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Lokhorst C, van der Werf S, Berger RMF, Douwes JM. Prognostic Value of Serial Risk Stratification in Adult and Pediatric Pulmonary Arterial Hypertension: A Systematic Review. J Am Heart Assoc 2024; 13:e034151. [PMID: 38904230 PMCID: PMC11255703 DOI: 10.1161/jaha.123.034151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/10/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND In pulmonary arterial hypertension, it is recommended to base therapeutic decisions on risk stratification. This systematic review aims to report the prognostic value of serial risk stratification in adult and pediatric pulmonary arterial hypertension and to explore the usability of serial risk stratification as treatment target. METHODS AND RESULTS Electronic databases PubMed, Embase, and Web of Science were searched up to January 30, 2023, using terms associated with pulmonary arterial hypertension, pediatric pulmonary hypertension, and risk stratification. Observational studies and clinical trials describing risk stratification at both baseline and follow-up were included. Sixty five studies were eligible for inclusion, including only 2 studies in a pediatric population. C-statistic range at baseline was 0.31 to 0.77 and improved to 0.30 to 0.91 at follow-up. In 53% of patients, risk status changed (42% improved, 12% worsened) over 168 days (interquartile range, 137-327 days; n=22 studies). The average proportion of low-risk patients increased from 18% at baseline to 36% at a median follow-up of 244 days (interquartile range, 140-365 days; n=40 studies). In placebo-controlled drug studies, risk statuses of the intervention groups improved more and worsened less compared with the placebo groups. Furthermore, a low-risk status, but also an improved risk status, at follow-up was associated with a better outcome. Similar results were found in the 2 pediatric studies. CONCLUSIONS Follow-up risk stratification has improved prognostic value compared with baseline risk stratification, and change in risk status between baseline and follow-up corresponded to a change in survival. These data support the use of serial risk stratification as treatment target in pulmonary arterial hypertension.
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Affiliation(s)
- Chantal Lokhorst
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Sjoukje van der Werf
- Central Medical LibraryUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Rolf M. F. Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Johannes M. Douwes
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
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Chen Y, Li J, Li F, Chen Z, Chen Z, Luo J, Qiu H, Chen W, Hu J, Luo X, Tan Y, Rathinasabapathy A, Chen J, Li J. Impact of Epicardial Adipose Tissue on Right Cardiac Function and Prognosis in Pulmonary Arterial Hypertension. Chest 2024; 165:1211-1223. [PMID: 38040053 DOI: 10.1016/j.chest.2023.11.039] [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: 05/19/2023] [Revised: 10/11/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Although epicardial adipose tissue (EAT) is linked to effects on survival in left-sided heart failure, the association between EAT and right-sided heart failure caused by pulmonary arterial hypertension (PAH) remains unknown. RESEARCH QUESTION What are the potential impacts of EAT volume (EATV) on right ventricular function, biomarkers of myocardial injury, and long-term prognosis in patients with PAH? STUDY DESIGN AND METHODS A total of 135 age- and BMI-matched patients with PAH and 49 control participants were included in this study. EATV was quantified by using cardiac magnetic resonance and was related to clinical correlates, N-terminal pro-brain natriuretic peptide, and cardiac function. Levels of EATV associated with the risk of clinical worsening were evaluated on a continuous scale (restricted cubic splines) and by previously defined centile categories with Cox proportional hazards regression models and Kaplan-Meier survival estimates. RESULTS Compared with the control participants, patients with PAH had a lower EATV (ln [EATV], 3.2 ± 0.8 mL vs 3.5 ± 0.7 mL; P = .034). The association of EATV with right ventricular end-diastolic volume (Pnonlinear = .001), right ventricular end-diastolic volume index (P < .001), right ventricular cardiac output (P = .003), N-terminal pro-brain natriuretic peptide (P = .030), and the risk of clinical worsening (P = .014) was U shaped. Compared with individuals with middle-level EATV, multivariable-adjusted hazard ratio for clinical worsening was 6.0 (95% CI, 1.3-27.8) for the individuals with low-level EATV and 6.8 (95% CI, 1.5-30.2) for high-level EATV in patients with PAH. INTERPRETATION Patients with PAH had a decreased EATV compared with control participants. EATV exhibited a U-shaped association with right ventricular function and biomarkers of myocardial injury in patients with PAH. Low and high levels of EATV might reduce long-term event-free survival in patients with PAH. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry; No. ChiCTR2100049804; www.chictr.org.cn.
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Affiliation(s)
- Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Junli Li
- Department of Medical Imaging, Huizhou Municipal Central Hospital, Huizhou, China
| | - Fang Li
- Department of Radiology and Imaging, Zhuzhou Central Hospital of Central South University, Zhuzhou, China
| | - Zheng Chen
- School of Information Science and Technology, Shanghaitech University, Shanghai City, China
| | - Zhangling Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Jun Luo
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Haihua Qiu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Wenjie Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Junjiao Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Xiaoqin Luo
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Yingjie Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | | | - Jingyuan Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha City, China.
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Liu M, Wang X, Yan Z, Wang Z, Wei H, Wang J, Luan X. Network Analysis on Family Resilience, Fear of Progression, and Quality of Life in Chinese Patients with Pulmonary Hypertension. Heart Lung 2024; 64:128-136. [PMID: 38176126 DOI: 10.1016/j.hrtlng.2023.12.005] [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] [Received: 07/08/2023] [Revised: 12/03/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The long-term quality of life of Chinese patients with pulmonary hypertension has been seriously compromised. Interventions to enhance patient quality of life of are urgently required. OBJECTIVE To investigate the relationship between quality of life and its influencing factors in patients through network analysis. METHOD 247 patients with pulmonary hypertension in 3 hospitals in Jinan, Shandong Province, self-reported their immediate family resilience, fear of progression, and quality of life via questionnaires. A mixed graphical model was constructed to investigate the relationship among multidimensional structures of variables. RESULTS A total of 247 patients (173 female and 74 male) were included (age 18-34, n=115; age 35-49, n=99; age 50-64, n=23; age > 65 years, n=10). "Family communication and problem solving" was at the center of the network, with serving as a bridge node. Within communities, the strongest edge was "Family communication and problem solving-maintaining a positive outlook." Across communities, the strongest edge between family resilience and quality of life was "Family communication and problem solving-environmental domain quality of life," and the strongest edge across the fear of progression and quality of life was "physiological health fear-psychological domain quality of life." CONCLUSIONS Family resilience and fear of progression may affect the quality of life in patients with pulmonary hypertension. Developing a program with "family communication and problem solving" as a primary target may reduce patient fear of progression, enhance family resilience, and improve patient quality of life.
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Affiliation(s)
- Mengqi Liu
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China
| | - Xiaoli Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China
| | - Zeping Yan
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China; University of Health and Rehabilitation Sciences, Qingdao, Shandong Province, China
| | - Zhiwei Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China
| | - Huimin Wei
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China
| | - Jiurui Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China
| | - Xiaorong Luan
- School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China; Department of Infection Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China.
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Long C, Fan W, Liu Y, Hong K. Stress hyperglycemia is associated with poor outcome in critically ill patients with pulmonary hypertension. Front Endocrinol (Lausanne) 2024; 15:1302537. [PMID: 38464971 PMCID: PMC10924302 DOI: 10.3389/fendo.2024.1302537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Background and objective Stress hyperglycemia is common in critically ill patients and is associated with poor prognosis. Whether this association exists in pulmonary hypertension (PH) patients is unknown. The present cohort study investigated the association of stress hyperglycemia with 90-day all-cause mortality in intensive care unit (ICU) patients with PH. Methods Data of the study population were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. A new index, the ratio of admission glucose to HbA1c (GAR), was used to evaluate stress hyperglycemia. The study population was divided into groups according to GAR quartiles (Q1-Q4). The outcome of interest was all-cause mortality within 90 days, which was considered a short-term prognosis. Result A total of 53,569 patients were screened. Ultimately, 414 PH patients were enrolled; 44.2% were male, and 23.2% were admitted to the cardiac ICU. As the GAR increased from Q2 to Q4, the groups had lower creatinine levels, longer ICU stays, and a higher proportion of renal disease. After adjusting for confounding factors such as demographics, vital signs, and comorbidities, an elevated GAR was associated with an increased risk of 90-day mortality. Conclusion Stress hyperglycemia assessed by the GAR was associated with increased 90-day mortality in ICU patients with PH.
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Affiliation(s)
- Chuyan Long
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weiguo Fan
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yang Liu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Kui Hong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Genetic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Mohananey D, Martin AK, Mandawat H, Hauser JM, Ramakrishna H. Analysis of the 2022 European Society of Cardiology/European Respiratory Society Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2024; 38:534-541. [PMID: 38052693 DOI: 10.1053/j.jvca.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Divyanshu Mohananey
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | - Himani Mandawat
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Josh M Hauser
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MI
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MI.
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Li X, Yang T, Zhang Y, Zhao Q, Zeng Q, Jin Q, Duan A, Huang Z, Hu M, Zhang S, Gao L, Xiong C, Luo Q, Zhao Z, Liu Z. Optimal short-term outcomes in balloon pulmonary angioplasty: the minimum frequency of three sessions annually. Ther Adv Respir Dis 2024; 18:17534666241232521. [PMID: 38409856 PMCID: PMC10898305 DOI: 10.1177/17534666241232521] [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: 08/14/2023] [Accepted: 01/29/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is typically performed in a sequential manner. OBJECTIVES This study aimed to determine the lowest frequency of BPA for patients who could not reach treatment goals in a short period. DESIGN Retrospective cohort. METHODS We retrospectively enrolled 186 BPA-treated patients diagnosed with chronic thromboembolic pulmonary hypertension. According to the accumulative number of performed BPA sessions or treated pulmonary vessels or the ratio of the number of treated pulmonary vessels/the number of baseline lesions (T/P) prior to the initial occurrence of clinical outcome or censored date, we divided patients into different groups. The principal outcome was clinical worsening. RESULTS After stratifying patients by the number of performed BPA sessions, most baseline parameters were comparable among groups. During follow-up, 31 (16.7%) of 186 patients experienced clinical worsening. The 6-month cumulative clinical worsening-free survival rates of ⩾2 performed sessions group were significantly higher than that of 1 performed session group. The 12-month cumulative rates of clinical worsening-free survival exhibited a declining pattern in the subsequent sequence: ⩾3, 2, and 1 performed BPA sessions, and this trend persisted when follow-up time exceeded 12 months. The 6-, 12-, and 24-month cumulative clinical worsening-free survival rates were comparable between patients with 3 and ⩾4 performed BPA sessions. Similar results were also observed when stratifying patients by the accumulative number of treated pulmonary vessels (⩽8, 9-16, ⩾17) and T/P (⩽0.789, 0.790-1.263, ⩾1.264). CONCLUSION To achieve optimal short-term outcomes, patients might need to undergo ⩾2 BPA sessions or have ⩾9 pulmonary vessels treated or have T/P ⩾0.790 within 6 months, and undergo ⩾3 BPA sessions or have ⩾17 pulmonary vessels treated or have T/P ⩾1.264 within 12 months.
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Affiliation(s)
- Xin Li
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Tao Yang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Yi Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
- Department of ICU, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qing Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qixian Zeng
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qi Jin
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Anqi Duan
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Zhihua Huang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Meixi Hu
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Sicheng Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Luyang Gao
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Changming Xiong
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
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Farmakis IT, Baroutidou A, Patsiou V, Arvanitaki A, Doundoulakis I, Hobohm L, Zafeiropoulos S, Konstantinides SV, D'Alto M, Badagliacca R, Giannakoulas G. Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients. ERJ Open Res 2024; 10:00706-2023. [PMID: 38259812 PMCID: PMC10801731 DOI: 10.1183/23120541.00706-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.
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Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michele D'Alto
- Department of Cardiology, University “L. Vanvitelli”-Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Celant LR, Wessels JN, Marcus JT, Meijboom LJ, Bogaard HJ, de Man FS, Vonk Noordegraaf A. Toward the Implementation of Optimal Cardiac Magnetic Resonance Risk Stratification in Pulmonary Arterial Hypertension. Chest 2024; 165:181-191. [PMID: 37527773 DOI: 10.1016/j.chest.2023.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND The 2022 European Society of Cardiology/European Respiratory Society pulmonary hypertension (PH) guidelines incorporate cardiac magnetic resonance (CMR) imaging metrics in the risk stratification of patients with pulmonary arterial hypertension (PAH). Thresholds to identify patients at estimated 1-year mortality risks of < 5%, 5% to 20%, and > 20% are introduced. However, these cutoff values are mostly single center-based and require external validation. RESEARCH QUESTION What are the discriminative prognostic properties of the current CMR risk thresholds stratifying patients with PAH? STUDY DESIGN AND METHODS We analyzed data from incident, treatment-naïve patients with PAH from the Amsterdam University Medical Centres, Vrije Universiteit, The Netherlands. The discriminative properties of the proposed CMR three risk strata were tested at baseline and first reassessment, using the following PH guideline variables: right ventricular ejection fraction, indexed right ventricular end-systolic volume, and indexed left ventricular stroke volume. RESULTS A total of 258 patients with PAH diagnosed between 2001 and 2022 fulfilled the study criteria and were included in this study. Of these, 172 had follow-up CMR imaging after 3 months to 1.5 years. According to the CMR three risk strata, most patients were classified at intermediate risk (n = 115 [45%]) upon diagnosis. Only 29 (11%) of patients with PAH were classified at low risk, and 114 (44%) were classified at high risk. Poor survival discrimination was seen between risk groups. Appropriate survival discrimination was seen at first reassessment. INTERPRETATION Risk stratifying patients with PAH with the recent proposed CMR cutoffs from the European Society of Cardiology/European Respiratory Society 2022 PH guidelines requires adjustment because post-processing consensus is lacking and general applicability is limited. Risk assessment at follow-up yielded better survival discrimination, emphasizing the importance of the individual treatment response.
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Affiliation(s)
- Lucas R Celant
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Jeroen N Wessels
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - J Tim Marcus
- Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Frances S de Man
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, The Netherlands.
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9
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de Barros JA, Sant'Ana G, Martins G, Madlum L, Scremim C, Petterle R, Escuissato D, Lima E. Severity of precapillary pulmonary hypertension: Predictive factor. Pulmonology 2023; 29 Suppl 4:S25-S35. [PMID: 34969648 DOI: 10.1016/j.pulmoe.2021.11.007] [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: 04/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pulmonary arterial hypertension (PAH) require risk assessments for prognosis and appropriate therapy. These assessments need to be improved by incorporating clinical and laboratory data such as the analysis of the right ventricle. We aim to establish echocardiographic morphometric data of the right ventricle and its relationship with the left ventricle, to estimate the hemodynamic severity of precapillary pulmonary hypertension (PHprecapillary). METHODS This cohort, prospective, observational, and cross-sectional study included 41 consecutive patients with PHprecapillary using echocardiographic study and cardiac catheterization. RESULTS Patients' mean age was 44.0±16.4 years, and 37 were women (90.2%). Idiopathic PAH was diagnosed in 18 patients (43.9%). The World Health Organization/New York Association functional class was III or IV in 31 patients (75.6%). The ratio of the right to left ventricles (RV/LV) echocardiographic diastolic diameters was associated with pulmonary arterial pressures in cardiac catheterization, with the best cutoff per receiver operating characteristic curve being 0.8 for systolic pressure (sensitivity 90.0%, specificity 78.3%, area under the curve [AUC] 0.882) and mean pressure (sensitivity 60.0%, specificity 95.7%, AUC 0.823). Spearman's correlation (R) of RV/LV echocardiographic ratio and the hemodynamic variables was significant for systolic pressure (R = 0.7015, p < 0.0001), mean pressure (R = 0.6332, p < 0.0001), transpulmonary pressure gradient (R = 0.6524, p < 0.0001), pulmonary vascular resistance (R = 0.6076, p = 0.0021), and pulmonary vascular resistance index (R = 0.6229, p = 0.0014). CONCLUSION The ratio of RV/LV echocardiographic diastolic diameters contribute to the estimates the hemodynamic severity of precapillary pulmonary hypertension. The best cutoff for this assessment was RV/LV of 0.8.
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Affiliation(s)
- J A de Barros
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil.
| | - G Sant'Ana
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - G Martins
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - L Madlum
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - C Scremim
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - R Petterle
- Federal University of Paraná, Department of Integrative Medicine, Curitiba, Brazil
| | - D Escuissato
- Federal University of Paraná, Department of Internal Medicine, Radiology Unit, Curitiba, Brazil
| | - E Lima
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
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10
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Labrada L, Vaidy A, Vaidya A. Right ventricular assessment in pulmonary hypertension. Curr Opin Pulm Med 2023; 29:348-354. [PMID: 37410491 PMCID: PMC10408730 DOI: 10.1097/mcp.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of assessment of right ventricular function in the context of pulmonary hypertension and pulmonary arterial hypertension (PAH). We will review unique features of right ventricular anatomy, delineation of cause of pulmonary hypertension through careful right ventricular assessment, echocardiographic and hemodynamic evaluation, and the importance of this assessment in prognosis. RECENT FINDINGS The importance of performance in prognosis and risk assessment in patients with pulmonary hypertension has been continually emphasized in ongoing research. Representative parameters of right ventricular function have been shown to be predictive of prognosis in patients with pulmonary hypertension. Further, the importance of serial right ventricular assessment in risk assessment and prognosis has remained an emerging theme. SUMMARY Careful evaluation of right ventricular function is paramount in assessing the cause of pulmonary hypertension and severity of disease. Further, it has prognostic significance, as many representative parameters of right ventricular function have been linked with mortality. In our opinion, right ventricular function should be assessed serially throughout the course of treatment in pulmonary hypertension, and baseline parameters in addition to dynamic changes should be incorporated into risk assessment. Achieving normal or near-normal right ventricular performance may serve as a principal goal in the treatment of pulmonary hypertension.
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Affiliation(s)
- Lyana Labrada
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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11
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Wessels JN, van Wezenbeek J, de Rover J, Smal R, Llucià-Valldeperas A, Celant LR, Marcus JT, Meijboom LJ, Groeneveldt JA, Oosterveer FPT, Winkelman TA, Niessen HWM, Goumans MJ, Bogaard HJ, Noordegraaf AV, Strijkers GJ, Handoko ML, Westerhof BE, de Man FS. Right Atrial Adaptation to Precapillary Pulmonary Hypertension: Pressure-Volume, Cardiomyocyte, and Histological Analysis. J Am Coll Cardiol 2023; 82:704-717. [PMID: 37587582 DOI: 10.1016/j.jacc.2023.05.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Precapillary pulmonary hypertension (precPH) patients have altered right atrial (RA) function and right ventricular (RV) diastolic stiffness. OBJECTIVES This study aimed to investigate RA function using pressure-volume (PV) loops, isolated cardiomyocyte, and histological analyses. METHODS RA PV loops were constructed in control subjects (n = 9) and precPH patients (n = 27) using magnetic resonance and catheterization data. RA stiffness (pressure rise during atrial filling) and right atrioventricular coupling index (RA minimal volume / RV end-diastolic volume) were compared in a larger cohort of patients with moderate (n = 39) or severe (n = 41) RV diastolic stiffness. Cardiomyocytes were isolated from RA tissue collected from control subjects (n = 6) and precPH patients (n = 9) undergoing surgery. Autopsy material was collected from control subjects (n = 6) and precPH patients (n = 4) to study RA hypertrophy, capillarization, and fibrosis. RESULTS RA PV loops showed 3 RA cardiac phases (reservoir, passive emptying, and contraction) with dilatation and elevated pressure in precPH. PrecPH patients with severe RV diastolic stiffness had increased RA stiffness and worse right atrioventricular coupling index. Cardiomyocyte cross-sectional area was increased 2- to 3-fold in precPH, but active tension generated by the sarcomeres was unaltered. There was no increase in passive tension of the cardiomyocytes, but end-stage precPH showed reduced number of capillaries per mm2 accompanied by interstitial and perivascular fibrosis. CONCLUSIONS RA PV loops show increased RA stiffness and suggest atrioventricular uncoupling in patients with severe RV diastolic stiffness. Isolated RA cardiomyocytes of precPH patients are hypertrophied, without intrinsic sarcomeric changes. In end-stage precPH, reduced capillary density is accompanied by interstitial and perivascular fibrosis.
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Affiliation(s)
- Jeroen N Wessels
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jessie van Wezenbeek
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jari de Rover
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Rowan Smal
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Aida Llucià-Valldeperas
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Lucas R Celant
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - J Tim Marcus
- Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joanne A Groeneveldt
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Frank P T Oosterveer
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Toon A Winkelman
- Department of Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marie-José Goumans
- Department of Cell and Chemical Biology, Leiden UMC, Leiden, the Netherlands
| | - Harm Jan Bogaard
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Gustav J Strijkers
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - M Louis Handoko
- Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Berend E Westerhof
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Frances S de Man
- PHEniX Laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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12
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Dayer N, Ltaief Z, Liaudet L, Lechartier B, Aubert JD, Yerly P. Pressure Overload and Right Ventricular Failure: From Pathophysiology to Treatment. J Clin Med 2023; 12:4722. [PMID: 37510837 PMCID: PMC10380537 DOI: 10.3390/jcm12144722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/01/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Right ventricular failure (RVF) is often caused by increased afterload and disrupted coupling between the right ventricle (RV) and the pulmonary arteries (PAs). After a phase of adaptive hypertrophy, pressure-overloaded RVs evolve towards maladaptive hypertrophy and finally ventricular dilatation, with reduced stroke volume and systemic congestion. In this article, we review the concept of RV-PA coupling, which depicts the interaction between RV contractility and afterload, as well as the invasive and non-invasive techniques for its assessment. The current principles of RVF management based on pathophysiology and underlying etiology are subsequently discussed. Treatment strategies remain a challenge and range from fluid management and afterload reduction in moderate RVF to vasopressor therapy, inotropic support and, occasionally, mechanical circulatory support in severe RVF.
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Affiliation(s)
- Nicolas Dayer
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Benoit Lechartier
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - John-David Aubert
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - Patrick Yerly
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
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13
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Arogundade F, Jani B, Church C, Brewis M, Johnson M, Stubbs H. The MRC Dyspnoea Scale and mortality risk prediction in pulmonary arterial hypertension: A retrospective longitudinal cohort study. Pulm Circ 2023; 13:e12257. [PMID: 37404903 PMCID: PMC10315452 DOI: 10.1002/pul2.12257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/06/2023] Open
Abstract
Risk stratification models in pulmonary arterial hypertension (PAH) rely on World Health Organisation Functional Class (WHO FC). A high proportion of patients are classified as WHO FC III, a heterogenous group which limits the stratification abilities of risk models. The Medical Research Council (MRC) Dyspnoea Scale may allow a more precise assessment of functional status and improve current risk models. We investigated the ability of the MRC Dyspnoea Scale to assess survival in PAH and compared performance to WHO FC and the COMPERA 2.0 models. Patients with Idiopathic, Hereditary or Drug-induced PAH who were diagnosed between 2010 and 2021 were included. The MRC Dyspnoea Scale was retrospectively applied as derived from a combination of patient notes, 6MWD tests results and WHO functional status using a purpose-designed algorithm. Survival was assessed using Kaplan-Meier analyses, log rank testing and Cox proportional hazard ratios. Model performance was compared with Harrell's C Statistic. Data from 216 patients were retrospectively analyzed. At baseline, of 120 patients classified as WHO FC III, 8% were MRC Dyspnoea Scale 2, 12% Scale 3, 71% Scale 4 and 10% Scale 5. The MRC Dyspnoea Scale performed well compared to the WHO FC and COMPERA models at follow up (respectively, C-statistic 0.74 vs. 0.69 vs. 0.75). It was possible to use the MRC Dyspnoea Scale to subdivide patients in WHO FC III into groups which had distinct survival estimates. We conclude that at follow-up, the MRC Dyspnoea Scale may be a valid tool for the assessment of risk stratification in pulmonary arterial hypertension.
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Affiliation(s)
| | - Bhautesh Jani
- School of Health & WellbeingUniversity of GlasgowGlasgowUK
| | - Colin Church
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Melanie Brewis
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Martin Johnson
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Harrison Stubbs
- School of Health & WellbeingUniversity of GlasgowGlasgowUK
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
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14
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Vraka A, Diamanti E, Kularatne M, Yerly P, Lador F, Aubert JD, Lechartier B. Risk Stratification in Pulmonary Arterial Hypertension, Update and Perspectives. J Clin Med 2023; 12:4349. [PMID: 37445381 DOI: 10.3390/jcm12134349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Risk stratification in pulmonary arterial hypertension (PAH) is crucial in assessing patient prognosis. It serves a prominent role in everyday patient care and can be determined using several validated risk assessment scores worldwide. The recently published 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines underline the importance of risk stratification not only at baseline but also during follow-up. Achieving a low-risk status has now become the therapeutic goal, emphasising the importance of personalised therapy. The application of these guidelines is also important in determining the timing for lung transplantation referral. In this review, we summarise the most relevant prognostic factors of PAH as well as the parameters used in PAH risk scores and their evolution in the guidelines over the last decade. Finally, we describe the central role that risk stratification plays in the current guidelines not only in European countries but also in Asian countries.
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Affiliation(s)
- Argyro Vraka
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Eleni Diamanti
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Patrick Yerly
- Division of Cardiology, Cardiovascular Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Division, Geneva University Hospital, 1211 Geneva, Switzerland
| | - John-David Aubert
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Benoit Lechartier
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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15
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Koudstaal T, Boomars KA. Inflammatory biomarkers in pulmonary arterial hypertension: ready for clinical implementation? Eur Respir J 2023; 61:61/3/2300018. [PMID: 36958746 DOI: 10.1183/13993003.00018-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 03/25/2023]
Affiliation(s)
- Thomas Koudstaal
- Department of Pulmonary Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin A Boomars
- Department of Pulmonary Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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16
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Kingrey JF, Zhou CY, Dalal B, Elwing JM. Expert provider survey of longitudinal assessment in patients with pulmonary arterial hypertension. Heart Lung 2023; 58:34-38. [PMID: 36372061 DOI: 10.1016/j.hrtlng.2022.10.016] [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: 07/18/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Patients suffering from pulmonary arterial hypertension (PAH) demand frequent assessment to keep pace with a dynamic and sometimes rapidly progressive disease course. To improve our understanding of patient monitoring, we conducted a survey of pulmonary hypertension (PH) providers to establish real-world practice patterns. OBJECTIVE To evaluate the type and frequency of patient assessment methods employed by expert PH providers following PAH diagnosis METHODS: A descriptive cross-sectional survey of PH providers across the United States was utilized to assess provider practices. Between September 14, 2017 to October 17, 2017, a survey was distributed electronically to PH experts assessing follow-up frequency and testing evaluation of patients with PAH. RESULTS 40 (11.4%) providers completed the survey, representing cardiologists, pulmonologists, and advanced practice providers at centers who cared for an average of 95 patients per year with PAH. Follow-up testing and clinic evaluation was influenced by severity of patient illness. Frequency of re-assessment of clinic follow-up, six-minute walk test, echocardiogram, brain natriuretic peptide, and right heart catheterization in various clinical scenarios all reflected disparate practice. CONCLUSIONS Current clinical practice patterns in the monitoring of patients with PAH are variable and do not necessarily reflect guideline-based practices, suggesting the need for further research and improved guidelines on the frequency of follow up and repeat testing.
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Affiliation(s)
- John F Kingrey
- Nazih Zuhdi Transplant Institute, Integris Baptist, Oklahoma City, OK, United States.
| | - Christine Y Zhou
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Bhavinkumar Dalal
- Department of Pulmonary and Critical Care Medicine, Beaumont Health and OWUB school of Medicine, Rochester, MI, United States
| | - Jean M Elwing
- Department of Pulmonary and Critical Care, University of Cincinnati, Cincinnati, OH, United States
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17
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Aslanger E, Akaslan D, Ataş H, Kocakaya D, Yıldızeli B, Mutlu B. Right Ventricular Energy Failure Predicts Mortality in Patients With Pulmonary Hypertension. Am J Cardiol 2023; 193:19-27. [PMID: 36857840 DOI: 10.1016/j.amjcard.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
Right ventricular (RV) failure has a significant adverse impact on pulmonary hypertension (PH) prognosis. None of the currently used parameters directly assess whether RV fails to provide enough energy output to propel the blood through diseased pulmonary vascular system. Furthermore, most of the current parameters are affected by the volume status of the patient. We aimed to explore whether RV energy failure has a predictive power for mortality on top of the established prognostic risk parameters in patients with PH. We screened 723 cases from our database. A total of 3 sets of binary regression analyses were executed to determine the hazard ratios (HRs) of RV energy failure for 5-year mortality in clinical, echocardiographic, and hemodynamic context, using adjustment variables chosen according to previous studies. The final study population encompassed 549 cases. A total of 77 patients died during the 5-year follow-up (14%). RV energy failure was observed in 146 of 549 patients (26.6%). In the univariate model, RV energy failure strongly associated with increased long-term mortality (HR 4.25, 95% confidence interval [CI] 2.58 to 7.00, p <0.001). It also emerged as a significant predictor of long-term mortality in clinical and hemodynamic multivariate models (HR 2.59, 95% CI 1.43 to 4.67, p = 0.002 and HR 2.05, 95% CI 1.15 to 3.63, p = 0.015, respectively). In conclusion, our study indicates that the presence of RV energy failure independently predicts long-term mortality in PH.
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Affiliation(s)
- Emre Aslanger
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey.
| | - Dursun Akaslan
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Halil Ataş
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | | | - Bedrettin Yıldızeli
- Thoracic Surgery, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
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18
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Ishii S, Hatano M, Maki H, Minatsuki S, Saito A, Yagi H, Shimbo M, Soma K, Numata G, Fujiwara T, Takeda N, Komuro I. Prognostic value of follow-up vasoreactivity test in pulmonary arterial hypertension. J Cardiol 2023:S0914-5087(23)00005-9. [PMID: 36682710 DOI: 10.1016/j.jjcc.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Acute vasoreactivity test with inhaled nitric oxide (NO) is performed during diagnostic right heart catheterization (RHC) to identify patients with pulmonary arterial hypertension (PAH) who respond to calcium channel blockers. Our purpose was to investigate the prognostic importance of follow-up vasoreactivity test after treatment. METHODS We retrospectively analyzed 36 PAH patients (mean age, 47 years; 61 % treatment-naïve), who underwent diagnostic and follow-up RHC and vasoreactivity tests at our center. The primary outcome was all-cause mortality. RESULTS The median time between baseline and follow-up RHC was 9.7 months. Absolute change in mean pulmonary arterial pressure (ΔmPAP) during NO challenge was less pronounced after treatment, but there was great variability among patients. Overall cohort was dichotomized into two groups: preserved vasoreactivity (ΔmPAP ≤ -1 mmHg) and less vasoreactivity (ΔmPAP ≥0 mmHg) at follow-up RHC. Less vasoreactivity group had higher usage rate of endothelin receptor antagonists and parenteral prostacyclin analogues. During a median observation period of 6.3 years after follow-up RHC, 7 patients died, of which 6 showed less vasoreactivity at follow-up. Absolute ΔmPAP ≥0 at follow-up RHC was associated with all-cause mortality in univariable Cox regression analysis (hazard ratio, 8.728; 95 % confidence interval, 1.045-72.887; p = 0.045), whereas other hemodynamic parameters were not. Absolute ΔmPAP ≥0 at follow-up RHC was associated with all-cause mortality in multivariable Cox analysis adjusted for age and known PAH prognostic factors (HR, 12.814; 95 % CI, 1.088-150.891; p = 0.043). Kaplan-Meier survival analysis revealed a significantly worse survival of less vasoreactivity group compared to preserved vasoreactivity group (log-rank test, p = 0.016). CONCLUSIONS Follow-up vasoreactivity test after treatment could contribute to the detection of high-risk subgroups who might need careful monitoring and referral for lung transplantation.
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Affiliation(s)
- Satoshi Ishii
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Advanced Medical Center for Heart Failure, The University of Tokyo Hospital, Tokyo, Japan.
| | - Hisataka Maki
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Cardiovascular Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shun Minatsuki
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Mai Shimbo
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Katsura Soma
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Genri Numata
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takayuki Fujiwara
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
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19
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 447] [Impact Index Per Article: 447.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Wang J, Ni C, Yang M, Zhang X, Ruan B, Sun L, Shen X, Shen J. Apply pressure-strain loop to quantify myocardial work in pulmonary hypertension: A prospective cohort study. Front Cardiovasc Med 2022; 9:1022987. [PMID: 36588563 PMCID: PMC9798095 DOI: 10.3389/fcvm.2022.1022987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives Pressure-strain loop (PSL) is a novel method to quantify myocardial work in many cardiovascular diseases. To investigate the value of myocardial work parameters derived from PSL for evaluating cardiac function and clinical prognosis in patients with pulmonary hypertension (PH). Methods A total of 52 patients with PH and 27 healthy controls were enrolled in this prospective study. PSLs determined by echocardiography were used to calculate global work index (GWI) of left ventricle (LV) and right ventricle (RV). Global constructive work (GCW) comprised the sum of myocardial work performed during shortening in systole and during lengthening in isovolumic relaxation. Global wasted work (GWW) comprised the sum of myocardial work performed during lengthening in systole and during shortening in isovolumic relaxation. Global work efficiency (GWE) was defined as GCW/(GCW + GWW). Results LVGWW, RVGWI, RVGCW and RVGWW were significantly higher in patients than controls (all P < 0.001). LVGWE, LVGWI, LVGCW, and RVGWE were lower in patients than controls (all P < 0.01). Myocardial work parameters correlated well with clinical and other conventional echocardiographic assessments (all P < 0.05). In binary logistic regression analysis, the combination of RVGWE and estimation of pulmonary arterial systolic pressure (ePASP) was the best model to predict clinical outcomes (OR = 0.803, P = 0.002 and OR = 1.052, P = 0.015, respectively). Receiver operating characteristic curv demonstrated the combination of RVGWE and ePASP was the best predictor of adverse events with 100% sensitivity and 76.3% specificity (AUC = 0.910, P < 0.001). Conclusion Myocardial work parameters derived from PSL are emerging markers of cardiac function. And the combination of RVGWE and ePASP is a useful predictor of clinical outcome in PH patients.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Department of Cardiology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Chao Ni
- Children’s Heart Center, Institute of Cardiovascular Development and Translational Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Menghui Yang
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xueming Zhang
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Binqian Ruan
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lingyue Sun
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuedong Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,*Correspondence: Jieyan Shen,
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21
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Cullivan S, Higgins M, Gaine S. Diagnosis and management of pulmonary arterial hypertension. Breathe (Sheff) 2022; 18:220168. [PMID: 36865939 PMCID: PMC9973456 DOI: 10.1183/20734735.0168-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature that is characterised by elevated pressures within the pulmonary vascular tree. Recent decades have witnessed a dramatic expansion in our understanding of the pathobiology and the epidemiology of PAH, and improvements in treatment options and outcomes. The prevalence of PAH is estimated to be between 48 and 55 cases per million adults. The definition was recently amended and a diagnosis of PAH now requires evidence of a mean pulmonary artery pressure >20 mmHg, a pulmonary vascular resistance >2 Wood units and a pulmonary artery wedge pressure ≤15 mmHg at right heart catheterisation. Detailed clinical assessment and a number of additional diagnostic tests are required to assign a clinical group. Biochemistry, echocardiography, lung imaging and pulmonary function tests provide valuable information to assist in the assignment of a clinical group. Risk assessment tools have been refined, and these greatly facilitate risk stratification and enhance treatment decisions and prognostication. Current therapies target three therapeutic pathways: the nitric oxide, prostacyclin and endothelin pathways. While lung transplantation remains the only curative intervention for PAH, there are a number of promising therapies under investigation which may further reduce morbidity and improve outcomes. This review describes the epidemiology, pathology and pathobiology of PAH and introduces important concepts regarding the diagnosis and risk stratification of PAH. The management of PAH is also discussed, with a special focus on PAH specific therapy and key supportive measures.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland,Corresponding author: Sarah Cullivan ()
| | - Margaret Higgins
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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22
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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23
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Zhang Y, Li X, Jin Q, Luo Q, Zhao Q, Yang T, Zeng Q, Yan L, Duan A, Huang Z, Hu M, Xiong C, Zhao Z, Liu Z. The original and two new derivative versions of the COMPERA 2.0 risk assessment model: useful tools for guiding balloon pulmonary angioplasty. Respir Res 2022; 23:312. [PMCID: PMC9664665 DOI: 10.1186/s12931-022-02232-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
The COMPERA 2.0 4-stratum (4-S) risk score has been demonstrated superior over the 3-stratum (3-S) one in patients with pulmonary arterial hypertension and medically managed patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to determine the prognostic value of the original 4-S and 3-S COMPERA 2.0 risk score and two new derivative versions in CTEPH patients who underwent balloon pulmonary angioplasty (BPA).
Methods
We retrospectively enrolled 175 BPA-treated patients with CTEPH. We assessed the risk stratification before and after each BPA session of CTEPH patients by the original 4-S and 3-S COMPERA 2.0 risk score (by rounding decimal to the nearest integer) and two new proposed derivative versions: the modified version (by rounding decimal to the next integer) and a hybrid version that fuses the original and modified versions. The primary endpoint was clinical worsening events. The secondary outcomes were achieving low-risk profile and mean pulmonary arterial pressure (mPAP) < 30 mmHg at follow-up. We used the Kaplan–Meier curve analysis to assess the survival differences between stratified patients. The comparative model’s performance was evaluated in terms of discrimination by Harrell’s C-index.
Results
All versions of COMPERA 2.0 4-S model outperformed the 3-S one in discriminating the differences in echocardiographic and hemodynamic parameters and clinical worsening-free survival rates. The original and hybrid 4-S model could independently predict the primary and secondary endpoints, and the hybrid version seemed to perform better. The first BPA session could significantly improve risk profiles, and these changes were associated with the likelihood of experiencing clinical worsening events, achieving a low-risk profile and mPAP < 30 mmHg at follow-up. The number of BPA sessions required to achieve low risk/mPAP < 30 mmHg increased as the baseline risk score escalated.
Conclusions
The COMPERA 2.0 4-S model outperformed the 3-S one in BPA-treated patients with CTEPH. The 4-S model, especially its hybrid version, could be used to predict clinical outcome before the initiation of BPA and monitor treatment response.
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Zhao J, Wang Q, Deng X, Qian J, Tian Z, Liu Y, Li M, Zeng X. The treatment strategy of connective tissue disease associated pulmonary arterial hypertension: Evolving into the future. Pharmacol Ther 2022; 239:108192. [DOI: 10.1016/j.pharmthera.2022.108192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1042] [Impact Index Per Article: 521.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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26
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Goh ZM, Balasubramanian N, Alabed S, Dwivedi K, Shahin Y, Rothman AMK, Garg P, Lawrie A, Capener D, Thompson AAR, Alandejani F, Wild JM, Johns CS, Lewis RA, Gosling R, Sharkey M, Condliffe R, Kiely DG, Swift AJ. Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response. Heart 2022; 108:1392-1400. [PMID: 35512982 PMCID: PMC9380507 DOI: 10.1136/heartjnl-2021-320733] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/29/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up. METHODS Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied. RESULTS A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass. CONCLUSIONS Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.
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Affiliation(s)
- Ze Ming Goh
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Nithin Balasubramanian
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
| | - Yousef Shahin
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Alexander M K Rothman
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Capener
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Faisal Alandejani
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
| | | | - Robert A Lewis
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Gosling
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Michael Sharkey
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
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27
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Hendriks PM, van de Groep LD, Veen KM, van Thor MCJ, Meertens S, Boersma E, Boomars KA, Post MC, van den Bosch AE. Prognostic value of brain natriuretic peptides in patients with pulmonary arterial hypertension: A systematic review and meta-analysis. Am Heart J 2022; 250:34-44. [PMID: 35533723 DOI: 10.1016/j.ahj.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Multiple biomarkers have been investigated in the risk stratification of patients with pulmonary arterial hypertension (PAH). This systematic review and meta-analysis is the first to investigate the prognostic value of (NT-pro)BNP in patients with PAH. METHODS A systematic literature search was performed using MEDLINE, Embase, Web of Science, the Cochrane Library and Google scholar to identify studies on the prognostic value of baseline (NT-pro)BNP levels in PAH. Studies reporting hazard ratios (HR) for the endpoints mortality or lung transplant were included. A random effects meta-analysis was performed to calculate the pooled HR of (NT-pro)BNP levels at the time of diagnosis. To account for different transformations applied to (NT-pro)BNP, the HR was calculated for a 2-fold difference of the weighted mean (NT-pro)BNP level of 247 pmol/L, for studies reporting a HR based on a continuous (NT-pro)BNP measurement. RESULTS Sixteen studies were included, representing 6999 patients (mean age 45.2-65.0 years, 97.3% PAH). Overall, 1460 patients reached the endpoint during a mean follow-up period between 1 and 10 years. Nine studies reported HRs based on cut-off values. The risk of mortality or lung transplant was increased for both elevated NT-proBNP and BNP with a pooled HR based on unadjusted HRs of 2.75 (95%-CI: 1.86-4.07) and 3.87 (95% CI 2.69-5.57) respectively. Six studies reported HRs for (NT-pro)BNP on a continues scale. A 2-fold difference of the weighted mean NT-proBNP resulted in an increased risk of mortality or lung transplant with a pooled HR of 1.17 (95%-CI: 1.03-1.32). CONCLUSIONS Increased levels of (NT-pro)BNP are associated with a significantly increased risk of mortality or lung transplant in PAH patients.
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Affiliation(s)
- Paul M Hendriks
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Liza D van de Groep
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Kevin M Veen
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mitch C J van Thor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sabrina Meertens
- Medical Library, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Clinical epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin A Boomars
- Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Utrecht University Medical Center, Utrecht, The Netherlands
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28
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Tan Z, Wu PY, Zhu TT, Su W, Fang ZF. Efficacy and safety of sequential combination therapy for pulmonary arterial hypertension: A meta-analysis of Randomized-Controlled Trials. Pulm Pharmacol Ther 2022; 76:102144. [PMID: 35918025 DOI: 10.1016/j.pupt.2022.102144] [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: 11/09/2021] [Revised: 05/18/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous meta-analyses of pulmonary arterial hypertension (PAH) combination therapy pooled sequential and initial combination together, which might threaten their authenticity and clinical significance for the difference between two strategies. METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) that compared sequential combination therapy (SCT) with background therapy (BT) in PAH patients. Raw data were extracted to calculate risk ratio (RR) or weighted mean difference (WMD) for predefined efficacy and safety outcomes. Mantel-Haenszel fixed or random effects model was used based on heterogeneity. RESULTS 17 RCTs involving 4343 patients (97.2% of patients with WHO-FC II-III) were included. SCT decreased clinical worsening (RR 0.66, 95% CI 0.58 to 0.76), nonfatal clinical worsening (RR 0.61, 95% CI 0.52 to 0.71), functional class (decrease of 28% in the portion of patients with WHO-FC worsening and increase of 33% in the portion of patients with WHO-FC improvement), and increased 6-min walk distance (WMD 17.68 m, 95% CI 10.16 to 25.20), but didn't reduce mortality, lung transplantation, admission to hospital, and treatment escalation compared with BT. Although any adverse event and serious adverse event were similar between SCT and BT, SCT increased all-cause treatment discontinuation (RR 1.49, 95% CI 1.30 to 1.71) and drug-related treatment discontinuation (RR 2.30, 95% CI 1.86 to 2.84) with higher incidence of headache, flushing, nausea, diarrhoea and jaw pain. CONCLUSIONS For WHO-FC II-III PAH patients who have established BT, our study reinforced the recommendation of SCT to improve clinical worsening, functional status, and exercise capacity, although with higher incidence of side-effects and withdrawal.
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Affiliation(s)
- Zhen Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Pan-Yun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Teng-Teng Zhu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Wen Su
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Zhen-Fei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
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Hoeper MM, Pausch C, Olsson KM, Huscher D, Pittrow D, Grünig E, Staehler G, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Park DH, Ewert R, Kaemmerer H, Kabitz HJ, Skowasch D, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H, Claussen M, Lange TJ, Rosenkranz S. COMPERA 2.0: a refined four-stratum risk assessment model for pulmonary arterial hypertension. Eur Respir J 2022. [PMID: 34737226 PMCID: PMC9260123 DOI: 10.1183/13993003.02311-2021,] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). The current European guidelines propose a three-stratum model to categorise risk as low, intermediate or high, based on the expected 1-year mortality. However, with this model, most patients are categorised as intermediate risk. We investigated a modified approach based on four risk categories, with intermediate risk subdivided into intermediate-low and intermediate-high risk. METHODS We analysed data from the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA), a European pulmonary hypertension registry, and calculated risk at diagnosis and first follow-up based on World Health Organization functional class, 6-min walk distance (6MWD) and serum levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), using refined cut-off values. Survival was assessed using Kaplan-Meier analyses, log-rank testing and Cox proportional hazards models. RESULTS Data from 1655 patients with PAH were analysed. Using the three-stratum model, most patients were classified as intermediate risk (76.0% at baseline and 63.9% at first follow-up). The refined four-stratum risk model yielded a more nuanced separation and predicted long-term survival, especially at follow-up assessment. Changes in risk from baseline to follow-up were observed in 31.1% of the patients with the three-stratum model and in 49.2% with the four-stratum model. These changes, including those between the intermediate-low and intermediate-high strata, were associated with changes in long-term mortality risk. CONCLUSIONS Modified risk stratification using a four-stratum model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically relevant changes in risk than the original three-stratum model.
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Affiliation(s)
- Marius M. Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany,Corresponding author: Marius M. Hoeper ()
| | | | - Karen M. Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany,Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Dept of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Dept of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J. Simon R. Gibbs
- Dept of Cardiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven – University of Leuven, Leuven, Belgium
| | - H. Ardeschir Ghofrani
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany,Dept of Medicine, Imperial College London, London, UK
| | - Da-Hee Park
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Dept of Respiratory Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für angeborene Herzfehler und Kinderkardiologie, TU München, Munich, Germany
| | - Hans-Joachim Kabitz
- Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Medizinische Klinik II, Konstanz, Germany
| | - Dirk Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik II, Innere Medizin – Kardiologie/Pneumologie, Bonn, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungenforschungsambulanz, Helmholtz Zentrum, München, Germany,Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Universitätsklinikum Leipzig, Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Leipzig, Germany
| | - Matthias Held
- Dept of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- Attikon University Hospital, 2nd Critical Care Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Dept of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Martin Claussen
- LungenClinic Grosshansdorf, Fachabteilung Pneumologie, Großhansdorf, Germany
| | - Tobias J. Lange
- Dept of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Shmalts AA. Dynamics of 6-Minute Walk Distance as a Predictor of Efficiency Specific Pulmonary Vasodilators. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-06-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension is a severe and often rapidly progressive disease with a fatal outcome. Approved specific therapy with five classes of drugs – prostanoids, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, soluble guanylate cyclase stimulators and prostacyclin receptor agonists has significantly improved the prognosis of patients. An accessible and reproducible criterion of exercise tolerance – a distance walked in six-minute walk test (6MXD) – occupies one of the central places among the performance indicators (clinical, echocardiographic and hemodynamic) of specific pulmonary vasodilators. Reflecting the clinical severity of pulmonary hypertension and, according to some data, its long-term prognosis, the dynamics of 6MXD is an integral component of the combined primary endpoints of randomized controlled trials. In the CHEST-2019 recommendations, the dynamics of the 6MXD was used to standardize the randomized controlled trials. The 6MXD is indispensable for dynamic observation and decisionmaking on further treatment tactics
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Affiliation(s)
- A. A. Shmalts
- A.N. Bakoulev National Medical Research Center for Cardiovascular Surgery; Russian State Medical Postgraduate Academy
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31
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Wilson M, Keeley J, Kingman M, McDevitt S, Brewer J, Rogers F, Hill W, Rideman Z, Broderick M. Clinical Application of Risk Assessment in PAH: Expert Center APRN Recommendations. Pulm Circ 2022; 12:e12106. [PMID: 36016667 PMCID: PMC9395695 DOI: 10.1002/pul2.12106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/17/2022] [Accepted: 06/14/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Jennifer Keeley
- Allegheny Health Network Allegheny General Hospital Pittsburgh PA
| | - Martha Kingman
- University of Texas Southwestern Medical Center Dallas TX
| | | | | | - Frances Rogers
- Temple University Hospital Pulmonary Hypertension, Right Heart Failure and CTEPH program Philadelphia PA
| | - Wendy Hill
- Cedars Sinai Medical Group Los Angeles CA
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32
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Sharma D, Shah RJ, Sreenivasan J, Kafle P, Gupta R, Levine A, Lanier GM, Aronow WS. The role of serial right heart catheterization in risk stratification and management of pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2022; 20:543-547. [PMID: 35726644 DOI: 10.1080/14779072.2022.2092095] [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: 10/18/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial blood pressure secondary to increased pulmonary vascular resistance. AREAS COVERED Invasive hemodynamic assessment by heart catheterization (RHC) remains the gold standard to confirm the diagnosis, to determine the severity of right ventricular dysfunction and to test for pulmonary vasoreactivity. After diagnosis and initiation of therapy, many PAH centers continue to perform RHC at regular intervals to monitor for disease progression and alter management. We discuss the importance of risk stratification in PAH, the role of RHC in the evaluation and treatment of these patients and compare non-invasive risk assessment tools to that of RHC. EXPERT OPINION RHC is useful for diagnosis of PAH, assessing the risk of mortality and morbidity, directing the escalation and de-escalation of therapy, and monitoring for disease progression. In the current era of improved non-invasive cardiac hemodynamic assessment, the role for routine follow-up serial RHC in patients with PAH needs to be reassessed in future studies. With the availability of non-invasive risk assessment tools such as REVEAL Lite 2, it may be reasonable to reconsider the role of annual or protocoled RHC, and instead, move on to an "as needed" and individual approach.
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Affiliation(s)
- Dikshya Sharma
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ravi J Shah
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Paritosh Kafle
- Dvision of Cardiology, Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Rahul Gupta
- Division of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Suzuki S, Asano R, Aoki T, Nakayama S, Ueda J, Tsuji A, Noguchi T, Ogo T. Prognostic impact of follow-up pulmonary vascular resistance in pulmonary arterial hypertension. Open Heart 2022; 9:openhrt-2022-002054. [PMID: 35675988 PMCID: PMC9185661 DOI: 10.1136/openhrt-2022-002054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Pulmonary arterial hypertension (PAH), caused by pulmonary artery remodelling and increased pulmonary vascular resistance (PVR) due to an unknown mechanism, is an intractable disease with a poor prognosis. The recent development of PAH-specific treatment medications may allow for higher PVR reduction than previously achieved. This study aimed to identify the prognostic significance of follow-up PVR levels achieved shortly after the initiation of targeted treatment in patients with idiopathic/heritable pulmonary arterial hypertension (I/H-PAH). Methods We analysed the data of all patients with I/H-PAH admitted to our hospital between 1998 and 2019. We collected data at baseline and during the first invasive haemodynamic evaluation. The primary outcome was death or lung transplantation. Results Of the 133 treatment-naïve patients enrolled in this study, 47 experienced adverse events during a median follow-up period of 6.4 (IQR 3.5–11.5) years. The median time interval to first follow-up from diagnosis was 162 (IQR 117–253) days. Incidence of the primary outcome was significantly lower in patients who achieved low PVR at follow-up. Of risk factors evaluated at follow-up, the multivariate Cox regression analysis revealed PVR as an independent predictor of the primary outcome (HR 1.103, 95% CI 1.029 to 1.183; p=0.006). The results were consistent across risk profiles according to the simplified risk stratification recommended by the European Society of Cardiology and European Respiratory Society guidelines. Conclusion Follow-up PVR was an independent predictor of transplant-free survival in patients with I/H-PAH. Evaluation of haemodynamic status shortly after initiating treatment may help predict long-term prognosis.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sayuri Nakayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Stubbe B, Halank M, Seyfarth HJ, Obst A, Desole S, Opitz CF, Ewert R. [Risk Stratification in Patients with Pulmonary Arterial Hypertension under Treatment - Results of Four German Centers]. Pneumologie 2022; 76:330-339. [PMID: 35373311 DOI: 10.1055/a-1740-3377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). According to the current European guidelines the expected 1-year risk of mortality for PAH patients can be categorized as low, intermediate, or high, based on clinical, non-invasive and hemodynamic data.Data from 131 patients with incident PAH (age 64 ± 14) and frequent comorbidities (in 66.4 %) treated between 2016 and 2018 at 4 German PH centers were analyzed. At baseline, most patients were classified as intermediate risk (76 %), 13.8 % as high risk and only 9.9 % as low risk.During follow-up while on treatment after 12 ± 3 months (range 9-16 months) 64.9 % were still classified as intermediate risk (76 %), 14.4 % as high risk and 20.7 % as low risk.Survival at 12 and 24 months was 96 % and 82 % in the intermediate risk group, while only 89 % and 51 % of the high risk patients were alive at these time points. In contrast, all patients in the low risk category were alive at 24 months.Despite the availability of various treatment options for patients with PAH even in specialized centers only a minority of patients can be stabilized in the low risk group associated with a good outcome.
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Affiliation(s)
- Beate Stubbe
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | | | - Anne Obst
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Susanna Desole
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | | | - Ralf Ewert
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
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35
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Rahaghi FF, Balasubramanian VP, Bourge RC, Burger CD, Chakinala MM, Eggert MS, Elwing JM, Feldman J, King C, Klinger JR, Mathai SC, Wesley McConnell J, Palevsky HI, Restrepo‐Jaramillo R, Safdar Z, Sager JS, Sood N, Sulica R, James White R, Hill NS. Delphi Consensus Recommendation for Optimization of Pulmonary Hypertension Therapy Focusing On Switching from a Phosphodiesterase 5 Inhibitor to Riociguat. Pulm Circ 2022; 12:e12055. [PMID: 35514769 PMCID: PMC9063960 DOI: 10.1002/pul2.12055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/06/2022] Open
Abstract
Dual combination therapy with a phosphodiesterase‐5 inhibitor (PDE5i) and endothelin receptor antagonist is recommended for most patients with intermediate‐risk pulmonary arterial hypertension (PAH). The RESPITE and REPLACE studies suggest that switching from a PDE5i to a soluble guanylate cyclase (sGC) activator may provide clinical improvement in this situation. The optimal approach to escalation or transition of therapy in this or other scenarios is not well defined. We developed an expert consensus statement on the transition to sGC and other treatment escalations and transitions in PAH using a modified Delphi process. The Delphi process used a panel of 20 physicians with expertise in PAH. Panelists answered three questionnaires on the management of treatment escalations and transitions in PAH. The initial questionnaire included open‐ended questions. Later questionnaires consolidated the responses into statements that panelists rated on a Likert scale from −5 (strongly disagree) to +5 (strongly agree) to determine consensus. The Delphi process produced several consensus recommendations. Escalation should be considered for patients who are at high risk or not achieving treatment goals, by adding an agent from a new class, switching from oral to parenteral prostacyclins, or increasing the dose. Switching to a new class or within a class should be considered if tolerability or other considerations unrelated to efficacy are affecting adherence. Switching from a PDE5i to an SGC activator may benefit patients with intermediate risk who are not improving on their present therapy. These consensus‐based recommendations may be helpful to clinicians and beneficial for patients when evidence‐based guidance is unavailable.
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Affiliation(s)
- Franck F. Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida Weston FL USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Zeenat Safdar
- Center for Advanced Lung Diseases, Houston Methodist Hospital, Weill Cornell Medicine Houston TX USA
| | | | - Namita Sood
- University of California‐ Davis Sacramento CA
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Chin KM, Doelberg M, Martin N, Perchenet L, Galie N. Reply: Reduction in Risk of Disease Progression With Triple Therapy: Is it True for All? J Am Coll Cardiol 2022; 79:e177. [PMID: 35177202 DOI: 10.1016/j.jacc.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
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37
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Biological heterogeneity in idiopathic pulmonary arterial hypertension identified through unsupervised transcriptomic profiling of whole blood. Nat Commun 2021; 12:7104. [PMID: 34876579 PMCID: PMC8651638 DOI: 10.1038/s41467-021-27326-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is a rare but fatal disease diagnosed by right heart catheterisation and the exclusion of other forms of pulmonary arterial hypertension, producing a heterogeneous population with varied treatment response. Here we show unsupervised machine learning identification of three major patient subgroups that account for 92% of the cohort, each with unique whole blood transcriptomic and clinical feature signatures. These subgroups are associated with poor, moderate, and good prognosis. The poor prognosis subgroup is associated with upregulation of the ALAS2 and downregulation of several immunoglobulin genes, while the good prognosis subgroup is defined by upregulation of the bone morphogenetic protein signalling regulator NOG, and the C/C variant of HLA-DPA1/DPB1 (independently associated with survival). These findings independently validated provide evidence for the existence of 3 major subgroups (endophenotypes) within the IPAH classification, could improve risk stratification and provide molecular insights into the pathogenesis of IPAH.
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38
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Shigeta A, Tanabe N, Naito A, Yokota H, Kato F, Jujo-Sanada T, Sakao S, Ishida K, Masuda M, Tatsumi K. Preoperative soluble cluster of differentiation 40 ligand level is associated with outcome of pulmonary endarterectomy. JTCVS OPEN 2021; 8:618-629. [PMID: 36004182 PMCID: PMC9390291 DOI: 10.1016/j.xjon.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/12/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
Objective Soluble CD40 ligand (sCD40L) is associated with some pathobiological states. However, whether sCD40L in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who underwent pulmonary endarterectomy (PEA) is associated with perioperative pulmonary hemodynamics and surgical outcomes has not been elucidated. Here we aimed to investigate whether sCD40L is a useful serologic biomarker of poor surgical outcome of PEA in patients with CTEPH. Methods Ninety patients with CTEPH who underwent PEA were enrolled. Independent preoperative parameters were examined, including sCD40L related to lower cardiac index (CI), higher pulmonary vascular resistance (PVR), and poor surgical outcomes after PEA, according to the multivariate logistic regression analysis. In addition, the area under the curve (AUC) value of sCD40L to predict poor surgical outcomes was compared with the AUCs of D-dimer and C-reactive protein (CRP). The generalizability of this study model was tested by a 5-fold cross-validation analysis. Results Multivariate logistic regression analysis showed that high sCD40L level was related to postoperative lower CI, higher PVR, and poor surgical outcomes independent of other preoperative parameters. The AUC value of sCD40L to predict poor surgical outcomes was higher than those of D-dimer and CRP. A sCD40L cutoff value of 1.45 ng/mL predicted poor surgical outcomes with 79.3% sensitivity and 67.3% specificity. The 5-fold cross-validation analysis showed the effectiveness of our model's performance. Conclusions Preoperative sCD40L level could be a promising serologic biomarker associated with poor surgical outcomes in CTEPH. In addition to known preoperative parameters, the biomarker might have the potential to identify patients at high risk of PEA, thereby reducing the mortality rates.
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Affiliation(s)
- Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Address for reprints: Ayako Shigeta, MD, PhD, Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-Ku Chiba 260-8670, Japan.
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, Japan
| | - Akira Naito
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Yokota
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Fumiaki Kato
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takayuki Jujo-Sanada
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Cardiovascular Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Cardiovascular Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Cerik IB, Dindas F, Koyun E, Dereli S, Sahin A, Turgut OO, Gul I. New prognostic markers in pulmonary arterial hypertension: CRP to albumin ratio and uric acid. Clin Biochem 2021; 100:22-28. [PMID: 34788635 DOI: 10.1016/j.clinbiochem.2021.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/27/2021] [Accepted: 11/10/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Idiopathic pulmonary hypertension(IPAH) is a rare disease that causes severe morbidity and mortality despite advances in treatment management. Evaluating the prognosis of the disease is critical in determining therapeutic approaches. We aimed to evaluate the prognostic significance of C-reactive protein/albumin ratio (CAR) and uric acid, which is an easily applicable and inexpensive parameter in patients with IPAH. METHODS Seventy-two IPAH patients and 99 consecutive non-IPAH patients as a control group were enrolled in the study retrospectively. Right heart catheterization(RHC), echocardiography, and laboratory parameters of the two groups and those who died and survived among the IPAH patients were compared. RESULTS IPAH and control group were compared at the first stage and CAR (1.98(0.28-10.74), 0.75(0.22-4.7),respectively;p < 0.01) and uric acid (0.33(0.19-0.87), 0.3(0.11-0.48) mmol/L, respectively; p = 0.03) values were significantly higher in the pulmonary hypertension group compared to the control group. Compared with the surviving IPAH patients, CAR (4.60(1.39-10.74),1.54(0.28-6.74),respectively;p < 0.001) and uric acid levels (0.458(0.26-0.87), 0.315(0.19-0.56) mmol/L, respectively; p < 0.001) were significantly higher in the group of patients who died. In the multivariate Cox regression models uric acid(p < 0.001) and CAR(p < 0.001) were found to be associated with survival time. Receiver operating characteristic curves (ROC) analyses showed that > 1.54 CAR value (AUC = 0.81,Sens:85.7%,Spec:56.9%,p < 0.001) and > 5.85 mg/dL (>0.348 mmol/L) uric acid value (AUC = 0.864, Sens:85.7%, Spec:78.4%, p < 0.001) are strong predictors for mortality. CONCLUSION In this study, we showed that simple markers such as CAR, which augment the inflammation marker feature of CRP, and uric acid can give prognostic information in PAH patients.
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Affiliation(s)
- Idris Bugra Cerik
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey.
| | - Ferhat Dindas
- Department of Cardiology, Uşak Training and Research Hospital, Uşak, Turkey
| | - Emin Koyun
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Seckin Dereli
- Department of Cardiology, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - Anil Sahin
- Department of Cardiology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Okan Onur Turgut
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Ibrahim Gul
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
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Hoeper MM, Pausch C, Olsson KM, Huscher D, Pittrow D, Grünig E, Staehler G, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Park DH, Ewert R, Kaemmerer H, Kabitz HJ, Skowasch D, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H, Claussen M, Lange TJ, Rosenkranz S. COMPERA 2.0: A refined 4-strata risk assessment model for pulmonary arterial hypertension. Eur Respir J 2021; 60:13993003.02311-2021. [PMID: 34737226 PMCID: PMC9260123 DOI: 10.1183/13993003.02311-2021] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/29/2021] [Indexed: 11/27/2022]
Abstract
Background Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). The current European guidelines propose a three-stratum model to categorise risk as low, intermediate or high, based on the expected 1-year mortality. However, with this model, most patients are categorised as intermediate risk. We investigated a modified approach based on four risk categories, with intermediate risk subdivided into intermediate-low and intermediate-high risk. Methods We analysed data from the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA), a European pulmonary hypertension registry, and calculated risk at diagnosis and first follow-up based on World Health Organization functional class, 6-min walk distance (6MWD) and serum levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), using refined cut-off values. Survival was assessed using Kaplan–Meier analyses, log-rank testing and Cox proportional hazards models. Results Data from 1655 patients with PAH were analysed. Using the three-stratum model, most patients were classified as intermediate risk (76.0% at baseline and 63.9% at first follow-up). The refined four-stratum risk model yielded a more nuanced separation and predicted long-term survival, especially at follow-up assessment. Changes in risk from baseline to follow-up were observed in 31.1% of the patients with the three-stratum model and in 49.2% with the four-stratum model. These changes, including those between the intermediate-low and intermediate-high strata, were associated with changes in long-term mortality risk. Conclusions Modified risk stratification using a four-stratum model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically relevant changes in risk than the original three-stratum model. COMPERA 2.0, a four-stratum risk assessment model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically significant changes in risk than the original three-stratum modelhttps://bit.ly/3mzPKjA
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany .,German Center of Lung Research (DZL), Germany
| | | | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,German Center of Lung Research (DZL), Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany.,Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- German Center of Lung Research (DZL), Germany.,Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Department of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Department of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J Simon R Gibbs
- Department of Cardiology, National Heart & Lung Institute; Imperial College London, London, United Kingdom
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - H Ardeschir Ghofrani
- German Center of Lung Research (DZL), Germany.,Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,Department of Medicine, Imperial College London, London, United Kingdom
| | - Da-Hee Park
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Department of Respiratory Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für angeborene Herzfehler und Kinderkardiologie; TU München, Munich, Germany
| | - Hans-Joachim Kabitz
- Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Medizinische Klinik II, Konstanz, Germany
| | - Dirk Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik II, Innere Medizin - Kardiologie/Pneumologie, Bonn, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungenforschungsambulanz, Helmholtz Zentrum, München, Germany.,Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Universitätsklinikum Leipzig, Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Leipzig, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- Attikon University Hospital, 2nd Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, , Amsterdam, Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Department of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Martin Claussen
- LungenClinic Grosshansdorf, Fachabteilung Pneumologie, Großhansdorf, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Long term prognosis in patients with pulmonary hypertension undergoing catheter ablation for supraventricular tachycardia. Sci Rep 2021; 11:16176. [PMID: 34376719 PMCID: PMC8355112 DOI: 10.1038/s41598-021-95508-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/21/2021] [Indexed: 11/11/2022] Open
Abstract
Various forms of supraventricular tachycardia (SVT) occur in patients with severe pulmonary hypertension (PH). Despite the high efficacy of radiofrequency catheter ablation (RFCA) for SVT, insufficient data exist regarding patients with PH. Thirty SVTs in 23 PH patients (age 47 [35–60] years; mean pulmonary artery pressure 44 [32–50] mmHg) were analyzed. Procedural success rate, short- and long-term clinical outcomes, were evaluated during a median follow-up of 5.1 years. Single-procedure success rate was 83%; 94% (17/18) in typical atrial flutter, 73% (8/11) in atrial tachycardia (AT), and 100% (1/1) in atrioventricular nodal reentrant tachycardia. Antiarrhythmic drugs, serum brain natriuretic peptide levels and number of hospitalizations significantly decreased after RFCA than that before (p = 0.002, 0.04, and 0.002, respectively). Four patients had several procedures. After last RFCA, 12 patients had SVT and 8 patients died. Kaplan–Meier curves showed that patients with SVT after the last RFCA had a lower survival rate compared to those without (p = 0.0297). Multivariate analysis identified any SVT after the last RFCA as significant risk factor of mortality (hazard ratio: 9.31; p = 0.016). RFCA for SVT in patients with PH is feasible and effective in the short-term, but SVT is common during long-term follow-up and associated with lower survival.
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Abstract
Exercise intolerance is the dominant symptom of pulmonary hypertension (PH). The gold standard for the estimation of exercise capacity is a cycle ergometer incremental cardiopulmonary exercise test (CPET). The main clinical variables generated by a CPET are peak oxygen uptake (Vo2peak), ventilatory equivalents for carbon dioxide (VE/Vco2), systolic blood pressure, oxygen (O2) pulse, and chronotropic responses. PH is associated with hyperventilation at rest and at exercise, and an increase in physiologic dead space. Maximal cardiac output depends on right ventricular function and critically determines a PH patient's exercise capacity. Dynamic arterial O2 desaturation can also depress the Vo2peak.
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Circulating Cell Biomarkers in Pulmonary Arterial Hypertension: Relationship with Clinical Heterogeneity and Therapeutic Response. Cells 2021; 10:cells10071688. [PMID: 34359858 PMCID: PMC8304946 DOI: 10.3390/cells10071688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endothelial dysfunction is central to PAH. In this study, we simultaneously analysed circulating levels of endothelial microvesicles (EMVs) and progenitor cells (PCs) in PAH and in controls, as biomarkers of pulmonary endothelial integrity and evaluated differences among PAH subtypes and as a response to treatment. METHODS Forty-seven controls and 144 patients with PAH (52 idiopathic, 9 heritable, 31 associated with systemic sclerosis, 15 associated with other connective tissue diseases, 20 associated with HIV and 17 associated with portal hypertension) were evaluated. Forty-four patients with scleroderma and 22 with HIV infection, but without PAH, were also studied. Circulating levels of EMVs, total (CD31+CD42b-) and activated (CD31+CD42b-CD62E+), as well as circulating PCs (CD34+CD133+CD45low) were measured by flow cytometry and the EMVs/PCs ratio was computed. In treatment-naïve patients, measurements were repeated after 3 months of PAH therapy. RESULTS Patients with PAH showed higher numbers of EMVs and a lower percentage of PCs, compared with healthy controls. The EMV/PC ratio was increased in PAH patients, and in patients with SSc or HIV without PAH. After starting PAH therapy, individual changes in EMVs and PCs were variable, without significant differences being observed as a group. Conclusion: PAH patients present disturbed vascular homeostasis, reflected in changes in circulating EMV and PC levels, which are not restored with PAH targeted therapy. Combined measurement of circulating EMVs and PCs could be foreseen as a potential biomarker of endothelial dysfunction in PAH.
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
| | - Girija G Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
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Boucly A, Savale L, Jaïs X, Bauer F, Bergot E, Bertoletti L, Beurnier A, Bourdin A, Bouvaist H, Bulifon S, Chabanne C, Chaouat A, Cottin V, Dauphin C, Degano B, De Groote P, Favrolt N, Feng Y, Horeau-Langlard D, Jevnikar M, Jutant EM, Liang Z, Magro P, Mauran P, Moceri P, Mornex JF, Palat S, Parent F, Picard F, Pichon J, Poubeau P, Prévot G, Renard S, Reynaud-Gaubert M, Riou M, Roblot P, Sanchez O, Seferian A, Tromeur C, Weatherald J, Simonneau G, Montani D, Humbert M, Sitbon O. Association Between Initial Treatment Strategy and Long-term Survival in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 204:842-854. [PMID: 34185620 DOI: 10.1164/rccm.202009-3698oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The relationship between initial treatment strategy and survival in pulmonary arterial hypertension (PAH) remains uncertain. Objectives: To evaluate long-term survival in PAH according to initial treatment strategy. Methods: Retrospective analysis of incident patients with idiopathic, heritable or anorexigen-induced PAH enrolled in the French Registry (01/2006 to 12/2018). Survival was assessed according to initial strategy: monotherapy, dual or triple combination (two oral medications and a parenteral prostacyclin). Results: Among 1611 enrolled patients, 984 were initiated with monotherapy, 551 with dual and 76 with triple therapy. The triple combination group was younger with fewer comorbidities but higher mortality risk. Survival was better with triple therapy (91% at 5 years) as compared to dual or monotherapy (both 61% at 5 years), p<0.001. A propensity score matching on age, sex and pulmonary vascular resistance also showed significant differences between triple and dual therapy (10-year survival 85% vs 65%). In high-risk patients (n=243), survival was better with triple therapy vs monotherapy or dual therapy, while there was no difference between monotherapy and double therapy. In intermediate-risk patients (n=1134), survival improved with increasing number of therapies. In multivariable Cox regression, triple therapy was independently associated with a lower risk of death (hazard ratio 0.29, 95% confidence interval 0.11-0.80, p=0.017). Among the 148 patients initiated with a parenteral prostacyclin, those on triple therapy had better survival than those on monotherapy or dual therapy. Conclusions: Initial triple combination therapy including parenteral prostacyclin seems to be associated with better survival in PAH, particularly in the youngest high-risk patients.
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Affiliation(s)
- Athénaïs Boucly
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Laurent Savale
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Xavier Jaïs
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Fabrice Bauer
- INSERM U1096, Heart Failure Clinic and Pulmonary Hypertension Center, Service de chirurgie cardiaque, Hôpital Charles Nicole, Rouen, France
| | | | - Laurent Bertoletti
- Université de Saint-Etienne, Jean Monnet; INSERM, Thrombosis Research Group, EA3065; CIC-CIE3, Saint-Etienne, France.,Centre Hospitalier Universitaire, Service de Médecine Interne et Thérapeutique, Saint-Etienne, France
| | - Antoine Beurnier
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Physiologie, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Arnaud Bourdin
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, Pneumonology, Montpellier, France
| | - Hélène Bouvaist
- CHU Grenoble Alpes Service de Cardiologie, 568151, Grenoble, France
| | - Sophie Bulifon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Céline Chabanne
- CHU de Rennes, Hôpital Pontchaillou, Cardiology, Rennes, France
| | - Ari Chaouat
- Centre hospitalier régional universitaire de Nancy, 26920, Département de Pneumologie Hôpital de Brabois, Nancy, France.,Université de Lorraine, 137665, Inserm UMR_S 1116, Défaillance Cardiovasculaire Aigüe et Chronique, Faculté de Médecine de Nancy, Nancy, France
| | - Vincent Cottin
- Louis Pradel University Hospital, Respiratory Medicine, Lyon, France
| | - Claire Dauphin
- Hôpital Gabriel Montpied, 55448, Service de Cardiologie et Maladies Vasculaires, Clermont-Ferrand, France
| | - Bruno Degano
- Centre Hospitalier Universitaire Grenoble Alpes, 36724, Pneumologie-Physiologie, Grenoble, France
| | - Pascal De Groote
- CHR Lille - Hôpital cardiologique, Clinique de cardiologie, Lille, France
| | - Nicolas Favrolt
- CHU François Mitterrand, Service de Pneumologie et Soins Intensifs Respiratoires, Dijon, France
| | - Yuanchao Feng
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | | | - Mitja Jevnikar
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Etienne-Marie Jutant
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Zhiying Liang
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | - Pascal Magro
- CHU de Tours, service de pneumologie, Tours, France
| | - Pierre Mauran
- Paediatric and Congenital Cardiology Unit, American Memorial Hospital, CHU Reims, Reims, France
| | | | | | | | - Florence Parent
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | | | - Jérémie Pichon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Patrice Poubeau
- CHU de La Réunion Sites Sud Saint-Pierre, 56577, Saint-Pierre, Réunion
| | | | - Sébastien Renard
- Hopital de la Timone - Deparment de Cardiologie, 375330, Marseille, France
| | | | | | - Pascal Roblot
- Department of Internal Medicine, Infectious and Tropical Diseases, Poitiers University Hospital, Poitiers, France
| | - Olivier Sanchez
- Hopital Europeen Georges Pompidou, 55647, Respiratory Unit, Paris, France
| | - Andrei Seferian
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Cécile Tromeur
- CHRU de Brest, 26990, Internal Medicine and Chest Disease, Brest, France
| | | | - Gérald Simonneau
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - David Montani
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Marc Humbert
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Olivier Sitbon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France;
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Cardiac index predicts long-term outcomes in patients with heart failure. PLoS One 2021; 16:e0252833. [PMID: 34086818 PMCID: PMC8177638 DOI: 10.1371/journal.pone.0252833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/24/2021] [Indexed: 12/28/2022] Open
Abstract
Background The role of cardiac index (CI) and right atrial pressure (RAP) for predicting long-term outcomes of heart failure has not been well established. The aim of this study was to investigate long-term cardiac outcomes in patients with heart failure having various combinations of CI and RAP. Methods A total of 787 heart failure patients who underwent right-heart catheterization were retrospectively categorized into the following four groups: Preserved CI (≥2.5 L/min/m2) and Low RAP (<8 mmHg) (PRE-CI/L-RAP; n = 285); Preserved CI (≥2.5 L/min/m2) and High RAP (≥8 mmHg) (PRE-CI/H-RAP; n = 242); Reduced CI (<2.5 L/min/m2) and Low RAP (<8 mmHg) (RED-CI/L-RAP; n = 123); and Reduced CI (<2.5 L/min/m2) and High RAP (≥8 mmHg) (RED-CI/H-RAP; n = 137). Survival analysis was applied to investigate which groups were associated with major adverse cardiovascular events (MACE). Results The RED-CI/L-RAP and RED-CI/H-RAP groups were significantly associated with MACE as compared with the PRE-CI/L-RAP and PRE-CI/H-RAP groups after adjustment for confounding factors (RED-CI/L-RAP vs. PRE-CI/L-RAP: HR 2.11 [95% CI 1.33–3.37], p = 0.002; RED-CI/H-RAP vs. PRE-CI/L-RAP: HR 2.18 [95% CI 1.37–3.49], p = 0.001; RED-CI/L-RAP vs. PRE-CI/H-RAP: HR 1.86 [95% CI 1.16–3.00], p = 0.01; RED-CI/H-RAP vs. PRE-CI/H-RAP: HR 1.92 [95% CI 1.26–2.92], p = 0.002), whereas the difference between the RED-CI/H-RAP and RED-CI/L-RAP groups was not significant (HR 1.03 [95% CI 0.64–1.66], p = 0.89). Conclusions The hemodynamic severity categorized by CI and RAP levels provided clear risk stratification in patients with symptomatic heart failure. Low CI was an independent predictor of long-term cardiac outcomes.
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Iwatani N, Kubota K, Ikeda Y, Tokushige A, Miyanaga S, Higo K, Ohishi M. Different characteristics of mitochondrial dynamics-related miRNAs on the hemodynamics of pulmonary artery hypertension and chronic thromboembolic pulmonary hypertension. J Cardiol 2021; 78:24-30. [PMID: 33836917 DOI: 10.1016/j.jjcc.2021.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mitochondria are dynamic organelles that undergo fission or fusion. These mitochondrial dynamics are reported to be associated with pulmonary hypertension (PH). PH is divided into 5 groups, including pulmonary artery hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), based on its pathogenesis. However, it is still unknown whether and how miRNAs related to mitochondrial dynamics (MD) affect PAH and CTEPH. METHODS We investigated patients who underwent right heart catheterization between October 2016 and January 2019. Out of 34 PH patients, 12 were diagnosed with PAH, and 22 were diagnosed with CTEPH. In addition, there were 30 patients diagnosed with left heart disease. We enrolled the 34 PH patients as the PH group and 30 left heart disease patients as the control group. RESULTS Among MD-related miRNAs, the circulating levels of miR-140-3p were higher, and those of miR-485-5p were lower in the PH group than in the control group (p < 0.01), suggesting that miRNAs inducing mitochondrial fission are related to PH. The miR-140-3p levels in the PAH and CTEPH groups were higher than those in the control group (p < 0.01). The levels of miR-140-3p and miR-485-5p in the PAH group correlated with pulmonary vascular resistance (r = 0.582, p = 0.046) and cardiac index (r = -0.36, p = 0.04), respectively. The miR-485-5p levels in the CTEPH group correlated with right atrium pressure (r = -0.456, p = 0.049). CONCLUSION MD-related miRNAs levels change to induce fission and are closely related to the hemodynamics of PAH and CTEPH.
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Affiliation(s)
- Noriko Iwatani
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Kayoko Kubota
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Yoshiyuki Ikeda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Akihiro Tokushige
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Sunao Miyanaga
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Kenjuro Higo
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
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Sonnweber T, Schneider EM, Nairz M, Theurl I, Weiss G, Tymoszuk P, Löffler-Ragg J. Risk assessment in precapillary pulmonary hypertension: a comparative analysis. Respir Res 2021; 22:28. [PMID: 33478493 PMCID: PMC7818775 DOI: 10.1186/s12931-021-01624-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/11/2021] [Indexed: 01/17/2023] Open
Abstract
Background Risk stratification is essential to assess mortality risk and guide treatment in patients with precapillary pulmonary hypertension (PH). We herein compared the accuracy of different currently used PH risk stratification tools and evaluated the significance of particular risk parameters. Methods We conducted a retrospective longitudinal observational cohort study evaluating seven different risk assessment approaches according to the current PH guidelines. A comprehensive assessment including multi-parametric risk stratification was performed at baseline and 4 yearly follow-up time-points. Multi-step Cox hazard analysis was used to analyse and refine risk prediction. Results Various available risk models effectively predicted mortality in patients with precapillary pulmonary hypertension. Right-heart catheter parameters were not essential for risk prediction. Contrary, non-invasive follow-up re-evaluations significantly improved the accuracy of risk estimations. A lack of accuracy of various risk models was found in the intermediate- and high-risk classes. For these patients, an additional evaluation step including assessment of age and right atrium area improved risk prediction significantly. Discussion Currently used abbreviated versions of the ESC/ERS risk assessment tool, as well as the REVEAL 2.0 and REVEAL Lite 2 based risk stratification, lack accuracy to predict mortality in intermediate- and high-risk precapillary pulmonary hypertension patients. An expanded non-invasive evaluation improves mortality risk prediction in these individuals.
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Affiliation(s)
- Thomas Sonnweber
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Eva-Maria Schneider
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Manfred Nairz
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Igor Theurl
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Piotr Tymoszuk
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria.
| | - Judith Löffler-Ragg
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria.
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Akagi S, Dohi Y, Ishikawa K, Kubota K, Horimoto K, Yagi S, Hirata T, Yamamoto E, Ito H, Nakamura K. Effects of Dual Initial Combination Therapy With Macitentan Plus Riociguat or Macitentan Plus Selexipag on Hemodynamics in Patients With Pulmonary Arterial Hypertension (SETOUCHI-PH Study) - Protocol of a Multicenter Randomized Control Trial. Circ Rep 2021; 3:105-109. [PMID: 33693297 PMCID: PMC7939949 DOI: 10.1253/circrep.cr-20-0133] [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] [Indexed: 02/01/2023] Open
Abstract
Background: The latest guideline from the European Society of Cardiology and European Respiratory Society recommends initial combination therapy with oral pulmonary arterial hypertension (PAH)-specific drugs in PAH patients with World Health Organization functional class (WHO-FC) II or III. However, whether this initial combination therapy improves hemodynamics and clinical failure events regardless of the combination of PAH-specific drugs remains unknown. This study was designed to evaluate whether the initial combination therapy with macitentan plus riociguat or macitentan plus selexipag showed equal efficacy in reducing pulmonary vascular resistance (PVR) 8 months after administration. Methods and Results: This study is a multicenter randomized control trial. PAH subjects with WHO-FC II or III will be randomized (1 : 1) into initial combination therapy with either macitentan plus riociguat or macitentan plus selexipag, and will be observed 8 months after the initiation of treatment. The primary endpoint will be the difference in the change ratio of PVR from baseline to after 8 months of treatment. Conclusions: The SETOUCHI-PH study will clarify whether initial combination therapy with macitentan plus riociguat or macitentan plus selexipag results in equal reductions in PVR 8 months after administration.
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Affiliation(s)
- Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Yoshihiro Dohi
- Department of Cardiology, Kure Kyosai Hospital Kure Japan
| | - Kaori Ishikawa
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University Kagawa Japan
| | - Kayoko Kubota
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Koshin Horimoto
- Department of Cardiology, Matsuyama Red Cross Hospital Matsuyama Japan
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences Tokushima Japan
| | - Tetsuo Hirata
- Cardiovascular Division, Department of Cardiovascular Medicine, Gifu Heart Center Gifu Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University Kumamoto Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
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Sahin A, Kaya H, Avci O. Cancer antigen-125 is a predictor of mortality in patients with pulmonary arterial hypertension. Clin Biochem 2020; 89:58-62. [PMID: 33382999 DOI: 10.1016/j.clinbiochem.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/06/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase and be associated with severity in heart failure and chronic obstructive pulmonary disease. Patients with pulmonary arterial hypertension may also die due to developing right heart failure. The aim of this study is to evaluate the prognostic role of CA-125 in PAH patients. METHODS A total of 40 consecutive patients with PAH were evaluated prospectively. The mean age of patients was 52 ± 11 years (12% males, 88% females) with a median follow-up period of 16 months. RESULTS After follow-up period, 12 out of 40 patients (30%) died. CA-125 levels were higher among those who died compared to those who survived [78.5 (11.0-292) vs. 27.5 (2.10-138) U/ml, p = 0.001]. The optimal cut-off value of CA-125 to predict mortality was found as 35.29 U/ml, with 85.7% specificity and 75% sensitivity. In multivariable Cox proportional-hazards model with forward stepwise method; CA-125 > 35.32 U/ml on admission (HR = 7.645, 95% CI: 1.356-43.121, p = 0.021), age (HR = 1.132, 95% CI: 1.040-1.233, p = 0.004), TAPSE (HR = 0.740, 95% CI: 0.549-0.998, p = 0.048) and uric acid (HR = 1.444, 95% CI: 1.022-2.042, p = 0.037) remained associated with an increased risk of death. CONCLUSION In this study, we showed for the first time that serum CA-125 values were an independent predictor for the long-term mortality in PAH patients.
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Affiliation(s)
- Anil Sahin
- Cardiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey.
| | - Hakki Kaya
- Cardiology Department, Canakkale Onsekiz Mart University, Canakkale, Turkey.
| | - Onur Avci
- Anesthesiology and Reanimation Department, Sivas Cumhuriyet University, Sivas, Turkey.
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