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Bindlish S. Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An obesity medicine association (OMA) clinical practice statement (CPS) 2023. OBESITY PILLARS (ONLINE) 2023; 8:100092. [PMID: 38125656 PMCID: PMC10728709 DOI: 10.1016/j.obpill.2023.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 12/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians with an overview on obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Methods The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results Topics in this CPS include obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Obesity increases the risk of thrombosis and cardiovascular disease via fat mass and adiposopathic mechanisms. Treatment of thrombosis or thrombotic risk includes healthful nutrition, physical activity, and the requisite knowledge of how body weight affects anti-thrombotic medications. In addition to obesity-related thrombotic considerations of acute coronary syndrome and ischemic non-hemorrhagic stroke, this Clinical Practice Statement briefly reviews the diagnosis and management of clinically relevant presentations of deep vein thromboses, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, corona phlebectatica, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post-thrombotic syndrome, as well as lymphedema and lipedema - which should be included in the differential diagnosis of other edematous or enlargement disorders of the lower extremities. Conclusions This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on obesity, thrombosis, and venous/lymphatic disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.
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Affiliation(s)
- Shagun Bindlish
- Adjunct Faculty Touro University, 7554 Dublin Blvd, Dublin, CA, USA
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2
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Yuriditsky E, Horowitz JM, Lau JF. Chronic thromboembolic pulmonary hypertension and the post-pulmonary embolism (PE) syndrome. Vasc Med 2023; 28:348-360. [PMID: 37036116 DOI: 10.1177/1358863x231165105] [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: 04/11/2023]
Abstract
Over a third of patients surviving acute pulmonary embolism (PE) will experience long-term cardiopulmonary limitations. Persistent thrombi, impaired gas exchange, and altered hemodynamics account for aspects of the postpulmonary embolism syndrome that spans mild functional limitations to debilitating chronic thromboembolic pulmonary hypertension (CTEPH), the most worrisome long-term consequence. Though pulmonary endarterectomy is potentially curative for the latter, less is understood surrounding chronic thromboembolic disease (CTED) and post-PE dyspnea. Advances in pulmonary vasodilator therapies and growing expertise in balloon pulmonary angioplasty provide options for a large group of patients ineligible for surgery, or those with persistent postoperative pulmonary hypertension. In this clinical review, we discuss epidemiology and pathophysiology as well as advances in diagnostics and therapeutics surrounding the spectrum of disease that may follow months after acute PE.
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Affiliation(s)
- Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - James M Horowitz
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - Joe F Lau
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
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Elhage Hassan M, Vinales J, Perkins S, Sandesara P, Aggarwal V, Jaber WA. Pathogenesis, Diagnosis, and Management of Chronic Thromboembolic Pulmonary Hypertension. Interv Cardiol Clin 2023; 12:e37-e49. [PMID: 38964822 DOI: 10.1016/j.iccl.2024.04.003] [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: 07/06/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to occur as a sequelae of thromboembolic processes in the pulmonary vasculature. The pathophysiology of CTEPH is multifactorial, including impaired fibrinolysis, endothelial dysregulation, and hypoxic adaptations. The diagnosis of CTEPH is typically delayed considering the nonspecific nature of the symptoms, lack of screening, and relatively low incidence. Diagnostic tools include ventilation-perfusion testing, echocardiography, cardiac catheterization, and pulmonary angiography. The only potentially curative treatment for CTEPH is pulmonary endarterectomy However, approximately 40% of patients are inoperable. Currently, only Riociguat is Food and Drug Administration approved specifically for CTEPH, with additional drug trials underway.
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Affiliation(s)
- Malika Elhage Hassan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA
| | - Jorge Vinales
- Department of Medicine, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Sidney Perkins
- Department of Internal Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pratik Sandesara
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA
| | - Vikas Aggarwal
- Department of Cardiology, Henry Ford Medical Center, 2799 W Grand Blvd, K-2 Cath Admin Suite, Detroit, MI 48206, USA
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA.
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Colebank MJ, Qureshi MU, Rajagopal S, Krasuski RA, Olufsen MS. A multiscale model of vascular function in chronic thromboembolic pulmonary hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H318-H338. [PMID: 34142886 DOI: 10.1152/ajpheart.00086.2021] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by recurrent or unresolved pulmonary thromboemboli, leading to perfusion defects and increased arterial wave reflections. CTEPH treatment aims to reduce pulmonary arterial pressure and reestablish adequate lung perfusion, yet patients with distal lesions are inoperable by standard surgical intervention. Instead, these patients undergo balloon pulmonary angioplasty (BPA), a multisession, minimally invasive surgery that disrupts the thromboembolic material within the vessel lumen using a catheter balloon. However, there still lacks an integrative, holistic tool for identifying optimal target lesions for treatment. To address this insufficiency, we simulate CTEPH hemodynamics and BPA therapy using a multiscale fluid dynamics model. The large pulmonary arterial geometry is derived from a computed tomography (CT) image, whereas a fractal tree represents the small vessels. We model ring- and web-like lesions, common in CTEPH, and simulate normotensive conditions and four CTEPH disease scenarios; the latter includes both large artery lesions and vascular remodeling. BPA therapy is simulated by simultaneously reducing lesion severity in three locations. Our predictions mimic severe CTEPH, manifested by an increase in mean proximal pulmonary arterial pressure above 20 mmHg and prominent wave reflections. Both flow and pressure decrease in vessels distal to the lesions and increase in unobstructed vascular regions. We use the main pulmonary artery (MPA) pressure, a wave reflection index, and a measure of flow heterogeneity to select optimal target lesions for BPA. In summary, this study provides a multiscale, image-to-hemodynamics pipeline for BPA therapy planning for patients with inoperable CTEPH. NEW & NOTEWORTHY This article presents novel computational framework for predicting pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension. The mathematical model is used to identify the optimal target lesions for balloon pulmonary angioplasty, combining simulated pulmonary artery pressure, wave intensity analysis, and a new quantitative metric of flow heterogeneity.
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Affiliation(s)
- Mitchel J Colebank
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - M Umar Qureshi
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richard A Krasuski
- Department of Cardiovascular Medicine, Duke University Health System, Durham, North Carolina
| | - Mette S Olufsen
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
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Waziri F, Mellemkjær S, Clemmensen TS, Hjortdal VE, Ilkjær LB, Nielsen SL, Poulsen SH. Long-term changes of exercise hemodynamics and physical capacity in chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy. Int J Cardiol 2020; 317:181-187. [PMID: 32497568 DOI: 10.1016/j.ijcard.2020.05.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A substantial number of chronic thromboembolic pulmonary hypertension (CTEPH) patients experience dyspnea on exertion and limited exercise capacity despite surgically successful pulmonary endarterectomy (PEA). We sought to prospectively evaluate resting and peak exercise hemodynamics before, 3 and 12 months after PEA in consecutive CTEPH-patients and correlate it to physical functional capacity. METHODS AND RESULTS Twenty consecutive CTEPH-patients were examined. Twelve months after PEA, 75% of patients with severely increased pre-PEA mean pulmonary arterial pressure (mPAP) at rest had normal or mildly increased mPAP. However, mPAP reduction was less pronounced during exercise where only 45% had normal or mildly increased mPAP at 12 months. Hemodynamic changes during exercise were tested using the pressure-flow relationship (i.e. mPAP/cardiac output (CO) slope). The average mPAP/CO slope was 7.5 ± 4.2 mm Hg/L/min preoperatively and 3.9 ± 3.0 mm Hg/L/min at 12 months (p < .005). CO reserve (CO increase from rest to peak exercise) was increased (5.7 ± 2.9 L/min) 12 months after PEA compared with pre-PEA (2.5 ± 1.8 L/min), p < .0001. However, 12 months after PEA, the CO reserve was only 49% of that of healthy controls, p < .0001. Changes in cardiac output (∆CO), calculated as the difference between CO before PEA and 12 months later, were significantly correlated with six-minute-walk-test and peak oxygen uptake (VO2), both at rest and peak exercise. CONCLUSION Invasive exercise hemodynamic examination in CTEPH-patients demonstrates that after otherwise successful PEA surgery, >50% of patients have a significant increase in exercise mPAP, and the CO reserve remains compromised 12 months after PEA. Improvement in physical capacity is correlated with ∆CO.
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Affiliation(s)
- Farhad Waziri
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Internal Medicine, Regional Hospital of Randers, Denmark.
| | | | - Tor Skibsted Clemmensen
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Vibeke Elisabeth Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Lars Bo Ilkjær
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Sten Lyager Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Long-term changes of right ventricular myocardial deformation and remodeling studied by cardiac magnetic resonance imaging in patients with chronic thromboembolic pulmonary hypertension following pulmonary thromboendarterectomy. Int J Cardiol 2020; 300:282-288. [DOI: 10.1016/j.ijcard.2019.09.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/22/2019] [Accepted: 09/16/2019] [Indexed: 11/20/2022]
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Waziri F, Mellemkjær S, Clemmensen TS, Hjortdal VE, Ilkjær LB, Nielsen SL, Poulsen SH. Long‐term changes of resting and exercise right ventricular systolic performance in patients with chronic thromboembolic pulmonary hypertension following pulmonary thromboendarterectomy – A two‐dimensional and three‐dimensional echocardiographic study. Echocardiography 2019; 36:1656-1665. [DOI: 10.1111/echo.14456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Farhad Waziri
- Department of Cardiology Aarhus University Hospital Aarhus N Denmark
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
- Department of Internal Medicine Regional Hospital of Randers Aarhus N Denmark
| | - Søren Mellemkjær
- Department of Cardiology Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Tor Skibsted Clemmensen
- Department of Cardiology Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Vibeke Elisabeth Hjortdal
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Lars Bo Ilkjær
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Sten Lyager Nielsen
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology Aarhus University Hospital Aarhus N Denmark
- Department of Clinical Medicine Aarhus University Aarhus N Denmark
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Wang W, Wen L, Song Z, Shi W, Wang K, Huang W. Balloon pulmonary angioplasty vs riociguat in patients with inoperable chronic thromboembolic pulmonary hypertension: A systematic review and meta-analysis. Clin Cardiol 2019; 42:741-752. [PMID: 31188483 PMCID: PMC6671827 DOI: 10.1002/clc.23212] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/28/2019] [Indexed: 01/06/2023] Open
Abstract
Backgrounds No previous meta‐analyses have compared the efficacy and safety of BPA with riociguat therapy in inoperable CTEPH patients. Methods Relevant published studies were searched in the PubMed, Embase and ClinicalTrial.gov databases. Results Twenty‐three clinical trials including 1454 patients (631 underwent BPA; 823 underwent riociguat therapy) were analyzed. BPA was associated with a greater improvement in RAP (mean difference (MD) = −3.53 mmHg, 95% CI: [−4.85, −2.21] vs MD = −1.05 mmHg, 95% CI: [−1.82, −0.29]); mPAP (MD = −15.02 mmHg, 95% CI: [−17.32, −12.71] vs MD = −4.19 mmHg, 95% CI: [−5.58, −2.80]); PVR (standard MD = −1.32 woods, 95% CI: [−1.57, −1.08] vs standard MD = −0.65 woods, 95% CI: [−0.79, −0.50]); NYHA functional class (RR = 6.78, 95% CI: [3.14, 14.64] vs RR = 1.49, 95% CI: [1.07, 2.07]); and 6MWD (MD = 71.66 m, 95% CI: [58.34, 84.99] vs MD = 45.25 m, 95% CI: [36.51, 53.99]) than riociguat treatment. However, the increase in CO was greater with riociguat (MD = 0.78 L/min, 95% CI: [0.61, 0.96]) than with BPA (MD = 0.33 L/min, 95% CI: [0.06, 0.59]). No significant difference in cardiac index (CI) was found between BPA (MD = 0.40 L/min/m2, 95% CI: [0.21, 0.58]) and riociguat (MD = 0.40 L/min/m2, 95% CI: [0.26, 0.54]). The most common complications of BPA were pulmonary injury (0.3%‐5.6%) and pulmonary edema (0.8%‐28.6%). The most common adverse events of riociguat were headache, dizziness, hypotension and nasopharyngitis. Conclusions Our meta‐analysis indicates that BPA might be associated with greater improvements in exercise tolerance and pulmonary hemodynamics except for cardiac output and cardiac index than riociguat therapy. However, both of them were well tolerated.
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Affiliation(s)
- Wuwan Wang
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Wen
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhengdong Song
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Wenhai Shi
- Department of Cardiology, The Sixth People's Hospital of Chengdu, Chengdu, China
| | - Ke Wang
- Institute of Cardiovascular Diseases of People's Liberation of Army (PLA), Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Li C, Zhao J, Liu S, Song W, Zhu J, Hua L, Wang Q, Li M, Zeng X, Zhao Y. Pulmonary thromboendarterectomy is a curative resolution for chronic thromboembolic pulmonary hypertension associated with antiphospholipid syndrome: a retrospective cohort study. Lupus 2018; 27:2206-2214. [PMID: 30451640 DOI: 10.1177/0961203318810427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and life-threatening condition with poor prognosis in patients with antiphospholipid syndrome (APS). Pulmonary thromboendarterectomy (PTE) is the optimal surgical option for CTEPH. Objectives This retrospective cohort study aimed to evaluate the efficacy and risk of PTE in patients with APS-associated CTEPH. Methods Consecutive patients with APS-associated CTEPH diagnosed between January 2012 and September 2017 at Peking Union Medical College Hospital were retrospectively evaluated. Demographics, clinical manifestations, antiphospholipid antibody (aPL) profiles, and pulmonary arterial hypertension–targeted medications were collected. Deterioration of cardiac function and death were chosen as the endpoints, in order to assess the effect of PTE on short-term and long-term prognoses (evaluated by the change of cardiac function after treatment and cardiac deterioration or death in the follow-up, respectively). Results A total of 20 patients with APS-associated CTEPH were enrolled, and eight patients underwent PTE. Chi-square test ( p = 0.01) and Kaplan–Meier curves (log rank test, p = 0.04) showed that there were statistically significant differences in both short-term and long-term prognoses between patients with and without PTE. Conclusion These results provide strong evidence that PTE is a curative resolution in patients with APS-associated CTEPH. Following a full specialized and multidisciplinary risk-benefit evaluation to limit the risk of thrombosis or bleeding and to manage possible thrombocytopenia, PTE is at least a temporal curative resolution for CTEPH complicated with APS.
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Affiliation(s)
- C Li
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - J Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - S Liu
- Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Science, Beijing, China
| | - W Song
- Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Science, Beijing, China
| | - J Zhu
- Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Science, Beijing, China
| | - L Hua
- Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Q Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - M Li
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - Y Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
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