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Oldham WM, Oliveira RKF, Wang RS, Opotowsky AR, Rubins DM, Hainer J, Wertheim BM, Alba GA, Choudhary G, Tornyos A, MacRae CA, Loscalzo J, Leopold JA, Waxman AB, Olschewski H, Kovacs G, Systrom DM, Maron BA. Network Analysis to Risk Stratify Patients With Exercise Intolerance. Circ Res 2018; 122:864-876. [PMID: 29437835 PMCID: PMC5924425 DOI: 10.1161/circresaha.117.312482] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 01/09/2023]
Abstract
RATIONALE Current methods assessing clinical risk because of exercise intolerance in patients with cardiopulmonary disease rely on a small subset of traditional variables. Alternative strategies incorporating the spectrum of factors underlying prognosis in at-risk patients may be useful clinically, but are lacking. OBJECTIVE Use unbiased analyses to identify variables that correspond to clinical risk in patients with exercise intolerance. METHODS AND RESULTS Data from 738 consecutive patients referred for invasive cardiopulmonary exercise testing at a single center (2011-2015) were analyzed retrospectively (derivation cohort). A correlation network of invasive cardiopulmonary exercise testing parameters was assembled using |r|>0.5. From an exercise network of 39 variables (ie, nodes) and 98 correlations (ie, edges) corresponding to P<9.5e-46 for each correlation, we focused on a subnetwork containing peak volume of oxygen consumption (pVo2) and 9 linked nodes. K-mean clustering based on these 10 variables identified 4 novel patient clusters characterized by significant differences in 44 of 45 exercise measurements (P<0.01). Compared with a probabilistic model, including 23 independent predictors of pVo2 and pVo2 itself, the network model was less redundant and identified clusters that were more distinct. Cluster assignment from the network model was predictive of subsequent clinical events. For example, a 4.3-fold (P<0.0001; 95% CI, 2.2-8.1) and 2.8-fold (P=0.0018; 95% CI, 1.5-5.2) increase in hazard for age- and pVo2-adjusted all-cause 3-year hospitalization, respectively, were observed between the highest versus lowest risk clusters. Using these data, we developed the first risk-stratification calculator for patients with exercise intolerance. When applying the risk calculator to patients in 2 independent invasive cardiopulmonary exercise testing cohorts (Boston and Graz, Austria), we observed a clinical risk profile that paralleled the derivation cohort. CONCLUSIONS Network analyses were used to identify novel exercise groups and develop a point-of-care risk calculator. These data expand the range of useful clinical variables beyond pVo2 that predict hospitalization in patients with exercise intolerance.
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Affiliation(s)
- William M Oldham
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Rudolf K F Oliveira
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Rui-Sheng Wang
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Alexander R Opotowsky
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - David M Rubins
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Jon Hainer
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Bradley M Wertheim
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - George A Alba
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Gaurav Choudhary
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Adrienn Tornyos
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Calum A MacRae
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Joseph Loscalzo
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Jane A Leopold
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Aaron B Waxman
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Horst Olschewski
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Gabor Kovacs
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - David M Systrom
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Bradley A Maron
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.).
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