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Pan L, Parini P, Tremmel R, Loscalzo J, Lauschke VM, Maron BA, Paci P, Ernberg I, Tan NS, Liao Z, Yin W, Rengarajan S, Li X. Single Cell Atlas: a single-cell multi-omics human cell encyclopedia. Genome Biol 2024; 25:104. [PMID: 38641842 PMCID: PMC11027364 DOI: 10.1186/s13059-024-03246-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/12/2024] [Indexed: 04/21/2024] Open
Abstract
Single-cell sequencing datasets are key in biology and medicine for unraveling insights into heterogeneous cell populations with unprecedented resolution. Here, we construct a single-cell multi-omics map of human tissues through in-depth characterizations of datasets from five single-cell omics, spatial transcriptomics, and two bulk omics across 125 healthy adult and fetal tissues. We construct its complement web-based platform, the Single Cell Atlas (SCA, www.singlecellatlas.org ), to enable vast interactive data exploration of deep multi-omics signatures across human fetal and adult tissues. The atlas resources and database queries aspire to serve as a one-stop, comprehensive, and time-effective resource for various omics studies.
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Affiliation(s)
- Lu Pan
- Institute of Environmental Medicine, Karolinska Institutet, 171 65, Solna, Sweden
| | - Paolo Parini
- Cardio Metabolic Unit, Department of Medicine, and, Department of Laboratory Medicine , Karolinska Institutet, 141 86, Stockholm, Sweden
- Theme Inflammation and Ageing, Medicine Unit, Karolinska University Hospital, 141 86, Stockholm, Sweden
| | - Roman Tremmel
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376, Stuttgart, Germany
- University of Tuebingen, 72076, Tuebingen, Germany
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Volker M Lauschke
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376, Stuttgart, Germany
- University of Tuebingen, 72076, Tuebingen, Germany
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 65, Solna, Sweden
| | - Bradley A Maron
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Paola Paci
- Department of Computer, Control and Management Engineering, Sapienza University of Rome, 00185, Rome, Italy
| | - Ingemar Ernberg
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 171 65, Solna, Sweden
| | - Nguan Soon Tan
- School of Biological Sciences, Nanyang Technological University, Singapore, 637551, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, 308232, Singapore
| | - Zehuan Liao
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 171 65, Solna, Sweden
- School of Biological Sciences, Nanyang Technological University, Singapore, 637551, Singapore
| | - Weiyao Yin
- Institute of Environmental Medicine, Karolinska Institutet, 171 65, Solna, Sweden
| | - Sundararaman Rengarajan
- Department of Physical Therapy, Movement & Rehabilitation Sciences, Northeastern University, Boston, MA, 02115, USA
| | - Xuexin Li
- Department of General Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, 110032, China.
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 171 65, Solna, Sweden.
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Jose A, Rahman N, Opotowsky AR, Glorioso TJ, Waldo SW, Zeder K, Seto A, Elwing JM, McCormack FX, Maron BA. Association of Cardiopulmonary Hemodynamics and Mortality in Veterans With Liver Cirrhosis: A Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e033847. [PMID: 38567662 DOI: 10.1161/jaha.123.033847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking. METHODS AND RESULTS As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m2, the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy. CONCLUSIONS These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.
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Affiliation(s)
- Arun Jose
- Veterans Affairs Cincinnati Healthcare System Cincinnati OH
- University of Cincinnati OH
| | - Natalia Rahman
- Rocky Mountain Regional VA Medical Center Aurora CO
- Denver Research Institute Aurora CO
| | - Alexander R Opotowsky
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati OH
| | - Thomas J Glorioso
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration Washington DC
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center Aurora CO
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration Washington DC
- University of Colorado School of Medicine Aurora CO
| | - Katarina Zeder
- Brigham and Women's Hospital and Harvard Medical School Boston MA
- Department of Medicine University of Maryland School of Medicine Baltimore MD
- The University of Maryland-Institute for Health Computing Bethesda MD
- Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of Graz Austria
| | - Arnold Seto
- Veteran's Affairs Long Beach Healthcare System Long Beach CA
| | | | - Francis X McCormack
- Veterans Affairs Cincinnati Healthcare System Cincinnati OH
- University of Cincinnati OH
| | - Bradley A Maron
- Veterans Affairs Boston Healthcare System Boston MA
- Brigham and Women's Hospital and Harvard Medical School Boston MA
- Department of Medicine University of Maryland School of Medicine Baltimore MD
- The University of Maryland-Institute for Health Computing Bethesda MD
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Cassady SJ, Maron BA. Mildly elevated pulmonary vascular resistance and worsened survival in PH-ILD: an opportunity for earlier diagnosis and intervention? Thorax 2024; 79:387-388. [PMID: 38413193 DOI: 10.1136/thorax-2023-221328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Steven J Cassady
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley A Maron
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland-Institute for Health Computing, Bethesda, Maryland, USA
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Maron BA, Wang RS, Shevtsov S, Drakos SG, Arons E, Wever-Pinzon O, Huggins GS, Samokhin AO, Oldham WM, Aguib Y, Yacoub MH, Rowin EJ, Maron BJ, Maron MS, Loscalzo J. Author Correction: Individualized interactomes for network-based precision medicine in hypertrophic cardiomyopathy with implications for other clinical pathophenotypes. Nat Commun 2024; 15:3038. [PMID: 38589351 PMCID: PMC11002015 DOI: 10.1038/s41467-024-45814-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Rui-Sheng Wang
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sergei Shevtsov
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute (CVRTI), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elena Arons
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gordon S Huggins
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Andriy O Samokhin
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - William M Oldham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yasmine Aguib
- Department of Cardiac Surgery, Imperial College of London, London, UK
- The Magdi Yacoub Heart Center, Aswan, Egypt
| | - Magdi H Yacoub
- Department of Cardiac Surgery, Imperial College of London, London, UK
- The Magdi Yacoub Heart Center, Aswan, Egypt
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Srivastava MC, Maron BA. Elevated Tricuspid Regurgitation Velocity in Left Ventricular Dysfunction: A Not So Innocent Bystander. JACC Heart Fail 2024:S2213-1779(24)00241-5. [PMID: 38573266 DOI: 10.1016/j.jchf.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Mukta C Srivastava
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bradley A Maron
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; University of Maryland-Institute for Health Computing, Bethesda, Maryland, USA.
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Khurshid S, Churchill TW, Diamant N, Di Achille P, Reeder C, Singh P, Friedman SF, Wasfy MM, Alba GA, Maron BA, Systrom DM, Wertheim BM, Ellinor PT, Ho JE, Baggish AL, Batra P, Lubitz SA, Guseh JS. Deep learned representations of the resting 12-lead electrocardiogram to predict at peak exercise. Eur J Prev Cardiol 2024; 31:252-262. [PMID: 37798122 PMCID: PMC10809171 DOI: 10.1093/eurjpc/zwad321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023]
Abstract
AIMS To leverage deep learning on the resting 12-lead electrocardiogram (ECG) to estimate peak oxygen consumption (V˙O2peak) without cardiopulmonary exercise testing (CPET). METHODS AND RESULTS V ˙ O 2 peak estimation models were developed in 1891 individuals undergoing CPET at Massachusetts General Hospital (age 45 ± 19 years, 38% female) and validated in a separate test set (MGH Test, n = 448) and external sample (BWH Test, n = 1076). Three penalized linear models were compared: (i) age, sex, and body mass index ('Basic'), (ii) Basic plus standard ECG measurements ('Basic + ECG Parameters'), and (iii) basic plus 320 deep learning-derived ECG variables instead of ECG measurements ('Deep ECG-V˙O2'). Associations between estimated V˙O2peak and incident disease were assessed using proportional hazards models within 84 718 primary care patients without CPET. Inference ECGs preceded CPET by 7 days (median, interquartile range 27-0 days). Among models, Deep ECG-V˙O2 was most accurate in MGH Test [r = 0.845, 95% confidence interval (CI) 0.817-0.870; mean absolute error (MAE) 5.84, 95% CI 5.39-6.29] and BWH Test (r = 0.552, 95% CI 0.509-0.592, MAE 6.49, 95% CI 6.21-6.67). Deep ECG-V˙O2 also outperformed the Wasserman, Jones, and FRIEND reference equations (P < 0.01 for comparisons of correlation). Performance was higher in BWH Test when individuals with heart failure (HF) were excluded (r = 0.628, 95% CI 0.567-0.682; MAE 5.97, 95% CI 5.57-6.37). Deep ECG-V˙O2 estimated V˙O2peak <14 mL/kg/min was associated with increased risks of incident atrial fibrillation [hazard ratio 1.36 (95% CI 1.21-1.54)], myocardial infarction [1.21 (1.02-1.45)], HF [1.67 (1.49-1.88)], and death [1.84 (1.68-2.03)]. CONCLUSION Deep learning-enabled analysis of the resting 12-lead ECG can estimate exercise capacity (V˙O2peak) at scale to enable efficient cardiovascular risk stratification.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - Timothy W Churchill
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
| | - Nathaniel Diamant
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Paolo Di Achille
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Christopher Reeder
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Pulkit Singh
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Samuel F Friedman
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Meagan M Wasfy
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- University of Maryland, Institute for Health Computing, Bethesda, MD, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - Jennifer E Ho
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, CardioVascular Institute, Boston, MA, USA
| | - Aaron L Baggish
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Département Coeur-Vaisseaux, Le Centre Hospitalier Universitaire Vaudois (CHUV), Institut des Sciences du Sport, Université de Lausanne, Écublens, Vaud, Switzerland
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - J Sawalla Guseh
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
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Alba GA, Zhou IY, Mascia M, Magaletta M, Alladina JW, Giacona FL, Ginns LC, Caravan P, Maron BA, Montesi SB. Plasma NEDD9 is increased following SARS-CoV-2 infection and associates with indices of pulmonary vascular dysfunction. Pulm Circ 2024; 14:e12356. [PMID: 38500738 PMCID: PMC10946282 DOI: 10.1002/pul2.12356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/31/2023] [Accepted: 03/10/2024] [Indexed: 03/20/2024] Open
Abstract
Compared to healthy volunteers, participants with post-acute sequelae of SARS-CoV-2 infection (PASC) demonstrated increased plasma levels of the prothrombotic protein NEDD9, which associated inversely with indices of pulmonary vascular function. This suggests persistent pulmonary vascular dysfunction may play a role in the pathobiology of PASC.
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Affiliation(s)
- George A. Alba
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Iris Y. Zhou
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMassachusettsUSA
- Institute for Innovation in ImagingMassachusetts General HospitalBostonMassachusettsUSA
| | - Molly Mascia
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Michael Magaletta
- Department of Radiology, Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMassachusettsUSA
| | - Jehan W. Alladina
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Francesca L. Giacona
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Leo C. Ginns
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Peter Caravan
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMassachusettsUSA
- Institute for Innovation in ImagingMassachusetts General HospitalBostonMassachusettsUSA
| | - Bradley A. Maron
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Sydney B. Montesi
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Institute for Innovation in ImagingMassachusetts General HospitalBostonMassachusettsUSA
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Synn AJ, Harder EM, Nardelli P, Ross JC, Maron BA, Leopold JA, Waxman AB, San José Estépar R, Washko GR, Rahaghi FN. Automated CT-Based Quantification of Pulmonary Veins Shows Greater Central Venous Dilation in Group 2 Pulmonary Hypertension Compared With Group 1 Pulmonary Arterial Hypertension and Control Subjects. CHEST Pulm 2023; 1:100020. [PMID: 38144213 PMCID: PMC10745213 DOI: 10.1016/j.chpulm.2023.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Affiliation(s)
- Andrew J Synn
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Eileen M Harder
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Pietro Nardelli
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - James C Ross
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Bradley A Maron
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Jane A Leopold
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Raúl San José Estépar
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - George R Washko
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care (A. J. S.), Beth Israel Deaconess Medical Center, the Division of Pulmonary and Critical Care (E. M. H., A. B. W., G. R. W., and F. N. R.), Department of Radiology (P. N., J. C. R., and R. S. J. E.), and the Division of Cardiovascular Medicine (J. A. L.), Brigham and Women's Hospital, Harvard Medical School; and the Department of Medicine (B. A. M.), University of Maryland School of Medicine, and the University of Maryland-Institute for Health Computing (B. A. M.), Bethesda, MD
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Bordag N, Nagy BM, Zügner E, Ludwig H, Foris V, Nagaraj C, Biasin V, Bodenhofer U, Magnes C, Maron BA, Ulrich S, Lange TJ, Hötzenecker K, Pieber T, Olschewski H, Olschewski A. Lipidomics for diagnosis and prognosis of pulmonary hypertension. medRxiv 2023:2023.05.17.23289772. [PMID: 37292870 PMCID: PMC10246148 DOI: 10.1101/2023.05.17.23289772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Pulmonary hypertension (PH) poses a significant health threat with high morbidity and mortality, necessitating improved diagnostic tools for enhanced management. Current biomarkers for PH lack functionality and comprehensive diagnostic and prognostic capabilities. Therefore, there is a critical need to develop biomarkers that address these gaps in PH diagnostics and prognosis. Methods To address this need, we employed a comprehensive metabolomics analysis in 233 blood based samples coupled with machine learning analysis. For functional insights, human pulmonary arteries (PA) of idiopathic pulmonary arterial hypertension (PAH) lungs were investigated and the effect of extrinsic FFAs on human PA endothelial and smooth muscle cells was tested in vitro. Results PA of idiopathic PAH lungs showed lipid accumulation and altered expression of lipid homeostasis-related genes. In PA smooth muscle cells, extrinsic FFAs caused excessive proliferation and endothelial barrier dysfunction in PA endothelial cells, both hallmarks of PAH.In the training cohort of 74 PH patients, 30 disease controls without PH, and 65 healthy controls, diagnostic and prognostic markers were identified and subsequently validated in an independent cohort. Exploratory analysis showed a highly impacted metabolome in PH patients and machine learning confirmed a high diagnostic potential. Fully explainable specific free fatty acid (FFA)/lipid-ratios were derived, providing exceptional diagnostic accuracy with an area under the curve (AUC) of 0.89 in the training and 0.90 in the validation cohort, outperforming machine learning results. These ratios were also prognostic and complemented established clinical prognostic PAH scores (FPHR4p and COMPERA2.0), significantly increasing their hazard ratios (HR) from 2.5 and 3.4 to 4.2 and 6.1, respectively. Conclusion In conclusion, our research confirms the significance of lipidomic alterations in PH, introducing innovative diagnostic and prognostic biomarkers. These findings may have the potential to reshape PH management strategies.
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Affiliation(s)
- Natalie Bordag
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- BioMedTech, Graz, Austria
| | - Bence Miklos Nagy
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elmar Zügner
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Helga Ludwig
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Chandran Nagaraj
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- BioMedTech, Graz, Austria
| | - Valentina Biasin
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Physiology, Otto Loewi Research Centre, Medical University of Graz, Graz, Austria
| | - Ulrich Bodenhofer
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Christoph Magnes
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Bradley A. Maron
- University of Maryland School of Medicine, Baltimore, MD and The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Silvia Ulrich
- Clinic of Pulmonology, University and University Hospital of Zurich, Zürich, Switzerland
| | - Tobias J. Lange
- Department of Internal Medicine II, Pulmonology and Critical Care, Kreisklinik Bad Reichenhall, Bad Reichenhall, Germany
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Konrad Hötzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Pieber
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz Austria
- BioMedTech, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Experimental Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
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10
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Kim JM, Stern RM, Maron BA. Bleeding and Myocardial Infarction in Acquired Factor VIII Deficiency. Circulation 2023; 148:1127-1133. [PMID: 37782697 DOI: 10.1161/circulationaha.123.063904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Joseph M Kim
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.K.)
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
| | - Robert M Stern
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
- Divisions of Hematology (R.M.S.), Brigham and Women's Hospital, Boston, MA
| | - Bradley A Maron
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
- Cardiovascular Medicine (B.A.M.), Brigham and Women's Hospital, Boston, MA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD and the University of Maryland-Institute for Health Computing, Bethesda, MD (B.A.M.)
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11
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Brittain EL, Tedford RJ, Maron BA. Reply to Wu et al. Am J Respir Crit Care Med 2023; 208:823-824. [PMID: 37562041 PMCID: PMC10563184 DOI: 10.1164/rccm.202307-1180le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023] Open
Affiliation(s)
- Evan L. Brittain
- Division of Cardiovascular Medicine and the Vanderbilt Pulmonary Circulation Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley A. Maron
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- Institute for Health Computing, University of Maryland, Bethesda, Maryland
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12
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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13
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Wang RS, Huang S, Waldo SW, Hess E, Gokhale M, Johnson SW, Zeder K, Choudhary G, Leopold JA, Oldham WM, Kovacs G, Freiberg MS, Tedford RJ, Maron BA, Brittain EL. Elevated Pulmonary Arterial Compliance Is Associated with Survival in Pulmonary Hypertension: Results from a Novel Network Medicine Analysis. Am J Respir Crit Care Med 2023; 208:312-321. [PMID: 37276608 PMCID: PMC10395727 DOI: 10.1164/rccm.202211-2097oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/31/2023] [Indexed: 06/07/2023] Open
Abstract
Rationale: Predictors of adverse outcome in pulmonary hypertension (PH) are well established; however, data that inform survival are lacking. Objectives: We aim to identify clinical markers and therapeutic targets that inform the survival in PH. Methods: We included data from patients with elevated mean pulmonary artery pressure (mPAP) diagnosed by right heart catheterization in the U.S. Veterans Affairs system (October 1, 2006-September 30, 2018). Network medicine framework was used to subgroup patients when considering an N of 79 variables per patient. The results informed outcome analyses in the discovery cohort and a sex-balanced validation right heart catheterization cohort from Vanderbilt University (September 24, 1998-December 20, 2013). Measurements and Main Results: From an N of 4,737 complete case patients with mPAP of 19-24 mm Hg, there were 21 distinct subgroups (network modules) (all-cause mortality range = 15.9-61.2% per module). Pulmonary arterial compliance (PAC) drove patient assignment to modules characterized by increased survival. When modeled continuously in patients with mPAP ⩾19 mm Hg (N = 37,744; age, 67.2 yr [range = 61.7-73.8 yr]; 96.7% male; median follow-up time, 1,236 d [range = 570-1,971 d]), the adjusted all-cause mortality hazard ratio was <1.0 beginning at PAC ⩾3.0 ml/mm Hg and decreased progressively to ∼7 ml/mm Hg. A protective association between PAC ⩾3.0 ml/mm Hg and mortality was also observed in the validation cohort (N = 1,514; age, 60.2 yr [range = 49.2-69.1 yr]; 48.0% male; median follow-up time, 2,485 d [range = 671-3,580 d]). The association was strongest in patients with precapillary PH at the time of catheterization, in whom 41% (95% confidence interval, 0.55-0.62; P < 0.001) and 49% (95% confidence interval, 0.38-0.69; P < 0.001) improvements in survival were observed for PAC ⩾3.0 versus <3.0 ml/mm Hg in the discovery and validation cohorts, respectively. Conclusions: These data identify elevated PAC as an important parameter associated with survival in PH. Prospective studies are warranted that consider PAC ⩾3.0 ml/mm Hg as a therapeutic target to achieve through proven interventions.
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Affiliation(s)
- Rui-Sheng Wang
- Division of Cardiovascular Medicine
- Channing Division of Network Medicine, and
| | | | - Stephen W. Waldo
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Veterans Affairs Clinical Assessment, Reporting, and Tracking Program, Veterans Health Administration Office of Quality and Patient Safety, Washington, DC
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Edward Hess
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Madhura Gokhale
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Shelsey W. Johnson
- Department of Pulmonary and Critical Care, Boston Medical Center, Boston, Massachusetts
| | - Katarina Zeder
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center and Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - William M. Oldham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Matthew S. Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Ryan J. Tedford
- Division of Cardiology, Medical Department of Medicine, University of South Carolina, Charleston, South Carolina; and
| | - Bradley A. Maron
- Division of Cardiovascular Medicine
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Evan L. Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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14
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Maron BA, Witkin AS, Dudzinski DM, Shenoy-Bhangle AS, Zhang W, Shroff SG. Case 23-2023: A 21-Year-Old Man with Progressive Dyspnea. N Engl J Med 2023; 389:360-370. [PMID: 37494488 DOI: 10.1056/nejmcpc2300906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- Bradley A Maron
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
| | - Alison S Witkin
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
| | - David M Dudzinski
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
| | - Anuradha S Shenoy-Bhangle
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
| | - Wei Zhang
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
| | - Stuti G Shroff
- From the Department of Medicine, University of Maryland School of Medicine, Baltimore (B.A.M.); and the Department of Medicine, Brigham and Women's Hospital (B.A.M.), the Departments of Medicine (B.A.M., A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Harvard Medical School, and the Departments of Medicine (A.S.W., D.M.D., W.Z.), Radiology (A.S.S.-B.), and Pathology (S.G.S.), Massachusetts General Hospital - all in Boston
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15
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Maron BA. Introducing the Pulmonary Hypertension Thematic Series. Am J Respir Crit Care Med 2023. [PMID: 37343302 PMCID: PMC10395723 DOI: 10.1164/rccm.202306-1005ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Bradley A Maron
- University of Maryland Baltimore, 12265, Baltimore, Maryland, United States;
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16
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Wang RS, Rowin EJ, Maron BJ, Maron MS, Maron BA. A novel patient-patient network medicine approach to refine hypertrophic cardiomyopathy subgrouping: implications for risk stratification. Cardiovasc Res 2023; 119:e125-e127. [PMID: 37129987 PMCID: PMC10409890 DOI: 10.1093/cvr/cvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Affiliation(s)
- Rui-Sheng Wang
- Division of Cardiovascular Medicine, Department of Medicine, 77 Ave Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, 77 Ave Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
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17
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Kim JM, Maron BA. A 65-Year-Old Woman With Dyspnea and Recurrent Abdominal Distension. JAMA Cardiol 2023; 8:510. [PMID: 37018008 DOI: 10.1001/jamacardio.2023.0363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
This case report discusses a diagnosis of extracardiac shunt in a woman aged 65 years with giant right atrium and recurrent heart failure exacerbations.
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Affiliation(s)
- Joseph M Kim
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
The definition of pulmonary hypertension (PH) has changed recently based, in part, on contemporary outcome data and to focus on early disease detection. Now, PH includes patients with mean pulmonary artery pressure >20 mm Hg measured by right heart catheterization. In contrast to the classical era, pulmonary vascular resistance >2.0 Wood units is also used for diagnosis and prognostication. These lowered thresholds aim to identify patients early in the disease course, which is important because delay to diagnosis of PH is common and linked to elevated morbidity and shortened lifespan. This clinical primer highlights key changes in diagnosis and approach to PH management, focusing on concepts that are likely to be encountered frequently in general practice. Specifically, this includes hemodynamic assessment of at-risk patients, pharmacotherapeutic management of pulmonary arterial hypertension, approach to PH in patients with heart failure with preserved ejection fraction, and newly established indications for early referral to PH centers to prompt comanagement of patients with pulmonary vascular disease experts.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School Boston MA
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, Veterans Affairs Boston Healthcare System West Roxbury MA
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19
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Benincasa G, Napoli C, Loscalzo J, Maron BA. Pursuing functional biomarkers in complex disease: Focus on pulmonary arterial hypertension. Am Heart J 2023; 258:96-113. [PMID: 36565787 DOI: 10.1016/j.ahj.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 05/11/2023]
Abstract
A major gap in diagnosis, classification, risk stratification, and prediction of therapeutic response exists in pulmonary arterial hypertension (PAH), driven in part by a lack of functional biomarkers that are also disease-specific. In this regard, leveraging big data-omics analyses using innovative approaches that integrate network medicine and machine learning correlated with clinically useful indices or risk stratification scores is an approach well-positioned to advance PAH precision medicine. For example, machine learning applied to a panel of 48 cytokines, chemokines, and growth factors could prognosticate PAH patients with immune-dominant subphenotypes at elevated or low-risk for mortality. Here, we discuss strengths and weaknesses of the most current studies evaluating omics-derived biomarkers in PAH. Progress in this field is offset by studies with small sample size, pervasive limitations in bioinformatics, and lack of standardized methods for data processing and interpretation. Future success in this field, in turn, is likely to hinge on mechanistic validation of data outputs in order to couple functional biomarker data with target-specific therapeutics in clinical practice.
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Affiliation(s)
- Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA.
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20
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Wang RS, Maron BA, Loscalzo J. Multiomics Network Medicine Approaches to Precision Medicine and Therapeutics in Cardiovascular Diseases. Arterioscler Thromb Vasc Biol 2023; 43:493-503. [PMID: 36794589 PMCID: PMC10038904 DOI: 10.1161/atvbaha.122.318731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death worldwide and display complex phenotypic heterogeneity caused by many convergent processes, including interactions between genetic variation and environmental factors. Despite the identification of a large number of associated genes and genetic loci, the precise mechanisms by which these genes systematically influence the phenotypic heterogeneity of CVD are not well understood. In addition to DNA sequence, understanding the molecular mechanisms of CVD requires data from other omics levels, including the epigenome, the transcriptome, the proteome, as well as the metabolome. Recent advances in multiomics technologies have opened new precision medicine opportunities beyond genomics that can guide precise diagnosis and personalized treatment. At the same time, network medicine has emerged as an interdisciplinary field that integrates systems biology and network science to focus on the interactions among biological components in health and disease, providing an unbiased framework through which to integrate systematically these multiomics data. In this review, we briefly present such multiomics technologies, including bulk omics and single-cell omics technologies, and discuss how they can contribute to precision medicine. We then highlight network medicine-based integration of multiomics data for precision medicine and therapeutics in CVD. We also include a discussion of current challenges, potential limitations, and future directions in the study of CVD using multiomics network medicine approaches.
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Affiliation(s)
- Rui-Sheng Wang
- Division of Cardiovascular Medicine
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Joseph Loscalzo
- Division of Cardiovascular Medicine
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Aktaa S, Gale CP, Brida M, Giannakoulas G, Kovacs G, Adir Y, Benza RL, Böhm M, Coats A, D'Alto M, Escribano-Subias P, Ferrari P, Galie N, Gibbs JSR, Gin-Sing W, Hoeper MM, Humbert M, Lang IM, Maron BA, Meszaros G, Noordegraaf AV, Price LC, Pepke-Zaba J, Rådegran G, Reis A, Sitbon O, Torbicki A, Ulrich S, Rosenkranz S, Delcroix M. European Society of Cardiology Quality Indicators for the care and outcomes of adults with pulmonary arterial hypertension. Eur J Heart Fail 2023; 25:469-477. [PMID: 36924171 DOI: 10.1002/ejhf.2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/18/2023] Open
Abstract
AIMS To develop a suite of quality indicators (QIs) for the evaluation of the care and outcomes for adults with pulmonary arterial hypertension (PAH). METHODS AND RESULTS We followed the ESC methodology for the development of QIs. This included the 1) identification of key domains of care for the management of PAH, 2) proposal of candidate QIs following systematic review of the literature, and 3) selection of a set of QIs using a modified-Delphi method. The process was undertaken in parallel with the writing of the 2022 European Society of Cardiology (ESC) / European Respiratory Society (ERS) guidelines for the diagnosis and treatment of pulmonary hypertension and involved Task Force chairs, experts in PAH, Heart Failure Association (HFA) members and patient representatives. We identified five domains of care for patients with PAH; structural framework, diagnosis and risk stratification, initial treatment, follow up, and outcomes. In total, 23 main and one secondary QIs for PAH were selected. CONCLUSION This document presents the ESC QIs for PAH, describes their development process and offers scientific rationale for their selection. The indicators may be used to quantify and improve adherence to guideline-recommended clinical practice and improve patient outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suleman Aktaa
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK.,Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK.,Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Margarita Brida
- Department of Medical Rehabilitation, Medical Faculty University of Rijeka, Ul. Braće Branchetta 20/1, Rijeka, 51000, Croatia.,Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton & Harefield Hospitals, Guys and St Thomas' NHS Trust, Sydney Street, London, SW3 6NP, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Gabor Kovacs
- Department of Pulmonology, University Clinic of Internal Medicine, Medical University of Graz, and the Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Yochai Adir
- Pulmonary Division, Lady Davis Carmel Medical Center, Faculty of Medicine Technion Institute of Technology, Haifa, Israel
| | - Raymond L Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit. Department of Cardiology. CIBER-CV. Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- Past President and Member of the Board, AIPI, Associazione Ipertensione Polmonare Italiana (Italian Pulmonary Hypertension Association), Italy
| | - Nazzareno Galie
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Dipartimento DIMES, Università di Bologna, Bologna, Italy
| | - J Simon R Gibbs
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Wendy Gin-Sing
- Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany, and German Centre of Lung Research, DZL, Hannover, Germany
| | - Marc Humbert
- Université Paris-Saclay, INSERM UMR_S 999, Assistance Publique Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Irene M Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gergely Meszaros
- European Pulmonary Hypertension Association (PHA Europe), Hungary
| | - Anton Vonk Noordegraaf
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, De Boelelaan, 1117, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK.,Honorary Senior Clinical Lecturer, Imperial College London, London, UK
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Abilio Reis
- Department of Medicine, PVDU, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal.,Department of Cardiovascular Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
| | - Olivier Sitbon
- Université Paris-Saclay, INSERM UMR_S 999, Assistance Publique Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center for Postgraduate Medical Education, ECZ-Otwock, Poland
| | - Silvia Ulrich
- Department of Pulmonology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University of Cologne, and Cologne Cardiovascular Research Center (CCRC), Cologne, Germany
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
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22
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Maron BA, Kleiner DE, Arons E, Wertheim BM, Sharma NS, Haley KJ, Samokhin AO, Rowin EJ, Maron MS, Rosing DR, Maron BJ. Evidence of Advanced Pulmonary Vascular Remodeling in Obstructive Hypertrophic Cardiomyopathy With Pulmonary Hypertension. Chest 2023; 163:678-686. [PMID: 36243062 PMCID: PMC9993337 DOI: 10.1016/j.chest.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Elevated mean pulmonary artery pressure (mPAP) is common in patients with hypertrophic cardiomyopathy (HCM) and heart failure symptoms. However, dynamic left ventricular (LV) outflow tract obstruction may confound interpretation of pulmonary hypertension (PH) pathophysiologic features in HCM when relying on resting invasive hemodynamic data alone. RESEARCH QUESTION Do structural changes to the lung vasculature clarify PH pathophysiologic features in patients with HCM with progressive heart failure? STUDY DESIGN AND METHODS Clinical data and ultrarare lung autopsy specimens were acquired retrospectively from the National Institutes of Health (1975-1992). Patients were included based on the availability of lung tissue and recorded mPAP. Discarded tissue from rejected lung donors served as control specimens. Histomorphology was performed on pulmonary arterioles and veins. Comparisons were calculated using the Student t test and Mann-Whitney U test; Pearson correlation was used to assess association between morphometric measurements and HCM cardiac and hemodynamic measurements. RESULTS The HCM cohort (n = 7; mean ± SD age, 43 ± 18 years; 71% men) showed maximum mean ± SD LV wall thickness of 25 ± 2.8 mm, mean ± SD outflow tract gradient of 90 ± 30 mm Hg, median mPAP of 25 mm Hg (interquartile range [IQR], 6 mm Hg), median pulmonary artery wedge pressure (PAWP) of 16 mm Hg (IQR, 4 mm Hg), and median pulmonary vascular resistance of 1.8 Wood units (WU; IQR, 2.4 WU). Compared with control samples (n = 5), patients with HCM showed greater indexed pulmonary arterial hypertrophy (20.7 ± 7.2% vs 49.7 ± 12%; P < .001) and arterial wall fibrosis (11.5 ± 3.4 mm vs 21.0 ± 4.7 mm; P < .0001), which correlated with mPAP (r = 0.84; P = .018), PAWP (r = 0.74; P = .05), and LV outflow tract gradient (r = 0.78; P = .035). Compared with control samples, pulmonary vein thickness was increased by 2.9-fold (P = .008) in the HCM group, which correlated with mPAP (r = 0.81; P = .03) and LV outflow tract gradient (r = 0.83; P = .02). INTERPRETATION To the best of our knowledge, these data demonstrate for the first time that in patients with obstructive HCM, heart failure is associated with pathogenic pulmonary vascular remodeling even when mPAP is elevated only mildly. These observations clarify PH pathophysiologic features in HCM, with future implications for clinical strategies that mitigate outflow tract obstruction.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD
| | - Elena Arons
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Nirmal S Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kathleen J Haley
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andriy O Samokhin
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Douglas R Rosing
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
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23
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Howard L, Kiely DG, Lawrie A, Maron BA, Preston I, Rosenkranz S, Toshner M, Wilkins M, Fong YL, Quinn D, Stamatiadis D, Villeneuve M, Chin K. PERFORMANCE OF THE ESC/ERS GUIDELINES FOR ASSESSING THE PROBABILITY OF PULMONARY HYPERTENSION (PH) BY TRANSTHORACIC ECHOCARDIOGRAM (TTE): AN ANALYSIS OF INCIDENT PATIENTS FROM THE CIPHER STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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24
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Wertheim BM, Wang RS, Guillermier C, Hütter CV, Oldham WM, Menche J, Steinhauser ML, Maron BA. Proline and glucose metabolic reprogramming supports vascular endothelial and medial biomass in pulmonary arterial hypertension. JCI Insight 2023; 8:163932. [PMID: 36626231 PMCID: PMC9977503 DOI: 10.1172/jci.insight.163932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
In pulmonary arterial hypertension (PAH), inflammation promotes a fibroproliferative pulmonary vasculopathy. Reductionist studies emphasizing single biochemical reactions suggest a shift toward glycolytic metabolism in PAH; however, key questions remain regarding the metabolic profile of specific cell types within PAH vascular lesions in vivo. We used RNA-Seq to profile the transcriptome of pulmonary artery endothelial cells (PAECs) freshly isolated from an inflammatory vascular injury model of PAH ex vivo, and these data were integrated with information from human gene ontology pathways. Network medicine was then used to map all aa and glucose pathways to the consolidated human interactome, which includes data on 233,957 physical protein-protein interactions. Glucose and proline pathways were significantly close to the human PAH disease module, suggesting that these pathways are functionally relevant to PAH pathobiology. To test this observation in vivo, we used multi-isotope imaging mass spectrometry to map and quantify utilization of glucose and proline in the PAH pulmonary vasculature at subcellular resolution. Our findings suggest that elevated glucose and proline avidity underlie increased biomass in PAECs and the media of fibrosed PAH pulmonary arterioles. Overall, these data show that anabolic utilization of glucose and proline are fundamental to the vascular pathology of PAH.
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Affiliation(s)
| | - Rui-Sheng Wang
- Division of Cardiovascular Medicine, Department of Medicine.,Channing Division of Network Medicine, Department of Medicine; and
| | - Christelle Guillermier
- Division of Genetics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Center for NanoImaging, Cambridge, Massachusetts, USA
| | - Christiane Vr Hütter
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Department of Structural and Computational Biology, Max Perutz Labs, University of Vienna, Vienna, Austria.,Vienna BioCenter PhD Program, Doctoral School of the University of Vienna and the Medical University of Vienna, Vienna, Austria
| | - William M Oldham
- Division of Pulmonary and Critical Medicine, Department of Medicine
| | - Jörg Menche
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Department of Structural and Computational Biology, Max Perutz Labs, University of Vienna, Vienna, Austria.,Faculty of Mathematics, University of Vienna, Vienna, Austria
| | - Matthew L Steinhauser
- Division of Genetics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Center for NanoImaging, Cambridge, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Aging Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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25
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Chouvarine P, Hysko K, Chan SY, Oliveira P, Maron BA, Kourembanas S, Hansmann G. Second International Pulmonary Hypertension/Heart Failure Symposium-Structural heart disease, right ventricular dysfunction, and stem cell therapy: The European Pediatric Pulmonary Vascular Disease Network. Pulm Circ 2023; 13:e12175. [PMID: 36628260 PMCID: PMC9826951 DOI: 10.1002/pul2.12175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/16/2022] Open
Affiliation(s)
- Philippe Chouvarine
- Department of Pediatric Cardiology and Critical CareHannover Medical SchoolHannoverGermany
| | - Klea Hysko
- Department of Pediatric Cardiology and Critical CareHannover Medical SchoolHannoverGermany
| | - Stephen Y. Chan
- Department of Medicine, Division of Cardiology, Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Paulo Oliveira
- CNC—Center for Neuroscience and Cell Biology, CIBB—Centre for Innovative Biomedicine and BiotechnologyUniversity of CoimbraCoimbraPortugal
| | - Bradley A. Maron
- Brigham and Women's Hospital, Harvard Medical School and the Department of Cardiology, Division of Cardiovascular MedicineVA Boston Healthcare SystemBostonMassachusettsUSA
| | - Stella Kourembanas
- Division of Newborn Medicine, Boston Children's Hospital and Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical CareHannover Medical SchoolHannoverGermany
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26
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Kheyfets VO, Sweatt AJ, Gomberg-Maitland M, Ivy DD, Condliffe R, Kiely DG, Lawrie A, Maron BA, Zamanian RT, Stenmark KR. Computational platform for doctor-artificial intelligence cooperation in pulmonary arterial hypertension prognostication: a pilot study. ERJ Open Res 2023; 9:00484-2022. [PMID: 36776484 PMCID: PMC9907150 DOI: 10.1183/23120541.00484-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a heterogeneous and complex pulmonary vascular disease associated with substantial morbidity. Machine-learning algorithms (used in many PAH risk calculators) can combine established parameters with thousands of circulating biomarkers to optimise PAH prognostication, but these approaches do not offer the clinician insight into what parameters drove the prognosis. The approach proposed in this study diverges from other contemporary phenotyping methods by identifying patient-specific parameters driving clinical risk. Methods We trained a random forest algorithm to predict 4-year survival risk in a cohort of 167 adult PAH patients evaluated at Stanford University, with 20% withheld for (internal) validation. Another cohort of 38 patients from Sheffield University were used as a secondary (external) validation. Shapley values, borrowed from game theory, were computed to rank the input parameters based on their importance to the predicted risk score for the entire trained random forest model (global importance) and for an individual patient (local importance). Results Between the internal and external validation cohorts, the random forest model predicted 4-year risk of death/transplant with sensitivity and specificity of 71.0-100% and 81.0-89.0%, respectively. The model reinforced the importance of established prognostic markers, but also identified novel inflammatory biomarkers that predict risk in some PAH patients. Conclusion These results stress the need for advancing individualised phenotyping strategies that integrate clinical and biochemical data with outcome. The computational platform presented in this study offers a critical step towards personalised medicine in which a clinician can interpret an algorithm's assessment of an individual patient.
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Affiliation(s)
- Vitaly O. Kheyfets
- Paediatric Critical Care Medicine, Developmental Lung Biology and CVP Research Laboratories, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Andrew J. Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, USA
| | | | - Dunbar D. Ivy
- Department of Paediatric Cardiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in-silico Medicine, University of Sheffield, Sheffield, UK
| | - Allan Lawrie
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for in-silico Medicine, University of Sheffield, Sheffield, UK
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Roham T. Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, USA
| | - Kurt R. Stenmark
- Paediatric Critical Care Medicine, Developmental Lung Biology and CVP Research Laboratories, School of Medicine, University of Colorado, Aurora, CO, USA
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27
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Benincasa G, Maron BA, Affinito O, D’Alto M, Franzese M, Argiento P, Schiano C, Romeo E, Bontempo P, Golino P, Berrino L, Loscalzo J, Napoli C. Association Between Circulating CD4 + T Cell Methylation Signatures of Network-Oriented SOCS3 Gene and Hemodynamics in Patients Suffering Pulmonary Arterial Hypertension. J Cardiovasc Transl Res 2023; 16:17-30. [PMID: 35960497 PMCID: PMC9944731 DOI: 10.1007/s12265-022-10294-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/19/2022] [Indexed: 02/06/2023]
Abstract
Pathogenic DNA methylation changes may be involved in pulmonary arterial hypertension (PAH) onset and its progression, but there is no data on potential associations with patient-derived hemodynamic parameters. The reduced representation bisulfite sequencing (RRBS) platform identified N = 631 differentially methylated CpG sites which annotated to N = 408 genes (DMGs) in circulating CD4+ T cells isolated from PAH patients vs. healthy controls (CTRLs). A promoter-restricted network analysis established the PAH subnetwork that included 5 hub DMGs (SOCS3, GNAS, ITGAL, NCOR2, NFIC) and 5 non-hub DMGs (NR4A2, GRM2, PGK1, STMN1, LIMS2). The functional analysis revealed that the SOCS3 gene was the most recurrent among the top ten significant pathways enriching the PAH subnetwork, including the growth hormone receptor and the interleukin-6 signaling. Correlation analysis showed that the promoter methylation levels of each network-oriented DMG were associated individually with hemodynamic parameters. In particular, SOCS3 hypomethylation was negatively associated with right atrial pressure (RAP) and positively associated with cardiac index (CI) (|r|≥ 0.6). A significant upregulation of the SOCS3, ITGAL, NFIC, NCOR2, and PGK1 mRNA levels (qRT-PCR) in peripheral blood mononuclear cells from PAH patients vs. CTRLs was found (P ≤ 0.05). By immunoblotting, a significant upregulation of the SOCS3 protein was confirmed in PAH patients vs. CTRLs (P < 0.01). This is the first network-oriented study which integrates circulating CD4+ T cell DNA methylation signatures, hemodynamic parameters, and validation experiments in PAH patients at first diagnosis or early follow-up. Our data suggests that SOCS3 gene might be involved in PAH pathogenesis and serve as potential prognostic biomarker.
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Affiliation(s)
- Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, MB Boston, USA ,Harvard Medical School, Boston, MA USA
| | | | - Michele D’Alto
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | | | - Paola Argiento
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Concetta Schiano
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paola Bontempo
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paolo Golino
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Liberato Berrino
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, MB Boston, USA
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy ,IRCCS SDN, Naples, Italy
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Maron BA, Wang RS, Shevtsov S, Drakos SG, Arons E, Wever-Pinzon O, Huggins GS, Samokhin AO, Oldham WM, Aguib Y, Yacoub MH, Rowin EJ, Maron BJ, Maron MS, Loscalzo J. Author Correction: Individualized interactomes for network-based precision medicine in hypertrophic cardiomyopathy with implications for other clinical pathophenotypes. Nat Commun 2022; 13:7026. [PMID: 36396654 PMCID: PMC9672304 DOI: 10.1038/s41467-022-34834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
PURPOSE OF REVIEW The right ventricle (RV) and left ventricle (LV) have different developmental origins, which likely plays a role in their chamber-specific response to physiological and pathological stress. RV dysfunction is encountered frequently in patients with congenital heart disease (CHD) and right heart abnormalities emerge from different causes than increased afterload alone as is observed in RV dysfunction due to pulmonary hypertension (PH). In this review, we describe the developmental, structural, and functional differences between ventricles while highlighting emerging therapies for RV dysfunction. RECENT FINDINGS There are new insights into the role of fibrosis, inflammation, myocyte contraction, and mitochondrial dynamics in the pathogenesis of RV dysfunction. We discuss the current state of therapies that may potentially improve RV function in both experimental and clinical trials. A clearer understanding of the differences in molecular alterations in the RV compared to the LV may allow for the development of better therapies that treat RV dysfunction.
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Affiliation(s)
- Matthew R. Lippmann
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 77 Ave. Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 77 Ave. Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA,Department of Cardiology, VA Boston Healthcare System, West Roxbury, MA, USA
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30
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Gillmeyer KR, Rinne ST, Qian SX, Maron BA, Johnson SW, Klings ES, Wiener RS. Socioeconomically disadvantaged veterans experience treatment delays for pulmonary arterial hypertension. Pulm Circ 2022; 12:e12171. [PMID: 36568691 PMCID: PMC9768567 DOI: 10.1002/pul2.12171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/09/2022] Open
Abstract
Prompt initiation of therapy after pulmonary arterial hypertension (PAH) diagnosis is critical to improve outcomes; yet delays in PAH treatment are common. Prior research demonstrates that individuals with PAH belonging to socially disadvantaged groups experience worse clinical outcomes. Whether these poor outcomes are mediated by delays in care or other factors is incompletely understood. We sought to examine the association between race/ethnicity and socioeconomic status and time-to-PAH treatment. We conducted a retrospective cohort study of Veterans diagnosed with incident PAH between 2006 and 2019 and treated with PAH therapy. Our outcome was time-to-PAH treatment. Our primary exposures were race/ethnicity, annual household income, health insurance status, education, and housing insecurity. We calculated time-to-treatment using multivariable mixed-effects Cox proportional hazard models. Of 1827 Veterans with PAH, 27% were Black, 4% were Hispanic, 22.1% had an income < $20,000, 53.3% lacked non-VA insurance, 25.5% had <high school education, and 3.9% had housing insecurity. Median time-to-treatment was 114 days (interquartile range [IQR] 21-336). Our multivariable models demonstrated increased time-to-treatment among patients with lower household income (hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.60-0.91 for < $20,000 vs. ≥ $100,000) and those without non-VA insurance (HR 0.90, 95% CI 0.82-1.00). Race/ethnicity, education, and housing insecurity were not associated with time-to-treatment. Veterans with PAH experienced substantial and potentially harmful treatment delays, with median time-to-treatment of 16 weeks after diagnosis. Those with lower income and those without non-VA health insurance experienced even greater treatment delays. Additional research is urgently needed to develop interventions to improve timely PAH treatment and mitigate economic disparities in treatment.
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Affiliation(s)
- Kari R. Gillmeyer
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA,Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
| | - Seppo T. Rinne
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA,Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
| | - Shirley X. Qian
- Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA,VA Boston Healthcare SystemBostonMassachusettsUSA
| | - Bradley A. Maron
- Department of CardiologyVA Boston Healthcare SystemBostonMassachusettsUSA,Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Shelsey W. Johnson
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA,Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
| | - Elizabeth S. Klings
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Renda S. Wiener
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA,Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
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Maron BA, Wang RS, Carnethon MR, Rowin EJ, Loscalzo J, Maron BJ, Maron MS. What Causes Hypertrophic Cardiomyopathy? Am J Cardiol 2022; 179:74-82. [PMID: 35843734 DOI: 10.1016/j.amjcard.2022.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 01/11/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a global and relatively common cause of patient morbidity and mortality and is among the first reported monogenic cardiac diseases. For 30 years, the basic etiology of HCM has been attributed largely to variants in individual genes encoding cardiac sarcomere proteins, with the implication that HCM is fundamentally a genetic disease. However, data from clinical and network medicine analyses, as well as contemporary genetic studies show that single gene variants do not fully explain the broad and diverse HCM clinical spectrum. These transformative advances place a new focus on possible novel interactions between acquired disease determinants and genetic context to produce complex HCM phenotypes, also offering a measure of caution against overemphasizing monogenics as the principal cause of this disease. These new perspectives in which HCM is not a uniformly genetic disease but likely explained by multifactorial etiology will also unavoidably impact how HCM is viewed by patients and families in the clinical practicing community going forward, including relevance to genetic counseling and access to healthcare insurance and psychosocial wellness.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine and Harvard Medical School, Boston, Massachusetts.
| | - Rui-Sheng Wang
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mercedes R Carnethon
- Division of Pulmonology and Critical Care, Feinberg School of Medicine, Chicago, Illinois
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine and Harvard Medical School, Boston, Massachusetts
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Brittain EL, Thenappan T, Huston JH, Agrawal V, Lai YC, Dixon D, Ryan JJ, Lewis EF, Redfield MM, Shah SJ, Maron BA. Elucidating the Clinical Implications and Pathophysiology of Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction: A Call to Action: A Science Advisory From the American Heart Association. Circulation 2022; 146:e73-e88. [PMID: 35862198 PMCID: PMC9901193 DOI: 10.1161/cir.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This science advisory focuses on the need to better understand the epidemiology, pathophysiology, and treatment of pulmonary hypertension in patients with heart failure with preserved ejection fraction. This clinical phenotype is important because it is common, is strongly associated with adverse outcomes, and lacks evidence-based therapies. Our goal is to clarify key knowledge gaps in pulmonary hypertension attributable to heart failure with preserved ejection fraction and to suggest specific, actionable scientific directions for addressing such gaps. Areas in need of additional investigation include refined disease definitions and interpretation of hemodynamics, as well as greater insights into noncardiac contributors to pulmonary hypertension risk, optimized animal models, and further molecular studies in patients with combined precapillary and postcapillary pulmonary hypertension. We highlight translational approaches that may provide important biological insight into pathophysiology and reveal new therapeutic targets. Last, we discuss the current and future landscape of potential therapies for patients with heart failure with preserved ejection fraction and pulmonary vascular dysfunction, including considerations of precision medicine, novel trial design, and device-based therapies, among other considerations. This science advisory provides a synthesis of important knowledge gaps, culminating in a collection of specific research priorities that we argue warrant investment from the scientific community.
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Hemnes AR, Leopold JA, Radeva MK, Beck GJ, Abidov A, Aldred MA, Barnard J, Rosenzweig EB, Borlaug BA, Chung WK, Comhair SAA, Desai AA, Dubrock HM, Erzurum SC, Finet JE, Frantz RP, Garcia JGN, Geraci MW, Gray MP, Grunig G, Hassoun PM, Highland KB, Hill NS, Hu B, Kwon DH, Jacob MS, Jellis CL, Larive AB, Lempel JK, Maron BA, Mathai SC, McCarthy K, Mehra R, Nawabit R, Newman JH, Olman MA, Park MM, Ramos JA, Renapurkar RD, Rischard FP, Sherer SG, Tang WHW, Thomas JD, Vanderpool RR, Waxman AB, Wilcox JD, Yuan JXJ, Horn EM. Clinical Characteristics and Transplant-Free Survival Across the Spectrum of Pulmonary Vascular Disease. J Am Coll Cardiol 2022; 80:697-718. [PMID: 35953136 PMCID: PMC9897285 DOI: 10.1016/j.jacc.2022.05.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/05/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND PVDOMICS (Pulmonary Vascular Disease Phenomics) is a precision medicine initiative to characterize pulmonary vascular disease (PVD) using deep phenotyping. PVDOMICS tests the hypothesis that integration of clinical metrics with omic measures will enhance understanding of PVD and facilitate an updated PVD classification. OBJECTIVES The purpose of this study was to describe clinical characteristics and transplant-free survival in the PVDOMICS cohort. METHODS Subjects with World Symposium Pulmonary Hypertension (WSPH) group 1-5 PH, disease comparators with similar underlying diseases and mild or no PH and healthy control subjects enrolled in a cross-sectional study. PH groups, comparators were compared using standard statistical tests including log-rank tests for comparing time to transplant or death. RESULTS A total of 1,193 subjects were included. Multiple WSPH groups were identified in 38.9% of PH subjects. Nocturnal desaturation was more frequently observed in groups 1, 3, and 4 PH vs comparators. A total of 50.2% of group 1 PH subjects had ground glass opacities on chest computed tomography. Diffusing capacity for carbon monoxide was significantly lower in groups 1-3 PH than their respective comparators. Right atrial volume index was higher in WSPH groups 1-4 than comparators. A total of 110 participants had a mean pulmonary artery pressure of 21-24 mm Hg. Transplant-free survival was poorest in group 3 PH. CONCLUSIONS PVDOMICS enrolled subjects across the spectrum of PVD, including mild and mixed etiology PH. Novel findings include low diffusing capacity for carbon monoxide and enlarged right atrial volume index as shared features of groups 1-3 and 1-4 PH, respectively; unexpected, frequent presence of ground glass opacities on computed tomography; and sleep alterations in group 1 PH, and poorest survival in group 3 PH. PVDOMICS will facilitate a new understanding of PVD and refine the current PVD classification. (Pulmonary Vascular Disease Phenomics Program PVDOMICS [PVDOMICS]; NCT02980887).
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Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Milena K Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aiden Abidov
- Division of Cardiology, Wayne State University, Detroit, Michigan, USA
| | - Micheala A Aldred
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Barnard
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erika B Rosenzweig
- Department of Pediatrics and Medicine, Columbia University, New York, New York, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University, New York, New York, USA
| | - Suzy A A Comhair
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ankit A Desai
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hilary M Dubrock
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Serpil C Erzurum
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J Emanuel Finet
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joe G N Garcia
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mark W Geraci
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael P Gray
- Department of Cardiology, The University of Sydney, Sydney, New South Wales, Australia
| | - Gabriele Grunig
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miriam S Jacob
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine L Jellis
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - A Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jason K Lempel
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Reena Mehra
- Neurologic and Respiratory Institutes, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rawan Nawabit
- Pediatrics Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Newman
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mitchell A Olman
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | - Margaret M Park
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose A Ramos
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Franz P Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, Arizona, USA
| | - Susan G Sherer
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - James D Thomas
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Illinois, USA
| | - Rebecca R Vanderpool
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer D Wilcox
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic Cleveland, Ohio, USA
| | - Jason X-J Yuan
- Department of Medicine, University of California, San Diego, California, USA
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
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Johnson SW, Finlay L, Mathai SC, Goldstein RH, Maron BA. Real-world use of inhaled treprostinil for lung disease-pulmonary hypertension: A protocol for patient evaluation and prescribing. Pulm Circ 2022; 12:e12126. [PMID: 36092795 PMCID: PMC9450844 DOI: 10.1002/pul2.12126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/08/2022] Open
Abstract
Inhaled treprostinil was approved recently for interstitial lung disease-pulmonary hypertension; however, efficacy in "real-world" populations is not known. We designed a protocol and report our experience evaluating 10 patients referred for therapy. Misdiagnosis at presentation was common; ultimately, three patients (30%) were prescribed drug. This protocol offers an opportunity to standardize longitudinal assessment of inhaled treprostinil in clinical practice.
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Affiliation(s)
- Shelsey W. Johnson
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical CareBoston University School of MedicineBostonMassachusettsUSA
| | - Lauren Finlay
- Department of PharmacyVA Boston Healthcare SystemBostonMassachusettsUSA
| | - Stephen C. Mathai
- Department of Pulmonary and Critical Care MedicineJohns Hopkins University, and Johns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Ronald H. Goldstein
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical CareBoston University School of MedicineBostonMassachusettsUSA
| | - Bradley A. Maron
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,Division of Cardiovascular MedicineBrigham and Women's Hospital, and Harvard Medical SchoolBostonMassachusettsUSA
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School and the Department of Cardiology, VA Boston Healthcare System, Boston, MA, USA
| | - Marc Humbert
- Université Paris-Saclay, INSERM UMR_S 999, AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Abstract
Pulmonary hypertension is a complex disease with multiple causes, corresponding to phenotypic heterogeneity and variable therapeutic responses. Advancing understanding of pulmonary hypertension pathogenesis is likely to hinge on integrated methods that leverage data from health records, imaging, novel molecular -omics profiling, and other modalities. In this review, we summarize key data sets generated thus far in the field and describe analytical methods that hold promise for deciphering the molecular mechanisms that underpin pulmonary vascular remodeling, including machine learning, network medicine, and functional genetics. We also detail how genetic and subphenotyping approaches enable earlier diagnosis, refined prognostication, and optimized treatment prediction. We propose strategies that identify functionally important molecular pathways, bolstered by findings across multi-omics platforms, which are well-positioned to individualize drug therapy selection and advance precision medicine in this highly morbid disease.
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Affiliation(s)
- Christopher J Rhodes
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Andrew J Sweatt
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.M.).,Division of Cardiology, VA Boston Healthcare System, West Roxbury, MA (B.A.M.)
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Alba GA, Samokhin AO, Wang R, Wertheim BM, Haley KJ, Padera RF, Vargas SO, Rosas IO, Hariri LP, Shih A, Thompson BT, Mitchell RN, Maron BA. Pulmonary endothelial NEDD9 and the prothrombotic pathophenotype of acute respiratory distress syndrome due to SARS-CoV-2 infection. Pulm Circ 2022; 12:e12071. [PMID: 35599981 PMCID: PMC9111030 DOI: 10.1002/pul2.12071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022] Open
Abstract
The pathobiology of in situ pulmonary thrombosis in acute respiratory distress syndrome (ARDS) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is incompletely characterized. In human pulmonary artery endothelial cells (HPAECs), hypoxia increases neural precursor cell expressed, developmentally downregulated 9 (NEDD9) and induces expression of a prothrombotic NEDD9 peptide (N9P) on the extracellular plasma membrane surface. We hypothesized that the SARS-CoV-2-ARDS pathophenotype involves increased pulmonary endothelial N9P. Paraffin-embedded autopsy lung specimens were acquired from patients with SARS-CoV-2-ARDS (n = 13), ARDS from other causes (n = 10), and organ donor controls (n = 5). Immunofluorescence characterized the expression of N9P, fibrin, and transcription factor 12 (TCF12), a putative binding target of SARS-CoV-2 and known transcriptional regulator of NEDD9. We performed RNA-sequencing on normal HPAECs treated with normoxia or hypoxia (0.2% O2) for 24 h. Immunoprecipitation-liquid chromatography-mass spectrometry (IP-LC-MS) profiled protein-protein interactions involving N9P relevant to thrombus stabilization. Hypoxia increased TCF12 messenger RNA significantly compared to normoxia in HPAECs in vitro (+1.19-fold, p = 0.001; false discovery rate = 0.005), and pulmonary endothelial TCF12 expression was increased threefold in SARS-CoV-2-ARDS versus donor control lungs (p < 0.001). Compared to donor controls, pulmonary endothelial N9P-fibrin colocalization was increased in situ in non-SARS-CoV-2-ARDS and SARS-CoV-2-ARDS decedents (3.7 ± 1.2 vs. 10.3 ± 3.2 and 21.8 ± 4.0 arb. units, p < 0.001). However, total pulmonary endothelial N9P was increased significantly only in SARS-CoV-2-ARDS versus donor controls (15 ± 4.2 vs. 6.3 ± 0.9 arb. units, p < 0.001). In HPAEC plasma membrane isolates, IP-LC-MS identified a novel protein-protein interaction between NEDD9 and the β3-subunit of the αvβ3-integrin, which regulates fibrin anchoring to endothelial cells. In conclusion, lethal SARS-CoV-2-ARDS is associated with increased pulmonary endothelial N9P expression and N9P-fibrin colocalization in situ. Further investigation is needed to determine the pathogenetic and potential therapeutic relevance of N9P to the thrombotic pathophenotype of SARS-CoV-2-ARDS.
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Affiliation(s)
- George A. Alba
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Andriy O. Samokhin
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Rui‐Sheng Wang
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Bradley M. Wertheim
- Division of Pulmonary and Critical Care MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Kathleen J. Haley
- Division of Pulmonary and Critical Care MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Robert F. Padera
- Department of PathologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Sara O. Vargas
- Department of PathologyBoston Children's HospitalBostonMassachusettsUSA
| | - Ivan O. Rosas
- Division of Pulmonary and Critical Care MedicineBaylor College of MedicineHoustonTexasUSA
| | - Lida P. Hariri
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of PathologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Angela Shih
- Department of PathologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Boyd Taylor Thompson
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | | | - Bradley A. Maron
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
| | - Marc Humbert
- Université Paris-Saclay, INSERM, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
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Zeder K, Banfi C, Steinrisser-Allex G, Maron BA, Humbert M, Lewis GD, Berghold A, Olschewski H, Kovacs G. Diagnostic, prognostic and differential-diagnostic relevance of pulmonary hemodynamics during exercise - a systematic review. Eur Respir J 2022; 60:13993003.03181-2021. [PMID: 35332069 PMCID: PMC9556812 DOI: 10.1183/13993003.03181-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/17/2022] [Indexed: 11/05/2022]
Abstract
The cardiopulmonary hemodynamic profile observed during exercise may identify patients with early stage pulmonary vascular and primary cardiac diseases, and is used clinically to inform prognosis. However, a standardised approach to interpreting hemodynamics is lacking.We performed a systematic literature search according to PRISMA guidelines to identify parameters that may be diagnostic for an abnormal hemodynamic response to exercise and offer optimal prognostic and differential-diagnostic value. We performed random-effects-meta-analyses of the normal values and reported effect sizes as weighted means and standard deviations (sd). Results of diagnostic and prognostic studies are reported descriptively.We identified n=45 eligible studies with n=5598 subjects. The mean pulmonary arterial pressure (mPAP)/cardiac output (CO) slope, pulmonary arterial wedge pressure (PAWP)/CO slope and peak cardiac index (or CO) provided the most consistent prognostic hemodynamic parameters during exercise. The best cut-offs for survival and cardiovascular events were mPAP/CO slope>3 Wood units (WU) and PAWP/CO slope>2 WU. A PAWP/CO slope cut-off>2 WU best differentiated pre- from post-capillary causes of PAP elevation during exercise. Upper limits of normal (defined as mean+2 sd) for the mPAP/CO and PAWP/CO slopes were strongly age-dependent and ranged in 30-to 70-year old healthy subjects from 1.6 to 3.3 WU and 0.6 to 1.8 WU, respectively.Increased mPAP/CO slope during exercise is associated with impaired survival and an independent, prognostically relevant cut-off>3 WU has been validated. A PAWP/CO slope>2 WU may be suitable for the differentiation between pre- and post-capillary causes of PAP increase during exercise.
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Affiliation(s)
- Katarina Zeder
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Chiara Banfi
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | | | - Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc Humbert
- University Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Gregory D Lewis
- Division of Cardiology and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria .,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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Johnson SW, Maron BA. COUNTERPOINT: Did the World Symposium on Pulmonary Hypertension Get It Right in Redefining Abnormal Pulmonary Arterial Pressure? No. Chest 2022; 161:313-315. [DOI: 10.1016/j.chest.2021.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/11/2021] [Indexed: 10/19/2022] Open
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Johnson SW, Maron BA. Rebuttal From Drs Johnson and Maron. Chest 2022; 161:316-317. [DOI: 10.1016/j.chest.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/11/2021] [Indexed: 11/25/2022] Open
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Kovacs G, Maron BA. The assessment of pulmonary arterial pressure and its clinical relevance: a 100-year journey from Europe, over the United States to Australia. Eur Respir J 2022; 59:59/1/2102064. [PMID: 34972686 DOI: 10.1183/13993003.02064-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria .,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Maron BA, Choudhary G, Goldstein RL, Garshick E, Jankowich M, Tucker TJS, LaCerda KA, Hattler B, Dempsey EC, Sadikot RT, Shapiro S, Rounds SI, Goldstein RH. Tadalafil for veterans with chronic obstructive pulmonary disease-pulmonary hypertension: A multicenter, placebo-controlled randomized trial. Pulm Circ 2022; 12:e12043. [PMID: 35506072 PMCID: PMC9053004 DOI: 10.1002/pul2.12043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022] Open
Abstract
Treating Veterans with chronic obstructive pulmonary disease complicated by pulmonary hypertension (COPD-PH) using phosphodiesterase type-5 inhibitor pharmacotherapy is common, but efficacy data are lacking. To address this further, patients with COPD-PH from five Department of Veterans Affairs hospitals were randomized (1∶1) to receive placebo or oral tadalafil (40 mg/day) for 12 months. The primary endpoint was changed from baseline in 6-min walk distance at 12 months. Secondary endpoints included change from baseline in pulmonary vascular resistance, mean pulmonary artery pressure, and symptom burden by the University of California San Diego shortness of breath questionnaire scale at 6 months. A total of 42 subjects (all male; 68 ± 7.6 years old) were randomized to placebo (N = 14) or tadalafil (N = 28). The group imbalance was related to under-enrollment. Compared to placebo, no significant difference was observed in the tadalafil group for change from the primary endpoint or change in mean pulmonary artery pressure or pulmonary vascular resistance from baseline at 6 months. A clinically meaningful improvement was observed in the secondary endpoint of shortness of breath questionnaire score in the tadalafil versus placebo group at 6 months. There was no significant difference in major adverse events between treatment groups, and tadalafil was well tolerated overall. For Veterans with COPD-PH enrolled in this study, once-daily treatment with tadalafil did not improve 6-min walk distance or cardiopulmonary hemodynamics although a decrease in shortness of breath was observed. Under-enrollment and imbalanced randomization confound interpreting conclusions from this clinical trial and limit the generalization of our findings.
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Affiliation(s)
- Bradley A. Maron
- Department of Medicine, Section of Cardiology and Division of Pulmonary, Allergy, Sleep, and Critical Care MedicineVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Division of Cardiovascular MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Gaurav Choudhary
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Rebekah L. Goldstein
- Research and Development ServiceVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Eric Garshick
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Jankowich
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Troo J. S. Tucker
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Kathleen A. LaCerda
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Brack Hattler
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
| | - Edward C. Dempsey
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
- Pulmonary Sciences and Critical Care Medicine SectionUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Ruxana T. Sadikot
- Department of MedicineAtlanta Veterans Affairs Medical CenterDecaturGeorgiaUSA
| | - Shelley Shapiro
- Department of Cardiology, Cardiology Section Greater Los AngelesVA Healthcare SystemLos AngelesCaliforniaUSA
- Division of Pulmonary Critical CareDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Sharon I. Rounds
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Ronald H. Goldstein
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Department of MedicineBoston University School of MedicineBostonMassachusettsUSA
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44
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Gong J, Castro RRT, Caron JP, Bay CP, Hainer J, Opotowsky AR, Mehra MR, Maron BA, Di Carli MF, Groarke JD, Nohria A. Usefulness of ventilatory inefficiency in predicting prognosis across the heart failure spectrum. ESC Heart Fail 2021; 9:293-302. [PMID: 34931762 PMCID: PMC8788025 DOI: 10.1002/ehf2.13761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/04/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
Aims The minute ventilation–carbon dioxide production relationship (VE/VCO2 slope) is widely used for prognostication in heart failure (HF) with reduced left ventricular ejection fraction (LVEF). This study explored the prognostic value of VE/VCO2 slope across the spectrum of HF defined by ranges of LVEF. Methods and results In this single‐centre retrospective observational study of 1347 patients with HF referred for cardiopulmonary exercise testing, patients with HF were categorized into HF with reduced (HFrEF, LVEF < 40%, n = 598), mid‐range (HFmrEF, 40% ≤ LVEF < 50%, n = 164), and preserved (HFpEF, LVEF ≥ 50%, n = 585) LVEF. Four ventilatory efficiency categories (VC) were defined: VC‐I, VE/VCO2 slope ≤ 29; VC‐II, 29 < VE/VCO2 slope < 36; VC‐III, 36 ≤ VE/VCO2 slope < 45; and VC‐IV, VE/VCO2 slope ≥ 45. The associations of these VE/VCO2 slope categories with a composite outcome of all‐cause mortality or HF hospitalization were evaluated for each category of LVEF. Over a median follow‐up of 2.0 (interquartile range: 1.9, 2.0) years, 201 patients experienced the composite outcome. Compared with patients in VC‐I, those in VC‐II, III, and IV demonstrated three‐fold, five‐fold, and eight‐fold increased risk for the composite outcome. This incremental risk was observed across HFrEF, HFmrEF, and HFpEF cohorts. Conclusions Higher VE/VCO2 slope is associated with incremental risk of 2 year all‐cause mortality and HF hospitalization across the spectrum of HF defined by LVEF. A multilevel categorical approach to the interpretation of VE/VCO2 slope may offer more refined risk stratification than the current binary approach employed in clinical practice.
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Affiliation(s)
- Jingyi Gong
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Renata R T Castro
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jesse P Caron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Camden P Bay
- Brigham and Women's Hospital Center for Clinical Investigation, Boston, MA, USA
| | - Jon Hainer
- Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alexander R Opotowsky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Marcelo F Di Carli
- Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - John D Groarke
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
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Abstract
It is important for both the patient and physician communities to have timely access to information recognizing rapid progress in the diagnosis and treatment of familiar but relatively uncommon cardiovascular diseases. Patients with 3 cardiovascular diseases (ie, hypertrophic cardiomyopathy, pulmonary arterial hypertension, and transthyretin (TTR) cardiac amyloidosis (ATTR)]), once considered rare without effective management options and associated with malignant prognosis, have now benefited substantially from the development of a variety of innovative therapeutic strategies. In addition, in each case, enhanced diagnostic testing has expanded the patient population and allowed for more widespread administration of contemporary treatments. In hypertrophic cardiomyopathy, introduction of implantable defibrillators to prevent sudden death as well as high-benefit:low-risk septal reduction therapies to reverse heart failure have substantially reduced morbidity and disease-related mortality (to 0.5% per year). For pulmonary arterial hypertension, a disease once characterized by a particularly grim prognosis, prospective randomized drug trials with aggressive single (or combined) pharmacotherapy have measurably improved survival and quality of life for many patients. In cardiac amyloidosis, development of disease-specific drugs can for the first time reduce morbidity and mortality, prominently with breakthrough ATTR-protein-stabilizing tafamidis. In conclusion, in less common and visible cardiovascular diseases, it is crucial to recognize substantial progress and achievement, given that penetration of such information into clinical practice and the patient community can be inconsistent. Diseases such as hypertrophic cardiomyopathy, pulmonary arterial hypertension, and ATTR cardiac amyloidosis, once linked to a uniformly adverse prognosis, are now associated with the opportunity for patients to experience satisfactory quality of life and extended longevity.
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Affiliation(s)
- Barry J Maron
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Martin S Maron
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Mathew S Maurer
- Cardiac Amyloidosis Center Columbia University Irving Medical CenterNew York-Presbyterian Hospital New York NY
| | - Ethan J Rowin
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Bradley A Maron
- Division of Cardiovascular Medicine Brigham & Women's Hospital and Harvard Medical School Boston MA
| | - Nazzareno Galiè
- Alma Mater Studiorum University of Bologna Bologna Italy.,S. Orsola University Hospital Bologna Italy
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47
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Benincasa G, Maron BA, Affinito O, D'Alto M, Franzese M, Argiento P, Schiano C, Romeo E, Bontempo P, Golino P, Berrino L, Loscalzo J, Napoli C. Circulating CD4+T/methylation signatures of network-oriented SOCS3, ITGAL, NFIC, NCOR2, PGK1 genes associate with hemodynamics in pulmonary arterial hypertension patients. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
CD4+ T cells are associated with pulmonary arterial hypertension (PAH) pathogenesis but mechanistic insights are limited.
Purpose
To identify differential CD4+ T methylation signatures in healthy controls vs PAH and evaluate a putative association with the cardiopulmonary hemodynamic profile of affected patients.
Methods
We used RRBS platform to profile CD4+ T DNA methylome in the CLEOPAHTRA clinical trial.
Results
Differentially methylated CpG sites (N=631) annotated to N=408 genes (DMGs). Most of them (65%) were hypermethylated and localized in distal intergenic (36%) and promoter regions (31%). Promoter-related network analysis established the PAH subnetwork highlighting 5 hub DMGs (SOCS3, GNAS, ITGAL, NCOR2, NFIC) and 5 non-hub DMGs (NR4A2, GRM2, PGK1, STMN1, LIMS2) as potential candidate genes (Figure 1). The Infinium Human MethylationEPIC BeadChip on CD4+ T cells from an independent study population confirmed the global RRBS-methylation trends. Both in idiopathic and Associated-PAH, each of these 10 network-oriented DMGs was strongly correlated with at least one hemodynamic parameter such as right atrial pressure (RAP), cardiac index (CI), mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and pulmonary capillary wedge pressure (PCWP) (Figure 2). In addition, mRNA levels of the ITGAL, NFIC, NCOR2, PGK1 genes and the IL-6-STAT3-SOCS3 signaling axis were significantly upregulated in PBMCs from patients with PAH vs controls suggesting putative drug targets. Furthermore, both SOCS3 methylation and mRNA levels were positively correlated with cardiac index (CI) in idiopathic PAH whereas both PGK1 methylation and mRNA levels were positively correlated with RAP and inversely with CI in Associated PAH suggesting putative non-invasive biomarkers.
Conclusions
This hypothesis-generating study shows for the first time that circulating CD4+ T methylation signatures, inclusive of SOCS3, ITGAL, NFIC, NCOR2, and PGK1 genes may yield insight into pro-inflammatory mechanisms that exacerbate vascular remodeling in PAH and suggest non-invasive biomarkers to optimize patient phenotyping and, possibly, prognostication in PAH.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PRIN2017F8ZB89 from Italian Ministry of University and Research (MIUR) (PI Prof Napoli) and Ricerca Corrente (RC) 2019 from Italian Ministry of Health (PI Prof. Napoli). Figure 1Figure 2
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Affiliation(s)
- G Benincasa
- University of Campania “L. Vanvitelli”, Naples, Italy
| | - B A Maron
- Brigham and Women's Hospital, Division of Cardiovascular Medicine, Department of Medicine, Boston, United States of America
| | | | - M D'Alto
- AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy
| | | | - P Argiento
- AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy
| | - C Schiano
- University of Campania “L. Vanvitelli”, Naples, Italy
| | - E Romeo
- AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy
| | - P Bontempo
- University of Campania “L. Vanvitelli”, Naples, Italy
| | - P Golino
- AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy
| | - L Berrino
- University of Campania “L. Vanvitelli”, Naples, Italy
| | - J Loscalzo
- Brigham and Women's Hospital, Division of Cardiovascular Medicine, Department of Medicine, Boston, United States of America
| | - C Napoli
- University of Campania “L. Vanvitelli”, Naples, Italy
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48
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Zeder K, Avian A, Bachmaier G, Douschan P, Foris V, Sassmann T, Troester N, Brcic L, Fuchsjaeger M, Marsh LM, Maron BA, Olschewski H, Kovacs G. Elevated pulmonary vascular resistance predicts mortality in COPD patients. Eur Respir J 2021; 58:13993003.00944-2021. [PMID: 33986032 DOI: 10.1183/13993003.00944-2021] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/14/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Katarina Zeder
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Philipp Douschan
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Teresa Sassmann
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Natascha Troester
- Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Luka Brcic
- Dept of Pathology, Medical University of Graz, Graz, Austria
| | | | | | - Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria .,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
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Alba GA, Atri D, Darbha S, Singh I, Tapson VF, Lewis MI, Chun HJ, Yu YR, Maron BA, Rajagopal S. Chronic Thromboembolic Pulmonary Hypertension: the Bench. Curr Cardiol Rep 2021; 23:141. [PMID: 34410515 DOI: 10.1007/s11886-021-01572-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary embolism (PE), in which the red, platelet-rich thrombus does not resolve but forms into an organized yellow, fibrotic scar-like obstruction in the pulmonary vasculature. Here we review the pathobiology of CTEPH. RECENT FINDINGS Our current knowledge has predominantly been informed by studies of human samples and animal models that are inherently limited in their ability to recapitulate all aspects of the disease. These studies have identified alterations in platelet biology and inflammation in the formation of a scar-like thrombus that comprised endothelial cells, myofibroblasts, and immune cells, along with a small vessel pulmonary arterial hypertension-like vasculopathy. The development of CTEPH-specific therapies is currently hindered by a limited knowledge of its pathobiology. The development of new CTEPH medical therapies will require new insights into its pathobiology that bridge the gap from bench to bedside.
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Affiliation(s)
- George A Alba
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Deepak Atri
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sriranjani Darbha
- College of Natural Sciences, The University of Texas, Austin, TX, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael I Lewis
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hyung J Chun
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Yen-Rei Yu
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Section of Cardiology, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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50
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Oldham WM, Hess E, Waldo SW, Humbert M, Choudhary G, Maron BA. Integrating haemodynamics identifies an extreme pulmonary hypertension phenotype. Eur Respir J 2021; 58:13993003.04625-2020. [PMID: 33833034 DOI: 10.1183/13993003.04625-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/27/2021] [Indexed: 11/05/2022]
Affiliation(s)
- William M Oldham
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward Hess
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | | | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center and Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Dept of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,Veterans Affairs Boston Healthcare System, Boston, MA, USA
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