, pulmonary arterial medial wall thickness (WT%), and right ventricle hypertrophy. However, no significant difference in the indices mentioned as above was found between DDCI-01 (3 mg/kg/day) and tadalafil (3 mg/kg/day). In addition, DDCI-01 at 9 mg/kg/day resulted in lower mPAP and WT%, as well as higher cyclic guanosine monophosphate levels in the lung and plasma compared with the same dose of tadalafil (9 mg/kg/day) (all P < 0.05). These findings suggested that DDCI-01 improved monocrotaline-induced pulmonary hypertension in rats, and a dose of DDCI-01 of 9 mg/kg/day might be more effective than the same dose of tadalafil in monocrotaline-induced pulmonary hypertension in rats.
Collapse
Affiliation(s)
- Ailing Li
- Cardiovascular Laboratory, Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
- Institute of Life Science, Chongqing Medical University, Chongqing, P.R. China
| | - Zhongkai Zhu
- Cardiovascular Laboratory, Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
- Institute of Life Science, Chongqing Medical University, Chongqing, P.R. China
| | - Yangke He
- Cardiovascular Laboratory, Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
- Institute of Life Science, Chongqing Medical University, Chongqing, P.R. China
| | - Qian Dong
- Cardiovascular Laboratory, Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Dianyong Tang
- Internation Academy of Targeted Therapeutics and Innovation, Chongqing University of Arts and Sciences, Chongqing, P.R. China
| | - Zhongzhu Chen
- Internation Academy of Targeted Therapeutics and Innovation, Chongqing University of Arts and Sciences, Chongqing, P.R. China
| | - Wei Huang
- Cardiovascular Laboratory, Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
- Institute of Life Science, Chongqing Medical University, Chongqing, P.R. China
| |
Collapse
|
5
|
Waller L, Krüger K, Conrad K, Weiss A, Alack K. Effects of Different Types of Exercise Training on Pulmonary Arterial Hypertension: A Systematic Review. J Clin Med 2020; 9:jcm9061689. [PMID: 32498263 PMCID: PMC7356848 DOI: 10.3390/jcm9061689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) represents a chronic progressive disease characterized by high blood pressure in the pulmonary arteries leading to right heart failure. The disease has been a focus of medical research for many years due to its worse prognosis and limited treatment options. The aim of this study was to systematically assess the effects of different types of exercise interventions on PAH. Electronic databases were searched until July 2019. MEDLINE database was used as the predominant source for this paper. Studies with regards to chronic physical activity in adult PAH patients are compared on retrieving evidence on cellular, physiological, and psychological alterations in the PAH setting. Twenty human studies and 12 rat trials were identified. Amongst all studies, a total of 628 human subjects and 614 rats were examined. Regular physical activity affects the production of nitric oxygen and attenuates right ventricular hypertrophy. A combination of aerobic, anaerobic, and respiratory muscle training induces the strongest improvement in functional capacity indicated by an increase of 6 MWD and VO2peak. In human studies, an increase of quality of life was found. Exercise training has an overall positive effect on the physiological and psychological components of PAH. Consequently, PAH patients should be encouraged to take part in regular exercise training programs.
Collapse
Affiliation(s)
- Lena Waller
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
- Correspondence: ; Tel.: +49-641-99-25212
| | - Karsten Krüger
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Kerstin Conrad
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Astrid Weiss
- Department of Internal Medicine, Institute of Pulmonary Pharmacotherapy, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany;
| | - Katharina Alack
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| |
Collapse
|
6
|
Sanders JL, Han Y, Urbina MF, Systrom DM, Waxman AB. Metabolomics of exercise pulmonary hypertension are intermediate between controls and patients with pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019882623. [PMID: 31695905 DOI: 10.1177/2045894019882623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/18/2019] [Indexed: 01/06/2023] Open
Abstract
Mechanisms underlying pulmonary arterial hypertension (PAH) remain elusive. Pulmonary arterial hypertension and exercise PH share similar physiologic consequences; it is debated whether they share biologic mechanisms and if exercise PH represents an early phase of pulmonary arterial hypertension. We conducted an observational study to test if there is a graded metabolic disturbance along the severity of PH, which may indicate shared or disparate pathophysiology. Individuals referred to an academic medical dyspnea center with unexplained exertional intolerance underwent invasive cardiopulmonary exercise testing. We identified controls with no hemodynamic exercise limitation, individuals with exercise PH (mean pulmonary arterial pressure (mPAP) < 25 mmHg at rest but ≥ 30 mmHg during exercise without pulmonary venous hypertension) and pulmonary arterial hypertension (mPAP > 25 mmHg at rest without pulmonary venous hypertension) (n = 26 in each group). Unbiased metabolomics with chromatography mass spectrometry was performed on pulmonary arterial blood at rest and peak exercise. Random forest analysis and hierarchical clustering were used to quantify metabolite prediction of group membership and rank metabolites which were significantly different between groups. Compared to controls, pulmonary arterial hypertension subjects exhibited perturbations in pathways involving glycolysis, TCA cycle, fatty acid and complex lipid oxidation, collagen deposition and fibrosis, nucleotide metabolism, and others. The metabolic signature of exercise PH was uniquely between that of control and pulmonary arterial hypertension subjects. Accuracy predicting control, exercise PH, and pulmonary arterial hypertension group was 96%, 90%, and 88%, respectively, using paired rest-exercise metabolic changes. Our data suggest the metabolic profile of exercise PH is between that of controls and patients with pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Jason L Sanders
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Yuchi Han
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Mariana F Urbina
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
7
|
Shaikh F, Anklesaria Z, Shagroni T, Saggar R, Gargani L, Bossone E, Ryan M, Channick R, Saggar R. A review of exercise pulmonary hypertension in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:225-237. [PMID: 35382504 DOI: 10.1177/2397198319851653] [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: 12/10/2018] [Accepted: 04/06/2019] [Indexed: 11/16/2022]
Abstract
In general, pulmonary vascular disease has important negative prognostic implications, regardless of the associated condition or underlying mechanism. In this regard, systemic sclerosis is of particular interest as it is the most common connective tissue disease associated with pulmonary hypertension, and a well-recognized at-risk population. In the setting of systemic sclerosis and unexplained dyspnea, the concept of using exercise to probe for underlying pulmonary vascular disease has acquired significant interest. In theory, a diagnosis of systemic sclerosis-associated exercise pulmonary hypertension may allow for earlier therapeutic intervention and a favorable alteration in the natural history of the pulmonary vascular disease. In the context of underlying systemic sclerosis, the purpose of this article is to provide a comprehensive review of the evolving definition of exercise pulmonary hypertension, the current role and methodologies for non-invasive and invasive exercise testing, and the importance of the right ventricle.
Collapse
Affiliation(s)
- Faisal Shaikh
- University of California-Los Angeles, Los Angeles, CA, USA
| | | | | | - Rajeev Saggar
- Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Michael Ryan
- Central Coast Chest Consultants, San Luis Obispo, CA, USA
| | | | - Rajan Saggar
- University of California-Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
8
|
Miyanaga S, Kubota K, Iwatani N, Higo K, Miyata M, Horizoe Y, Ojima S, Kawasoe S, Kubozono T, Ohishi M. Predictors of exercise-induced pulmonary hypertension in patients with connective tissue disease. Heart Vessels 2019; 34:1509-1518. [DOI: 10.1007/s00380-019-01373-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/01/2019] [Indexed: 01/25/2023]
|
9
|
Douschan P, Kovacs G, Avian A, Foris V, Gruber F, Olschewski A, Olschewski H. Mild Elevation of Pulmonary Arterial Pressure as a Predictor of Mortality. Am J Respir Crit Care Med 2019; 197:509-516. [PMID: 29099619 DOI: 10.1164/rccm.201706-1215oc] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Normal mean pulmonary arterial pressure (mPAP) is 14.0 ± 3.3 mm Hg (mean ± SD). The prognostic relevance of mildly elevated mPAP not fulfilling the definition of pulmonary hypertension (PH; mPAP ≥ 25 mm Hg) has not been prospectively evaluated in a real-world setting. OBJECTIVES To assess the association of resting mPAP with all-cause mortality in a retrospective and a prospective cohort of patients with unexplained dyspnea and/or at risk of PH. METHODS Prognostic cutoffs were calculated by means of 1) classification and regression tree (CART) analysis without any preset thresholds, and 2) preset thresholds on the basis of literature data defining mPAP as lower-normal (≤mean + 1 SD), upper-normal (between mean + 1 SD and mean + 2 SD), borderline (between mean + 2 SD and 25 mm Hg), and manifest PH (≥25 mm Hg). We performed univariate and multivariate survival analysis adjusted for age and comorbidities. MEASUREMENTS AND MAIN RESULTS We enrolled 547 patients, of whom 137, 56, 64, and 290 presented with lower-normal, upper-normal, or borderline mPAP, and manifest PH, respectively. The CART analysis on mPAP discriminated three prognostic groups: mPAP less than 17 mm Hg, 17 to 26 mm Hg, and greater than 26 mm Hg, with significantly decreasing survival. The univariate analysis on the basis of preset thresholds showed that upper-normal mPAP, borderline mPAP, and manifest PH were significantly associated with poor survival compared with lower-normal mPAP. In the multivariate model, considering age and comorbidities, only borderline mPAP (hazard ratio, 2.37; 95% confidence interval, 1.14-4.97; P = 0.022) and manifest PH (hazard ratio, 5.05; 95% confidence interval, 2.79-9.12; P < 0.001) were significantly associated with poor survival. CONCLUSIONS In patients at risk for PH and/or with unexplained dyspnea, CART analysis detects prognostic thresholds at a resting mPAP of 17 mm Hg and 26 mm Hg, and values between 20 mm Hg and 25 mm Hg represent an independent predictor of poor survival. Clinical trial registered with www.clinicaltrials.gov (NCT 01607502).
Collapse
Affiliation(s)
- Philipp Douschan
- 1 Division of Pulmonology, Department of Internal Medicine, and.,2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Gabor Kovacs
- 1 Division of Pulmonology, Department of Internal Medicine, and.,2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Alexander Avian
- 3 Institute for Medical Informatics, Statistics, and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- 1 Division of Pulmonology, Department of Internal Medicine, and.,2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Fabian Gruber
- 1 Division of Pulmonology, Department of Internal Medicine, and.,2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Andrea Olschewski
- 2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and.,4 Medical School, Johannes Kepler University Linz, Linz, Austria
| | - Horst Olschewski
- 1 Division of Pulmonology, Department of Internal Medicine, and.,2 Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| |
Collapse
|
10
|
Boutou AK, Pitsiou G, Panagiotidou E, Stanopoulos I. Exercise capacity in borderline mean pulmonary artery pressure: Is it all about peak VO 2 ? THE CLINICAL RESPIRATORY JOURNAL 2019; 13:480-481. [PMID: 31054184 DOI: 10.1111/crj.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/28/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Afroditi K Boutou
- Department of Respiratory Medicine, "G. Papanikolaou" Hospital, Thessaloniki, Greece
| | - Georgia Pitsiou
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Panagiotidou
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Stanopoulos
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
11
|
Skjørten I, Hilde JM, Melsom MN, Hisdal J, Hansteen V, Steine K, Humerfelt S. Exercise capacity in COPD patients with exercise-induced pulmonary hypertension. Int J Chron Obstruct Pulmon Dis 2018; 13:3599-3610. [PMID: 30464443 PMCID: PMC6219408 DOI: 10.2147/copd.s161175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Pulmonary hypertension (PH) in patients with COPD is associated with reduced exercise capacity. A subgroup of COPD patients has normal mean pulmonary artery pressure (mPAP) at rest, but develops high mPAP relative to cardiac output (CO) during exercise, a condition we refer to as exercise-induced pulmonary hypertension (EIPH). We hypothesized that COPD patients with EIPH could be identified by cardiopulmonary exercise test (CPET) and that these patients have lower exercise capacity and more abnormal CPET parameters compared to COPD patients with normal hemodynamic exercise response. Methods Ninety-three stable outpatients with COPD underwent right heart catheterization with the measurement of mPAP, CO, and capillary wedge pressure at rest and during supine exercise. Resting mPAP <25 mmHg with ΔmPAP/ΔCO slope above or below 3 mmHg/L/min were defined as COPD-EIPH and COPD-normal, respectively. Pulmonary function tests and CPET with arterial blood gases were performed. Linear mixed models were fitted to estimate differences between the groups with adjustment for gender, age, and airflow obstruction. Results EIPH was observed in 45% of the study population. Maximal workload was lower in COPD-EIPH compared to COPD-normal, whereas other CPET measurements at peak exercise in % predicted values were similar between the two groups. After adjustment for gender, age, and airflow obstruction, patients with COPD-EIPH showed significantly greater increase in oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate with increasing work load, as well as more reduction in pH compared to those with normal hemodynamic responses. Conclusion COPD-EIPH could not be discriminated from COPD-normal by CPET. However, COPD-EIPH experienced a higher cost of exercise in terms of higher oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate for a given increase in workload compared to COPD-normal.
Collapse
Affiliation(s)
- Ingunn Skjørten
- Department of Pulmonary Medicine, LHL Hospital Gardermoen, Jessheim, .,Faculty of Medicine, University of Oslo, Oslo,
| | | | | | - Jonny Hisdal
- Section of Vascular Investigations, Oslo University Hospital-Aker
| | | | - Kjetil Steine
- Faculty of Medicine, University of Oslo, Oslo, .,Department of Cardiology, Akershus University Hospital, Lørenskog
| | - Sjur Humerfelt
- Clinic of Allergology and Respiratory Medicine, Oslo, Norway
| |
Collapse
|
12
|
Ferrara F, Gargani L, Armstrong WF, Agoston G, Cittadini A, Citro R, D'Alto M, D'Andrea A, Dellegrottaglie S, De Luca N, Di Salvo G, Ghio S, Grünig E, Guazzi M, Kasprzak JD, Kolias TJ, Kovacs G, Lancellotti P, La Gerche A, Limongelli G, Marra AM, Moreo A, Ostenfeld E, Pieri F, Pratali L, Rudski LG, Saggar R, Saggar R, Scalese M, Selton-Suty C, Serra W, Stanziola AA, Voilliot D, Vriz O, Naeije R, Bossone E. The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications. Heart Fail Clin 2018; 14:443-465. [PMID: 29966641 DOI: 10.1016/j.hfc.2018.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.
Collapse
Affiliation(s)
| | - Luna Gargani
- Institute of Clinical Physiology-C.N.R., Pisa, Italy
| | - William F Armstrong
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Gergely Agoston
- Department of Family Medicine, University of Szeged, Szeged, Hungary
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Rodolfo Citro
- Heart Department, University Hospital of Salerno, Salerno, Italy
| | - Michele D'Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Santo Dellegrottaglie
- Division of Cardiology, Ospedale Medico-Chirurgico Accreditato Villa dei Fiori, Acerra, Naples, Italy; Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicola De Luca
- Hypertension Research Center "CIRIAPA", Federico II University, Napoli, Italy
| | | | - Stefano Ghio
- Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic, Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Guazzi
- Heart Failure Unit, Cardiopulmonary Laboratory, University Cardiology Department, IRCCS Policlinico San Donato University Hospital, Milan, Italy
| | | | - Theodore John Kolias
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Liege, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | | | - Giuseppe Limongelli
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy; Institute of Cardiovascular Sciences, University College of London, London, UK
| | | | | | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Francesco Pieri
- Department of Heart, Thorax and Vessels, Azienda Ospedaliero Universitaria, Florence, Italy
| | | | - Lawrence G Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Rajan Saggar
- Lung and Heart-Lung Transplant Program, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; Pulmonary Hypertension Program, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Rajeev Saggar
- Lung Institute Banner University Medical Center-Phoenix, University of Arizona, Phoenix, AZ, USA
| | - Marco Scalese
- Institute of Clinical Physiology-C.N.R., Pisa, Italy
| | | | - Walter Serra
- Cardiology Unit, Surgery Department, University Hospital of Parma, Italy
| | - Anna Agnese Stanziola
- Department of Respiratory Diseases, Monaldi Hospital, University "Federico II", Naples, Italy
| | - Damien Voilliot
- Centre Hospitalier Lunéville, Service de Cardiologie, Lunéville, France
| | - Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Eduardo Bossone
- Cardiology Division, Heart Department, "Cava de' Tirreni and Amalfi Coast" Hospital, University of Salerno, Salerno, Italy.
| |
Collapse
|
13
|
Wallace WD, Nouraie M, Chan SY, Risbano MG. Treatment of exercise pulmonary hypertension improves pulmonary vascular distensibility. Pulm Circ 2018; 8:2045894018787381. [PMID: 29916285 PMCID: PMC6047253 DOI: 10.1177/2045894018787381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Exercise pulmonary hypertension (ePH) is an underappreciated form of exertional limitation. Despite normal resting pulmonary artery pressures, patients with ePH demonstrate early pulmonary vascular changes with reduced pulmonary arterial compliance (PAC) and vascular distensibility (α). Recent data suggest that targeted vasodilator therapy may improve hemodynamics in ePH, but it is not well-known whether such medications alter pulmonary vascular distensibility. Thus, we sought to evaluate if vasodilator therapy improved α a marker of early pulmonary vascular disease in ePH. Ten patients performed supine exercise right heart catheterization (exRHC) with bicycle ergometer to peak exercise. Patients diagnosed with ePH were treated with pulmonary vasodilators. A repeat symptom-limited exercise RHC was performed at least six months after therapy. Patients with ePH had evidence of early pulmonary vascular disease, as baseline PAC and α were reduced. After pulmonary vasodilator therapy, a number of peak exercise hemodynamics statistically improved, including a decrease of total pulmonary resistance and pulmonary vascular resistance, while cardiac output increased. Importantly, vasodilator therapy partially reversed the pathogenic decreases of α at the time of repeat exRHC. Pulmonary vascular distensibility, α, a marker of early pulmonary vascular disease, improves in ePH after therapy with pulmonary vasodilators.
Collapse
Affiliation(s)
- William D Wallace
- 1 Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - Mehdi Nouraie
- 2 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen Y Chan
- 3 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,4 Division of Cardiology, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael G Risbano
- 2 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
14
|
Abstract
INTRODUCTION Altitude is associated with a decrease in partial pressure of oxygen. Hypoxia induces pulmonary vasoconstriction with subsequent fixed increase in pulmonary artery pressure, and eventual right heart failure. CURRENT KNOWLEDGE High altitude exposure is associated with an increase in pulmonary artery pressure that is proportional to initial vasoconstriction. Echocardiographic evaluations on a large number of subjects show that the altitude-induced increase in pulmonary pressure is generally modest and does not exceed the 25mmHg that are diagnostic of pulmonary hypertension. This does not greatly increase right ventricular afterload, so that imaging of the right ventricle only shows some alterations of indices of systolic or diastolic function, but preserved contractile reserve during exercise. In less than 1% of cases, hypoxic vasoconstriction is strong and may be a cause of severe pulmonary hypertension and right heart failure. PERSPECTIVES The prognostic relevance of altitude-induced pulmonary hypertension and associated cardiac function alterations is not known. Treatment of hypoxic pulmonary hypertension relies on evacuation to a lower altitude, oxygen and pulmonary vasodilators. These treatment strategies have not been rigorously evaluated. CONCLUSIONS Altitude may be a cause of right heart failure. This uncommon complication of altitude exposure requires further epidemiological and therapeutic studies.
Collapse
|
15
|
Naeije R, Saggar R, Badesch D, Rajagopalan S, Gargani L, Rischard F, Ferrara F, Marra AM, D' Alto M, Bull TM, Saggar R, Grünig E, Bossone E. Exercise-Induced Pulmonary Hypertension: Translating Pathophysiological Concepts Into Clinical Practice. Chest 2018; 154:10-15. [PMID: 29382472 DOI: 10.1016/j.chest.2018.01.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/18/2017] [Accepted: 01/05/2018] [Indexed: 11/18/2022] Open
Abstract
Exercise stress testing of the pulmonary circulation for the diagnosis of latent or early-stage pulmonary hypertension (PH) is gaining acceptance. There is emerging consensus to define exercise-induced PH by a mean pulmonary artery pressure > 30 mm Hg at a cardiac output < 10 L/min and a total pulmonary vascular resistance> 3 Wood units at maximum exercise, in the absence of PH at rest. Exercise-induced PH has been reported in association with a bone morphogenetic receptor-2 gene mutation, in systemic sclerosis, in left heart conditions, in chronic lung diseases, and in chronic pulmonary thromboembolism. Exercise-induced PH is a cause of decreased exercise capacity, may precede the development of manifest PH in a proportion of patients, and is associated with a decreased life expectancy. Exercise stress testing of the pulmonary circulation has to be dynamic and rely on measurements of the components of the pulmonary vascular equation during, not after exercise. Noninvasive imaging measurements may be sufficiently accurate in experienced hands, but suffer from lack of precision, so that invasive measurements are required for individual decision-making. Exercise-induced PH is caused either by pulmonary vasoconstriction, pulmonary vascular remodeling, or by increased upstream transmission of pulmonary venous pressure. This differential diagnosis is clinical. Left heart disease as a cause of exercise-induced PH can be further ascertained by a pulmonary artery wedge pressure above or below 20 mm Hg at a cardiac output < 10 L/min or a pulmonary artery wedge pressure-flow relationship above or below 2 mm Hg/L/min during exercise.
Collapse
Affiliation(s)
- Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Rajeev Saggar
- Department of Medicine, University of Arizona, Phoenix, AZ
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sanjay Rajagopalan
- Cardiovascular Research Institute, Case Western Reserve School of Medicine, Cleveland, OH
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Franz Rischard
- Division of Cardiology, University of Arizona, Tucson, AZ
| | - Francesco Ferrara
- 'Cava de' Tirreni and Amalfi Coast' Hospital, Division of Cardiology, Heart Department, University Hospital, Salerno, Italy
| | | | - Michele D' Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rajan Saggar
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital, Heidelberg, Germany; German Center of Lung Research, Germany
| | - Eduardo Bossone
- 'Cava de' Tirreni and Amalfi Coast' Hospital, Division of Cardiology, Heart Department, University Hospital, Salerno, Italy.
| |
Collapse
|
16
|
Go YY, Dulgheru R, Sugimoto T, Marchetta S, Oury C, Lancellotti P. Exercise Doppler echocardiography for the diagnosis of pulmonary hypertension: renewed interest and evolving roles. J Thorac Dis 2017; 9:2856-2861. [PMID: 29221256 DOI: 10.21037/jtd.2017.08.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yun Yun Go
- Department of Cardiology, National Heart Centre Singapore, Singapore.,Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, University Hospital Sart Tilman, Liège, Belgium
| | - Raluca Dulgheru
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, University Hospital Sart Tilman, Liège, Belgium
| | - Tadafumi Sugimoto
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, University Hospital Sart Tilman, Liège, Belgium
| | - Stella Marchetta
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, University Hospital Sart Tilman, Liège, Belgium
| | - Cécile Oury
- GIGA Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, University Hospital Sart Tilman, Liège, Belgium.,GIGA Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| |
Collapse
|
17
|
Kovacs G, Herve P, Barbera JA, Chaouat A, Chemla D, Condliffe R, Garcia G, Grünig E, Howard L, Humbert M, Lau E, Laveneziana P, Lewis GD, Naeije R, Peacock A, Rosenkranz S, Saggar R, Ulrich S, Vizza D, Vonk Noordegraaf A, Olschewski H. An official European Respiratory Society statement: pulmonary haemodynamics during exercise. Eur Respir J 2017; 50:50/5/1700578. [DOI: 10.1183/13993003.00578-2017] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/08/2017] [Indexed: 01/18/2023]
Abstract
There is growing recognition of the clinical importance of pulmonary haemodynamics during exercise, but several questions remain to be elucidated. The goal of this statement is to assess the scientific evidence in this field in order to provide a basis for future recommendations.Right heart catheterisation is the gold standard method to assess pulmonary haemodynamics at rest and during exercise. Exercise echocardiography and cardiopulmonary exercise testing represent non-invasive tools with evolving clinical applications. The term “exercise pulmonary hypertension” may be the most adequate to describe an abnormal pulmonary haemodynamic response characterised by an excessive pulmonary arterial pressure (PAP) increase in relation to flow during exercise. Exercise pulmonary hypertension may be defined as the presence of resting mean PAP <25 mmHg and mean PAP >30 mmHg during exercise with total pulmonary resistance >3 Wood units. Exercise pulmonary hypertension represents the haemodynamic appearance of early pulmonary vascular disease, left heart disease, lung disease or a combination of these conditions. Exercise pulmonary hypertension is associated with the presence of a modest elevation of resting mean PAP and requires clinical follow-up, particularly if risk factors for pulmonary hypertension are present. There is a lack of robust clinical evidence on targeted medical therapy for exercise pulmonary hypertension.
Collapse
|
18
|
Segrera SA, Lawler L, Opotowsky AR, Systrom D, Waxman AB. Open label study of ambrisentan in patients with exercise pulmonary hypertension. Pulm Circ 2017; 7:531-538. [PMID: 28597763 PMCID: PMC5467947 DOI: 10.1177/2045893217709024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A growing body of evidence suggests that exercise pulmonary hypertension (ePH) is an early form of pulmonary arterial hypertension (PAH). Identifying the disease at an early, potentially more responsive phase, and initiating treatment may improve functional status and prevent progression to severe forms of PAH. This was a single-center, open-label six-month treatment trial to evaluate the effect of ambrisentan on pulmonary hemodynamics and exercise capacity in ePH utilizing invasive cardiopulmonary exercise testing (iCPET). After six months of treatment with ambrisentan, patients repeated iCPET; exercise capacity, symptoms, and pulmonary hemodynamics were reassessed. Twenty-two of 30 patients completed the treatment phase and repeat iCPET. After six months of treatment there was a significant decline in peak exercise mPAP (−5.2 ± 5.6 mmHg, P = 0.001), TPG (−7.1 ± 8.0 mmHg, P = 0.001), PVR (−0.9 ± 0.7 Woods units, P = 0.0002), and Ca-vO2 (−1.8 ± 2.3 mL/dL, P = 0.0002), with significant increases in peak PCWP (+2.9 ± 5.6 mmHg, P = 0.02), PVC (+0.8 ± 1.4 mL/mmHg, P = 0.03), and CO (+2.3 ± 1.4 L/min, P = 0.0001). A trend toward increased VO2max (+4.4 ± 2.6% predicted, P = 0.07) was observed. In addition, there were improvements in 6MWD and WHO FC after 24 weeks. Our findings suggest that treatment of ePH with ambrisentan results in improved pulmonary hemodynamics and functional status over a six-month period. Treatment of ePH may prevent the progression of vascular remodeling and development of established PAH.
Collapse
Affiliation(s)
- Sergio A Segrera
- Center for Pulmonary-Heart Diseases, Pulmonary Vascular Disease Program, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Laurie Lawler
- Center for Pulmonary-Heart Diseases, Pulmonary Vascular Disease Program, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alexander R Opotowsky
- Center for Pulmonary-Heart Diseases, Pulmonary Vascular Disease Program, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David Systrom
- Center for Pulmonary-Heart Diseases, Pulmonary Vascular Disease Program, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Center for Pulmonary-Heart Diseases, Pulmonary Vascular Disease Program, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
19
|
Medarov BI, Jogani S, Sun J, Judson MA. Readdressing the entity of exercise pulmonary arterial hypertension. Respir Med 2017; 124:65-71. [PMID: 28284324 DOI: 10.1016/j.rmed.2017.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 01/25/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
Abstract
Exercise pulmonary hypertension (EPH) indicates an abnormally elevated pulmonary artery pressure (PAP) during exercise. The physiological range of PAP during exercise remains poorly defined and, therefore, a universally accepted definition of EPH remains elusive. Nevertheless, previous data concerning the distribution of PAP in normal populations and more recent retrospective clinical data enhanced our ability to define EPH. EPH can impair exercise capacity and cause dyspnea. The underlying pathophysiology of the arterial form of EPH (EPAH) appears to be similar to that seen in resting pulmonary arterial hypertension (PAH), and EPAH individuals are at risk of developing resting PAH. Patients with collagen vascular disease, especially scleroderma, are at risk for EPAH and its presence indicates a relatively poor prognosis. The prevalence of EPAH in scleroderma may be as high as 50%. The utility of pulmonary vasodilator therapy for EPAH is not well defined; however, a sizable subgroup of EPAH patients will achieve an improvement in symptoms.
Collapse
Affiliation(s)
- Boris I Medarov
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA.
| | - Sidharth Jogani
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Johnathan Sun
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| |
Collapse
|
20
|
Panagiotou M, Church AC, Johnson MK, Peacock AJ. Pulmonary vascular and cardiac impairment in interstitial lung disease. Eur Respir Rev 2017; 26:26/143/160053. [PMID: 28096284 PMCID: PMC9488566 DOI: 10.1183/16000617.0053-2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/19/2022] Open
Abstract
Pulmonary vascular and cardiac impairment is increasingly appreciated as a major adverse factor in the natural history of interstitial lung disease. This clinically orientated review focuses on the current concepts in the pathogenesis, pathophysiology and implications of the detrimental sequence of increased pulmonary vascular resistance, pre-capillary pulmonary hypertension and right heart failure in interstitial lung disease, and provides guidance on its management. Development of pulmonary hypertension is a major adverse factor in the natural history of interstitial lung diseasehttp://ow.ly/nJB0302XAmD
Collapse
Affiliation(s)
- Marios Panagiotou
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Alistair C Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| |
Collapse
|
21
|
Hsu S, Brusca SB, Rhodes PS, Kolb TM, Mathai SC, Tedford RJ. Use of thermodilution cardiac output overestimates diagnoses of exercise-induced pulmonary hypertension. Pulm Circ 2017; 7:253-255. [PMID: 28680584 PMCID: PMC5448537 DOI: 10.1086/690629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/07/2016] [Indexed: 11/26/2022] Open
Abstract
Two new definitions of exercise-induced pulmonary hypertension (EIPH) have emerged. Both rely on measuring cardiac output (CO), yet this remains unstandardized. In our cohort of patients undergoing invasive cardiopulmonary exercise testing, we found that using thermodilution CO rather than direct Fick CO led to a significant excess of EIPH diagnoses.
Collapse
Affiliation(s)
- Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Parker S Rhodes
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
22
|
Lau EMT, Thakkar V, Humbert M, Herve P. To stress or not to stress? Exercise pulmonary haemodynamic testing in systemic sclerosis. Eur Respir J 2016; 48:1549-1552. [PMID: 27903685 DOI: 10.1183/13993003.01809-2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/15/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Edmund M T Lau
- Sydney Medical School, University of Sydney, Sydney, Australia .,Dept of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Vivek Thakkar
- Dept of Rheumatology, Liverpool Hospital, Sydney, Australia.,School of Medicine, Western Sydney University, Campbelltown, Australia
| | - Marc Humbert
- Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Herve
- AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, DHU Thorax Innovation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| |
Collapse
|
23
|
Stamm A, Saxer S, Lichtblau M, Hasler ED, Jordan S, Huber LC, Bloch KE, Distler O, Ulrich S. Exercise pulmonary haemodynamics predict outcome in patients with systemic sclerosis. Eur Respir J 2016; 48:1658-1667. [DOI: 10.1183/13993003.00990-2016] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/03/2016] [Indexed: 12/26/2022]
Abstract
The aim of the present study was to investigate the prognostic value of exercise haemodynamics measured during right heart catheterisation (RHC) in patients with systemic sclerosis (SSc) referred for evaluation of pulmonary hypertension.SSc patients undergoing RHC at rest and during maximal supine incremental cycle exercise were grouped into resting precapillary pulmonary hypertension (PHrest) (mean pulmonary artery pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure <15 mmHg), exercise-induced pulmonary hypertension (PHex) (mPAP ≥30 mmHg and mPAP/cardiac output >3 mmHg·L−1·min−1 at maximal exercise), and without pulmonary hypertension (PHnone). Patients' characteristics, haemodynamics and follow up data were compared between groups.72 SSc patients were followed for median (interquartile range) 33 (15–55) months. Mean (95% CI) survival without transplantation estimated by Kaplan-Meyer analysis was 4.4 (0.8–2.9) years in PHrest (n=17), 5.2 (4.4–6.1) years in PHex (n=28) and 9.5(8.4–10.6) years in PHnone (n=27; p<0.05 versus others). In Cox regression models, the exercise-induced increase in mPAP (hazard ratio (HR) 1.097, 95% CI 1.002–1.200) and the coefficient of pulmonary vascular distensibility alpha (HR 0.100, 95% CI 0.012–0.871) controlled for age, but not resting haemodynamics predicted transplant-free survival.Among SSc patients with normal mPAP at rest, an excessive increase in mPAP during exercise and an impaired vascular distensibility may indicate an early stage of pulmonary vasculopathy, associated with reduced survival similar to resting pulmonary hypertension patients.
Collapse
|
24
|
|
25
|
Lau EM, Naeije R. Provocative testing of the pulmonary circulation: advances and unresolved issues. Eur Respir J 2016; 48:18-20. [DOI: 10.1183/13993003.00860-2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 05/03/2016] [Indexed: 11/05/2022]
|
26
|
Thakkar V, Lau EMT. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol 2016; 30:22-38. [PMID: 27421214 DOI: 10.1016/j.berh.2016.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/12/2016] [Accepted: 03/29/2016] [Indexed: 01/05/2023]
Abstract
Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH.
Collapse
Affiliation(s)
- Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Ingham Institute, Liverpool, Australia.
| | - Edmund M T Lau
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Camperdown, Australia.
| |
Collapse
|
27
|
Naeije R, D'Alto M. The Diagnostic Challenge of Group 2 Pulmonary Hypertension. Prog Cardiovasc Dis 2016; 59:22-9. [PMID: 27195751 DOI: 10.1016/j.pcad.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension (PH) secondary to left heart diseases associated with an increased pulmonary venous pressure is the second of a total of five groups recognized in the classification of PH. Group 2 PH is the commonest form of PH, and is associated with high morbidity and mortality. The diagnosis of group 2 PH relies on a clinical probability assessment in which echocardiography plays a major role, eventually followed by the invasive measurements of a mean pulmonary artery pressure (mPAP) ≥25mmHg and a wedged PAP (PAWP) >15mmHg. This combination of mPAP and PAWP defines "post-capillary PH" (pcPH). Post-capillary PH is most often associated with a diastolic pressure gradient (DPG) or gradient between diastolic PAP and PAWP <7mmHg and/or a pulmonary vascular resistance (PVR) ≤3Wood units (WU), and is called isolated pcPH (IpcPH). Postcapillary PH with a DPG ≥7mmHg and/or a PVR >3WU is then combined pre- and postcapillary PH (CpcPH). Post-capillary PH is associated with a decreased survival in proportion to increased PAP and decreased right ventricular (RV) ejection fraction. CpcPH occurs in 12-13% of patients with pcPH. CpcPH is associated with pulmonary vascular remodeling and altered RV-arterial coupling. The prognosis of CpcPH is poor.
Collapse
Affiliation(s)
- Robert Naeije
- Department of Cardiology, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
| | - Michele D'Alto
- Department of Cardiology, Second University of Naples - Monaldi Hospital, Naples, Italy
| |
Collapse
|
28
|
Oliveira RKF, Waxman AB, Agarwal M, Badr Eslam R, Systrom DM. Pulmonary haemodynamics during recovery from maximum incremental cycling exercise. Eur Respir J 2016; 48:158-67. [PMID: 27126692 DOI: 10.1183/13993003.00023-2016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/17/2016] [Indexed: 02/04/2023]
Abstract
Assessment of cardiac function during exercise can be technically demanding, making the recovery period a potentially attractive diagnostic window. However, the validity of this approach for exercise pulmonary haemodynamics has not been validated.The present study, therefore, evaluated directly measured pulmonary haemodynamics during 2-min recovery after maximum invasive cardiopulmonary exercise testing in patients evaluated for unexplained exertional intolerance. Based on peak exercise criteria, patients with exercise pulmonary hypertension (ePH; n=36), exercise pulmonary venous hypertension (ePVH; n=28) and age-matched controls (n=31) were analysed.By 2-min recovery, 83% (n=30) of ePH patients had a mean pulmonary artery pressure (mPAP) <30 mmHg and 96% (n=27) of ePVH patients had a pulmonary arterial wedge pressure (PAWP) <20 mmHg. Sensitivity of pulmonary hypertension-related haemodynamic measurements during recovery for ePH and ePVH diagnosis was ≤25%. In ePVH, pulmonary vascular compliance (PVC) returned to its resting value by 1-min recovery, while in ePH, elevated pulmonary vascular resistance (PVR) and decreased PVC persisted throughout recovery.In conclusion, we observed that mPAP and PAWP decay quickly during recovery in ePH and ePVH, compromising the sensitivity of recovery haemodynamic measurements in diagnosing pulmonary hypertension. ePH and ePVH had different PVR and PVC recovery patterns, suggesting differences in the underlying pulmonary hypertension pathophysiology.
Collapse
Affiliation(s)
- Rudolf K F Oliveira
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Manyoo Agarwal
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Roza Badr Eslam
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
29
|
Affiliation(s)
- Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Center for Postgraduate Education, ECZ-Otwock. ul. borowa 14/18, 05-400 Otwock, Poland
| |
Collapse
|
30
|
Lau EM, Godinas L, Sitbon O, Montani D, Savale L, Jaïs X, Lador F, Gunther S, Celermajer DS, Simonneau G, Humbert M, Chemla D, Herve P. Resting pulmonary artery pressure of 21–24 mmHg predicts abnormal exercise haemodynamics. Eur Respir J 2016; 47:1436-44. [DOI: 10.1183/13993003.01684-2015] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 01/18/2016] [Indexed: 02/07/2023]
Abstract
A resting mean pulmonary artery pressure (mPAP) of 21–24 mmHg is above the upper limit of normal but does not reach criteria for the diagnosis of pulmonary hypertension (PH). We sought to determine whether an mPAP of 21–24 mmHg is associated with an increased risk of developing an abnormal pulmonary vascular response during exercise.Consecutive patients (n=290) with resting mPAP <25 mmHg who underwent invasive exercise haemodynamics were analysed. Risk factors for pulmonary vascular disease or left heart disease were present in 63.4% and 43.8% of subjects. An abnormal pulmonary vascular response (or exercise PH) was defined by mPAP >30 mmHg and total pulmonary vascular resistance >3 WU at maximal exercise.Exercise PH occurred in 74 (86.0%) out of 86 versus 96 (47.1%) out of 204 in the mPAP of 21–24 mmHg and mPAP <21 mmHg groups, respectively (OR 6.9, 95% CI: 3.6–13.6; p<0.0001). Patients with mPAP of 21–24 mmHg had lower 6-min walk distance (p=0.002) and higher New York Heart Association functional class status (p=0.03). Decreasing levels of mPAP were associated with a lower prevalence of exercise PH, which occurred in 60.3%, 38.7% and 7.7% of patients with mPAP of 17–20, 13–16 and <13 mmHg, respectively.In an at-risk population, a resting mPAP between 21–24 mmHg is closely associated with exercise PH together with worse functional capacity.
Collapse
|
31
|
Oliveira RKF, Agarwal M, Tracy JA, Karin AL, Opotowsky AR, Waxman AB, Systrom DM. Age-related upper limits of normal for maximum upright exercise pulmonary haemodynamics. Eur Respir J 2015; 47:1179-88. [PMID: 26677941 DOI: 10.1183/13993003.01307-2015] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/31/2015] [Indexed: 11/05/2022]
Abstract
The exercise definition of pulmonary hypertension was eliminated from the pulmonary hypertension guidelines in part due to uncertainty of the upper limits of normal (ULNs) for exercise haemodynamics in subjects >50 years old.The present study, therefore, evaluated the pulmonary haemodynamic responses to maximum upright incremental cycling exercise in consecutive subjects who underwent an invasive cardiopulmonary exercise testing for unexplained exertional intolerance, deemed normal based on preserved exercise capacity and normal resting supine haemodynamics. Subjects aged >50 years old (n=41) were compared with subjects ≤50 years old (n=25). ULNs were calculated as mean + 2 sdPeak exercise mean pulmonary arterial pressure was not different for subjects >50 and ≤50 years old (23 ± 5 versus 22 ± 4 mmHg, p=0.22), with ULN of 33 and 30 mmHg, respectively. Peak cardiac output was lower in older subjects (median (interquartile range): 12.1 (9.4-14.2)versus16.2 (13.8-19.2) L·min(-1), p<0.001). Peak pulmonary vascular resistance was higher in older subjects compared with younger subjects (mean ± sd: 1.20 ± 0.45 versus 0.82 ± 0.26 Wood units, p<0.001), with ULN of 2.10 and 1.34 Wood units, respectively.We observed that subjects >50 and ≤ 50 years old have different pulmonary vascular responses to exercise. Older subjects have higher pulmonary vascular resistance at peak exercise, resulting in different exercise haemodynamics ULNs compared with the younger population.
Collapse
Affiliation(s)
- Rudolf K F Oliveira
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil These authors contributed equally to the study
| | - Manyoo Agarwal
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA These authors contributed equally to the study
| | - Julie A Tracy
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Abbey L Karin
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Alexander R Opotowsky
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Dept of Cardiology, Boston Children's Hospital, Boston, MA, USA Division of Cardiovascular Medicine, Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|