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Alabed S, Karunasaagarar K, Alandejani F, Garg P, Uthoff J, Metherall P, Sharkey M, Lu H, Wild JM, Kiely DG, Van Der Geest RJ, Swift AJ. High interstudy repeatability of automatic deep learnt biventricular CMR measurements. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.035] [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: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Wellcome Trust (UK), NIHR (UK)
Introduction
Cardiac magnetic resonance (CMR) measurements have significant diagnostic and prognostic value. Accurate and repeatable measurements are essential to assess disease severity, evaluate therapy response and monitor disease progression. Deep learning approaches have shown promise for automatic left ventricular (LV) segmentation on CMR, however fully automatic right ventricular (RV) segmentation remains challenging. We aimed to develop a biventricular automatic contouring model and evaluate the interstudy repeatability of the model in a prospectively recruited cohort.
Methods
A deep learning CMR contouring model was developed in a retrospective multi-vendor (Siemens and General Electric), multi-pathology cohort of patients, predominantly with heart failure, pulmonary hypertension and lung diseases (n = 400, ASPIRE registry). Biventricular segmentations were made on all CMR studies across cardiac phases. To test the accuracy of the automatic segmentation, 30 ASPIRE CMRs were segmented independently by two CMR experts. Each segmentation was compared to the automatic contouring with agreement assessed using the Dice similarity coefficient (DSC).
A prospective validation cohort of 46 subjects (10 healthy volunteers and 36 patients with pulmonary hypertension) were recruited to assess interstudy agreement of automatic and manual CMR assessments. Two CMR studies were performed during separate sessions on the same day. Interstudy repeatability was assessed using intraclass correlation coefficient (ICC) and Bland-Altman plots.
Results
DSC showed high agreement (figure 1) comparing automatic and expert CMR readers, with minimal bias towards either CMR expert. The scan-scan repeatability CMR measurements were higher for all automatic RV measurements (ICC 0.89 to 0.98) compared to manual RV measurements (0.78 to 0.98). LV automatic and manual measurements were similarly repeatable (figure 2). Bland-Altman plots showed strong agreement with small mean differences between the scan-scan measurements (figure 2).
Conclusion
Fully automatic biventricular short-axis segmentations are comparable with expert manual segmentations, and have shown excellent interstudy repeatability.
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Affiliation(s)
- S Alabed
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - K Karunasaagarar
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - F Alandejani
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Garg
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - J Uthoff
- University of Sheffield, Department of Computer Science, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Metherall
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - M Sharkey
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - H Lu
- University of Sheffield, Department of Computer Science, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - JM Wild
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - DG Kiely
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | | | - AJ Swift
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
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Alabed S, Karunasaagarar K, Alandejani F, Garg P, Uthoff J, Metherall P, Sharkey M, Lu H, Wild JM, Kiely DG, Van Der Geest RJ, Swift AJ. Fully automated CMR derived stroke volume correlates with right heart catheter measurements in patients with suspected pulmonary hypertension. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.036] [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
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Welcome Trust (UK), NIHR (UK)
Introduction
Cardiac magnetic resonance (CMR) assessment plays a significant role in the diagnosis, prognosis and monitoring of patients with pulmonary hypertension (PH). We developed a deep learning model to automatically generate biventricular contours and validated its result in a prospective cohort of patients with suspected PH who underwent right heart catheterization (RHC).
Methods
A deep learning CMR contouring model was developed in a retrospective multi-vendor (Siemens and General Electric), multi-pathology cohort of patients, predominantly with heart failure, lung disease and PH (n = 400, ASPIRE registry). Biventricular segmentations were made on all CMR studies across cardiac phases. A prospective validation cohort of 102 suspected PH patients was recruited and they had RHC within 24 hours of the CMR. To test the accuracy of the automatic segmentation, the RHC-thermodilution and CMR-derived measures of stroke volume (SV) were compared for manual and automated measurements.
Results
The mean and standard deviation for the derived SV was 59 ml ± 21 measured by RHC and 75 ml ± 25 for automated and 79 ml ± 26 for manual CMR measurements. Automatic and manual CMR measurement correlated strongly with RHC derived SV; 0.73, 95% CI [0.62, 0.81] and 0.78, 95% CI [0.69, 0.85], respectively (figure 1). The agreement between automatic and manual SV was high; interclass correlation coefficient (ICC) = 0.88, 95% CI [0.83, 0.92] and Bland-Altman plots showed a narrow spread of mean differences between manual and automatic measurements (figure 2).
Conclusion
In a prospective cohort, fully automatic CMR assessments corresponded accurately to invasive hemodynamics performed within 24 hours of a CMR study.
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Affiliation(s)
- S Alabed
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - K Karunasaagarar
- University of Sheffield, Academic Unit of Radiology, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - F Alandejani
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Garg
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - J Uthoff
- University of Sheffield, Department of Computer Science, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Metherall
- University of Sheffield, Academic Unit of Radiology, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - M Sharkey
- University of Sheffield, Academic Unit of Radiology, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - H Lu
- University of Sheffield, Department of Computer Science, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - JM Wild
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - DG Kiely
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | | | - AJ Swift
- University of Sheffield, Department of Infection, Immunity & Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
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Barker N, Fidock B, Balasubramanian N, Macdonald AW, Capener D, Johns CS, Karunasaagarar K, Fent G, Al-Mohammad A, Rothman A, Kiely DG, Wild JM, Swift A, Garg P. P165A novel cardiac magnetic resonance imaging model to predict level of mixed venous oxygen levels in pulmonary hypertension. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez117.027] [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: 11/14/2022] Open
Affiliation(s)
- N Barker
- University of Sheffield, Infection Immunity and Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - B Fidock
- University of Sheffield, Infection Immunity and Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - N Balasubramanian
- University of Sheffield, Infection Immunity and Cardiovascular Disease, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - A W Macdonald
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - D Capener
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - C S Johns
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - K Karunasaagarar
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - G Fent
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - A Al-Mohammad
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - A Rothman
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - D G Kiely
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - J M Wild
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - A Swift
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Garg
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
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Swift AJ, Lu H, Garg P, Taylor J, Metherall P, Zhou S, Johns C, Condliffe RA, Lawrie A, Wild JM, Kiely DG. 543A machine-learning CMR approach to extract disease features and automate pulmonary arterial hypertension diagnosis. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez104.001] [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: 11/13/2022] Open
Affiliation(s)
- A J Swift
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - H Lu
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Garg
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - J Taylor
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - P Metherall
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - S Zhou
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - C Johns
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - R A Condliffe
- Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - A Lawrie
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - J M Wild
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - D G Kiely
- University of Sheffield, IICD, Sheffield, United Kingdom of Great Britain & Northern Ireland
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Farge D, Burt RK, Oliveira MC, Mousseaux E, Rovira M, Marjanovic Z, de Vries-Bouwstra J, Del Papa N, Saccardi R, Shah SJ, Lee DC, Denton C, Alexander T, Kiely DG, Snowden JA. Cardiopulmonary assessment of patients with systemic sclerosis for hematopoietic stem cell transplantation: recommendations from the European Society for Blood and Marrow Transplantation Autoimmune Diseases Working Party and collaborating partners. Bone Marrow Transplant 2017; 52:1495-1503. [PMID: 28530671 PMCID: PMC5671927 DOI: 10.1038/bmt.2017.56] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/29/2017] [Indexed: 02/07/2023]
Abstract
Systemic sclerosis (SSc) is a rare disabling autoimmune disease with a similar mortality to many cancers. Two randomized controlled trials of autologous hematopoietic stem cell transplantation (AHSCT) for SSc have shown significant improvement in organ function, quality of life and long-term survival compared to standard therapy. However, transplant-related mortality (TRM) ranged from 3–10% in patients undergoing HSCT. In SSc, the main cause of non-transplant and TRM is cardiac related. We therefore updated the previously published guidelines for cardiac evaluation, which should be performed in dedicated centers with expertize in HSCT for SSc. The current recommendations are based on pre-transplant cardiopulmonary evaluations combining pulmonary function tests, echocardiography, cardiac magnetic resonance imaging and invasive hemodynamic testing, initiated at Northwestern University (Chicago) and subsequently discussed and endorsed within the EBMT ADWP in 2016.
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Affiliation(s)
- D Farge
- Department of Internal Medicine, Unité Clinique de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire, UF 04, Hôpital Saint-Louis, AP-HP Assistance Publique des Hôpitaux de Paris, INSERM UMRS 1160, Paris Denis Diderot University, Paris, France
| | - R K Burt
- Department of Medicine, Division of Immunotherapy, Northwestern University, Chicago, IL, USA
| | - M-C Oliveira
- Departamento de Clínica Médica, Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - E Mousseaux
- Hôpital Européen Georges Pompidou, AP-HP Assistance Publique des Hôpitaux de Paris, INSERM UMR 970, Université Paris Descartes, Paris, France
| | - M Rovira
- Department of Hematology, HSCT Unit, Hospital Clinic, Barcelona, Spain
| | - Z Marjanovic
- Department of Hematology, Saint-Antoine Hospital Paris, Assistance Publique des Hôpitaux de Paris, APHP, Paris, France
| | | | - N Del Papa
- Department of Rheumatology, Scleroderma Clinic, Osp. G. Pini, Milan, Italy
| | - R Saccardi
- Department of Hematology, Cord Blood Bank, Careggi University Hospital, Florence, Italy
| | - S J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D C Lee
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C Denton
- UCL Division of Medicine Royal Free Campus, London, UK
| | - T Alexander
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - D G Kiely
- Sheffield Pulmonary Vascular Disease Unit, M-floor, Royal Hallamshire Hospital, Sheffield, UK
| | - J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, UK
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Quadery SR, Condliffe RA, Billings C, Thompson R, Elliot CA, Charalampopolous A, Hurdman J, Hamilton N, Armstrong I, Sephton P, Sabroe I, Swift A, Wild J, Kiely DG. P28 Chronic thromboembolic pulmonary hypertension: long term outcomes in surgical and non-surgical patients. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ramjug S, Hussain N, Hurdman J, Billings C, Elliot CA, Kiely DG, Sabroe I, Rajaram S, Swift AJ, Condliffe R. S111 Differences in characteristics and outcomes in systemic sclerosis-associated and idiopathic pulmonary arterial hypertension. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.117] [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] [Indexed: 11/04/2022]
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Johns CS, Capener D, Hammerton C, Shotton K, Kiely DG, Wild JM, Swift AJ. P45 Non-invasive methods for the estimation of mpap in COPD patients using cardiac mri. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.188] [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] [Indexed: 11/03/2022]
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Rajaram S, Swift AJ, Wild JM, Kiely DG. Response to: 'CT assessment for pulmonary hypertension requires systematic assessment of cardiac, vascular and parenchymal signs' by Marloes et al. Thorax 2015; 70:1087-8. [PMID: 26108572 DOI: 10.1136/thoraxjnl-2015-207394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 11/03/2022]
Affiliation(s)
- S Rajaram
- Academic Department of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - A J Swift
- Academic Department of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - J M Wild
- Academic Department of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - D G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
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Rajaram S, Swift AJ, Condliffe R, Johns C, Elliot CA, Hill C, Davies C, Hurdman J, Sabroe I, Wild JM, Kiely DG. CT features of pulmonary arterial hypertension and its major subtypes: a systematic CT evaluation of 292 patients from the ASPIRE Registry. Thorax 2014; 70:382-7. [PMID: 25523307 PMCID: PMC4392204 DOI: 10.1136/thoraxjnl-2014-206088] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [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] [Indexed: 11/25/2022]
Abstract
We evaluated the prevalence and prognostic value of CT-pulmonary angiographic (CTPA) measures in 292 treatment naive patients with pulmonary arterial hypertension (PAH). Pulmonary artery calcification (13%) and thrombus (10%) were exclusively seen in PAH-congenital heart disease. Oesophageal dilation (46%) was most frequent in PAH-systemic sclerosis. Ground glass opacification (GGO) (41%), pericardial effusion (38%), lymphadenopathy (19%) and pleural effusion (11%) were common. On multivariate analysis, inferior vena caval area, the presence of pleural effusion and septal lines predicted outcome. In PAH, CTPA provides diagnostic and prognostic information. In addition, the presence of GGO on a CT performed for unexplained breathlessness should alert the physician to the possibility of PAH.
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Affiliation(s)
- S Rajaram
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - A J Swift
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - R Condliffe
- Sheffield Pulmonary Vascular Disease Unit and Academic Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - C Johns
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - C A Elliot
- Sheffield Pulmonary Vascular Disease Unit and Academic Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - C Hill
- Department of Radiology, Sheffield Teaching Hospitals, UK
| | - C Davies
- Department of Radiology, Sheffield Teaching Hospitals, UK
| | - J Hurdman
- Sheffield Pulmonary Vascular Disease Unit and Academic Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - I Sabroe
- Sheffield Pulmonary Vascular Disease Unit and Academic Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - J M Wild
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - D G Kiely
- Sheffield Pulmonary Vascular Disease Unit and Academic Department of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield, UK
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Lungu A, Wild JM, Capener D, Kiely DG, Swift AJ, Hose DR. MRI model-based non-invasive differential diagnosis in pulmonary hypertension. J Biomech 2014; 47:2941-7. [PMID: 25145313 DOI: 10.1016/j.jbiomech.2014.07.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/01/2014] [Accepted: 07/14/2014] [Indexed: 11/30/2022]
Abstract
Pulmonary hypertension(PH) is a disorder characterised by increased mean pulmonary arterial pressure. Currently, the diagnosis of PH relies upon measurements taken during invasive right heart catheterisation (RHC). This paper describes a process to derive diagnostic parameters using only non-invasive methods based upon MRI imaging alone. Simultaneous measurements of main pulmonary artery (MPA) anatomy and flow are interpreted by 0D and 1D mathematical models, in order to infer the physiological status of the pulmonary circulation. Results are reported for 35 subjects, 27 of whom were patients clinically investigated for PH and eight of whom were healthy volunteers. The patients were divided into 3 sub-groups according to the severity of the disease state, one of which represented a negative diagnosis (NoPH), depending on the results of the clinical investigation, which included RHC and complementary MR imaging. Diagnostic indices are derived from two independent mathematical models, one based on the 1D wave equation and one based on an RCR Windkessel model. Using the first model it is shown that there is an increase in the ratio of the power in the reflected wave to that in the incident wave (Wpb/Wptotal) according to the classification of the disease state. Similarly, the second model shows an increase in the distal resistance with the disease status. The results of this pilot study demonstrate that there are statistically significant differences in the parameters derived from the proposed models depending on disease status, and thus suggest the potential for development of a non-invasive, image-based diagnostic test for pulmonary hypertension.
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Affiliation(s)
- A Lungu
- University of Sheffield, Cardiovascular Science Department, Sheffield, South Yorkshire, UK.
| | - J M Wild
- University of Sheffield, Cardiovascular Science Department, Sheffield, South Yorkshire, UK; INSIGNEO-Institute for in silico Medicine, University of Sheffield, Sheffield, South Yorkshire, UK
| | - D Capener
- University of Sheffield, Cardiovascular Science Department, Sheffield, South Yorkshire, UK
| | - D G Kiely
- Pulmonary Vascular Disease Unit, Sheffield, South Yorkshire, UK
| | - A J Swift
- University of Sheffield, Cardiovascular Science Department, Sheffield, South Yorkshire, UK; INSIGNEO-Institute for in silico Medicine, University of Sheffield, Sheffield, South Yorkshire, UK
| | - D R Hose
- University of Sheffield, Cardiovascular Science Department, Sheffield, South Yorkshire, UK; INSIGNEO-Institute for in silico Medicine, University of Sheffield, Sheffield, South Yorkshire, UK
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Condliffe R, Elliot CA, Sabroe I, Zamanian RT, Morton A, Swift AJ, Kiely DG, Lawrie A. P157 Hepatocyte growth factor concentration correlates with haemodynamic severity in connective tissue disease-associated pulmonary arterial hypertension. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.308] [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] [Indexed: 11/03/2022]
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Kawar B, Ellam T, Jackson C, Kiely DG. Pulmonary hypertension in renal disease: epidemiology, potential mechanisms and implications. Am J Nephrol 2013; 37:281-90. [PMID: 23548763 DOI: 10.1159/000348804] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 02/02/2013] [Indexed: 12/12/2022]
Abstract
Pulmonary hypertension (PH) is highly prevalent in end-stage renal disease. Several observational studies, based on an echocardiographic diagnosis of PH, have suggested a prevalence of 30-60% and an association with increased mortality and poorer outcome following renal transplantation. The pathogenesis of PH in this population remains poorly understood. Reported associations include arteriovenous fistulae, cardiac dysfunction, fluid overload, bone mineral disorder and non-biocompatible dialysis membranes. However, due to the small numbers, the cross-sectional nature of the majority of studies in this field, and the reliance on echocardiography for the diagnosis of PH, no consistent association with any individual risk factor has been demonstrated. There is no difference in prevalence between patients receiving different dialysis modalities and emerging evidence suggests that the onset of the condition may precede dialysis treatment in many patients. Furthermore, little is known about the impact of the 'uraemic vasculopathy' on the pulmonary vasculature. Given the similarities between vascular changes in uraemia and those seen in pulmonary arterial hypertension, it is possible that a pulmonary vasculopathy may be present in a proportion of patients. There is a need for better understanding of the natural history and the pathogenesis of the condition which would help to individualise treatment of PH in end-stage renal disease. To enable such understanding, prospective adequately powered studies with an integrated investigational approach including right heart catheterisation are needed.
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Affiliation(s)
- B Kawar
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK.
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Sitbon O, Baloira Villar A, Bauer F, Ekmehag B, Gin-Sing W, Jansson K, Kiely DG, Leuchte H, Manes A, Rosenkranz S, Escribano P. Treat-to-target approach in pulmonary arterial hypertension: a consensus-based proposal. Eur Respir Rev 2012; 21:259-62. [DOI: 10.1183/09059180.00003612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Rajaram S, Swift AJ, Capener D, Hill C, Davies C, Elliot R, Hurdman J, Condliffe R, Wild JM, Kiely DG. S23 Accuracy of contrast enhanced MR lung perfusion compared to perfusion scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054b.23] [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] [Indexed: 11/04/2022]
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Swift AJ, Rajaram S, Condliffe R, Capener D, Hill C, Davies C, Hurdman J, Elliot C, Wild JM, Kiely DG. S70 Diagnostic utility and prognostic value of quantitative cardiac MR indices in patients with suspected pulmonary hypertension. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054b.70] [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] [Indexed: 11/04/2022]
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Hurdman J, Condliffe RA, Elliot CA, Sabroe I, Kiely DG. P39 Pulmonary Hypertension (PH) associated with lung disease/ hypoxia. Thorax 2010. [DOI: 10.1136/thx.2010.150961.39] [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] [Indexed: 11/04/2022]
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Kiely DG, Condliffe R, Webster V, Mills GH, Wrench I, Gandhi SV, Selby K, Armstrong IJ, Martin L, Howarth ES, Bu’Lock FA, Stewart P, Elliot CA. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG 2010; 117:565-74. [DOI: 10.1111/j.1471-0528.2009.02492.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hagger D, Condliffe R, Woodhouse N, Elliot CA, Armstrong IJ, Davies C, Hill C, Akil M, Wild JM, Kiely DG. Ventricular mass index correlates with pulmonary artery pressure and predicts survival in suspected systemic sclerosis-associated pulmonary arterial hypertension. Rheumatology (Oxford) 2009; 48:1137-42. [DOI: 10.1093/rheumatology/kep187] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Condliffe R, Kiely DG, Gibbs JSR, Corris PA, Peacock AJ, Jenkins DP, Goldsmith K, Coghlan JG, Pepke-Zaba J. Prognostic and aetiological factors in chronic thromboembolic pulmonary hypertension. Eur Respir J 2008; 33:332-8. [DOI: 10.1183/09031936.00092008] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Humbert M, Segal ES, Kiely DG, Carlsen J, Schwierin B, Hoeper MM. Results of European post-marketing surveillance of bosentan in pulmonary hypertension. Eur Respir J 2007; 30:338-44. [PMID: 17504794 DOI: 10.1183/09031936.00138706] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
After the approval of bosentan for the treatment of pulmonary arterial hypertension (PAH), European authorities required the introduction of a post-marketing surveillance system (PMS) to obtain further data on its safety profile. A novel, prospective, internet-based PMS was designed, which solicited reports on elevated aminotransferases, medical reasons for bosentan discontinuation and other serious adverse events requiring hospitalisation. Data captured included demographics, PAH aetiology, baseline functional status and concomitant PAH-specific medications. Safety signals captured included death, hospitalisation, serious adverse events, unexpected adverse events and elevated aminotransferases. Within 30 months, 4,994 patients were included, representing 79% of patients receiving bosentan in Europe. In total, 4,623 patients were naïve to treatment; of these, 352 had elevated aminotransferases, corresponding to a crude incidence of 7.6% and an annual rate of 10.1%. Bosentan was discontinued due to elevated aminotransferases in 150 (3.2%) bosentan-naïve patients. Safety results were consistent across subgroups and aetiologies. The novel post-marketing surveillance captured targeted safety data ("potential safety signals") from the majority of patients and confirmed that the incidence and severity of elevated aminotransferase levels in clinical practice was similar to that reported in clinical trials. These data complement those from randomised controlled clinical trials and provide important additional information on the safety profile of bosentan.
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Affiliation(s)
- M Humbert
- Dept of Respiratory Medicine, Antoine Béclère Hospital, Clamart, France.
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Abstract
Vasopressin is a peptide synthesized in the hypothalamus whose primary role is in fluid homeostasis. It has recently gained interest as a potential agent in the treatment of cardiorespiratory arrest. Initial human studies have shown benefits with vasopressin in patients with out of hospital ventricular fibrillation and asystolic cardiac arrest. One subgroup of patients not included in these trials is patients with pulmonary hypertension, who have a five-year mortality rate of 50%. Animal studies have shown vasopressin to be a vasodilator in the pulmonary vascular system of rats, under normoxic and hypoxic conditions, with conflicting results in canines. Human studies have shown conflicting results with increases, decreases and no changes seen in pulmonary artery pressures of patients with a variety of clinical conditions. Research needs to be done in patients with pulmonary hypertension regarding the potential role of vasopressin during cardiac arrest in this subgroup.
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Affiliation(s)
- A M Smith
- Hormone and Vascular Biology Group, Academic Unit of Endocrinology, Div. of Genomic Medicine, University of Sheffield, Sheffield S10 2JF, UK
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Elliot CA, Stewart P, Webster VJ, Mills GH, Hutchinson SP, Howarth ES, Bu'lock FA, Lawson RA, Armstrong IJ, Kiely DG. The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension. Eur Respir J 2005; 26:168-73. [PMID: 15994404 DOI: 10.1183/09031936.05.00128504] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients with pulmonary hypertension, pregnancy is associated with a high risk of maternal death. Such patients are counselled to avoid pregnancy, or if it occurs, are offered early interruption. Some patients, however, decide to continue with their pregnancy and others may present with symptoms for the first time whilst pregnant. Pulmonary vasodilator therapy provides a treatment option for these high-risk patients. The present study describes three patients with pulmonary arterial hypertension of various aetiologies who were treated with the prostacyclin analogue iloprost during pregnancy, and the post-partum period. Nebulised iloprost commenced as early as 8 weeks of gestation and patients were admitted to hospital between 24-36 weeks of gestation. All pregnancies were completed with a duration of between 25-36 weeks and all deliveries were by caesarean section under local anaesthetic. All patients delivered children free from congenital abnormalities, and there was no post-partum maternal or infant mortality. In conclusion, although pregnancy is strongly advised against in those with pulmonary hypertension, the current authors have achieved a successful outcome for mother and foetus with a multidisciplinary approach and targeted pulmonary vascular therapy.
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Affiliation(s)
- C A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, UK
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Kiely DG, Ansari S, Davey WA, Mahadevan V, Taylor GJ, Seaton D. Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax. Thorax 2001; 56:617-21. [PMID: 11462064 PMCID: PMC1746118 DOI: 10.1136/thorax.56.8.617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is no technique in general use that reliably predicts the outcome of manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a pleural leak at the time of aspiration will identify a group of patients in whom immediate discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis by using a simple bedside tracer gas technique. METHODS Eighty four episodes of primary spontaneous pneumothorax and 35 episodes of secondary spontaneous pneumothorax were studied prospectively. Patients breathed air containing a tracer (propellant gas from a pressurised metered dose inhaler) while the pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1 part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a persistent pleural leak. Failure of manual aspiration and the need for a further intervention was based on chest radiographic appearances showing either failure of the lung to re-expand or re-collapse following initial re-expansion. RESULTS A negative tracer gas test alone implied that manual aspiration would be successful in the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86% of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that manual aspiration would either fail to re-expand the lung or that early re-collapse would occur despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71% of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-collapse occurring in 34% of episodes by the following day such that a further intervention was required. CONCLUSIONS National guidelines currently recommend immediate discharge of patients with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a simple bedside test in combination with the post-aspiration chest radiograph, we can predict with high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby identifying patients with primary spontaneous pneumothorax who can be safely and immediately discharged home and those who should be observed overnight because of a significant risk of re-collapse, with an estimated re-admission rate of 1%.
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Affiliation(s)
- D G Kiely
- Department of Respiratory Medicine, The Ipswich Hospital NHS Trust, Ipswich IP4 5PD, UK
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Kiely DG, Ansari S, Davey WA, Mahadevan V, Taylor GJ, Seaton D. Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax. Thorax 2001. [DOI: 10.1136/thx.56.8.617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUNDThere is no technique in general use that reliably predicts the outcome of manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a pleural leak at the time of aspiration will identify a group of patients in whom immediate discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis by using a simple bedside tracer gas technique.METHODSEighty four episodes of primary spontaneous pneumothorax and 35 episodes of secondary spontaneous pneumothorax were studied prospectively. Patients breathed air containing a tracer (propellant gas from a pressurised metered dose inhaler) while the pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1 part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a persistent pleural leak. Failure of manual aspiration and the need for a further intervention was based on chest radiographic appearances showing either failure of the lung to re-expand or re-collapse following initial re-expansion.RESULTSA negative tracer gas test alone implied that manual aspiration would be successful in the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86% of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that manual aspiration would either fail to re-expand the lung or that early re-collapse would occur despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71% of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-collapse occurring in 34% of episodes by the following day such that a further intervention was required.CONCLUSIONSNational guidelines currently recommend immediate discharge of patients with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a simple bedside test in combination with the post-aspiration chest radiograph, we can predict with high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby identifying patients with primary spontaneous pneumothorax who can be safely and immediately discharged home and those who should be observed overnight because of a significant risk of re-collapse, with an estimated re-admission rate of 1%.
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Abstract
BACKGROUND Although manual aspiration is used for treating pneumothorax, the post-aspiration radiograph may not be a reliable indicator of whether the pleural leak remains. We have previously shown that marker gas can identify an air leak in patients with spontaneous pneumothoraces. OBJECTIVE This study examines whether a marker gas technique can be safely used to manage patients with iatrogenic pneumothoraces. METHODS 10 patients with iatrogenic pneumothorax were identified among a cohort referred for manual aspiration of pneumothorax, using a marker gas technique, in which inspired metered-dose inhaler propellant gas is detectable in pneumothorax aspirate using a portable flame ioniser. The presence of marker gas was taken to imply a persistent air leak. RESULTS Marker gas was detected in the aspirate from 3 out of 10 pneumothoraces. 2 required intercostal tube drainage because of lung collapse following initial aspiration and 1 was treated conservatively. Marker gas was not detected in 7 cases (2 post-pacemaker insertion, 5 pleural aspiration +/- biopsy), and in all these cases, manual aspiration resulted in sustained re-expansion of the lung. There was a trend towards a significant relationship between the presence or absence of marker gas and the need for a further intervention (p = 0.055). CONCLUSION The presence or absence of a pleural leak during manual aspiration of iatrogenic pneumothorax can be demonstrated by this technique. The absence of marker gas in the aspirate implies that manual aspiration will be successful, whereas its presence, in most cases, predicts either failure of manual aspiration to expand the lung or early re-collapse of the lung.
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Affiliation(s)
- D G Kiely
- Department of Thoracic Medicine, Ipswich Hospital NHS Trust, Ipswich, UK
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Lee AF, Kiely DG, Coutie WJ, Struthers AD. The effect of nitric oxide inhibition on the renin response to frusemide, in man. Br J Clin Pharmacol 1999; 48:355-60. [PMID: 10510146 PMCID: PMC2014337 DOI: 10.1046/j.1365-2125.1999.00014.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/1998] [Accepted: 05/12/1999] [Indexed: 11/20/2022] Open
Abstract
AIMS We wished to see if renin release in man was inhibited by nitric oxide blockade, suggesting a role for nitric oxide in renin release. Evidence from animal studies has shown variable effects on renin release depending on the model and stimulus used. METHODS Ten normal male volunteers, received either L-NMMA as a front loaded infusion (4 mg kg-1 bolus, with 4 mg kg-1 infusion), or placebo, followed by an intravenous bolus of 5 mg frusemide to stimulate renin. To investigate whether any alteration in renin release was due to the pressor effect of the L-NMMA, the experiment was repeated using an equipressor dose of phenylephrine (0.5 microg kg-1 min-1 ). RESULTS L-NMMA caused the expected increase in mean arterial pressure (96+/-2.6 vs 89+/-3.3 mmHg P<0.05 [mean+/-s.e.mean]), and a reduction in heart rate (59+/-3.6 vs 67+/-2.5 beats min-1 P<0.05). L-NMMA completely blocked the renin rise following the bolus of frusemide (1.18+/-0.196 vs 1.96+/-0.333 ng ml-1 h-1 P<0.01). Phenylephrine 0.5 microg kg-1 min-1 produced very similar haemodynamic effects to L-NMMA, and also suppressed the renin response to frusemide (1.43+/-0.290 vs 2.67+/-0.342 ng ml-1 h-1 P<0. 01). CONCLUSIONS In man, the renin inhibition seen with NO synthesis inhibition is similar to that seen with a standard pressor stimulus, hence inhibition of renin in man by L-NMMA, may be due to both direct effects on macula densa cells and indirect haemodynamic effects.
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Affiliation(s)
- A F Lee
- Department of Medical Cardiology, Glasgow Royal Infirmary, Glasgow
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Abstract
AIMS The aim of this study was to examine whether nitric oxide (NO) has an important role in maintaining basal vascular tone in normal man by examining the effects of nitric oxide inhibition using N(G)-monomethyl-L-arginine (L-NMMA) on systemic and pulmonary haemodynamics. METHODS Ten normal male volunteers 26 +/- 1.6 years were studied on two separate occasions in a double-blind, placebo controlled crossover study. They were randomised to receive either a continuous infusion of L-NMMA (4 mg kg(-1) h(-1)) with a front loaded bolus (4 mg kg(-1)) or volume matched placebo. Pulsed wave Doppler echocardiography was used to measure cardiac output (CO), mean pulmonary artery pressure (MPAP) and hence systemic vascular resistance (SVR) and total pulmonary vascular resistance (TPR). Measurements were made prior to infusion (t0) and after 4, 8, and 12 min (t1, t2 and t3). RESULTS Infusion of L-NMMA significantly increased mean arterial blood pressure (MAP), SVR and TPR and significantly reduced heart rate (HR), stroke volume (SV) and CO compared to placebo. These effects were observed at t1 and persisted during the entire infusion period. CONCLUSIONS These results are consistent with a role for basal nitric oxide generation in the maintenance of basal systemic and pulmonary vascular tone in normal man.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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Abstract
AIMS Diuretic therapy is conventionally used to treat oedema in patients with hypoxic cor pulmonale. This condition is associated with activation of the renin angiotensin system (RAS) with elevated levels of angiotensin II (ANG II), a potent pulmonary pressor agent. We explored the hypothesis that RAS activation by diuretic therapy might therefore worsen hypoxic pulmonary vasoconstriction via the effects of ANG II on the pulmonary vascular bed. METHODS Eight normal volunteers were studied on 2 separate days. They either received 40 mg frusemide daily or placebo for 4 days and were then rendered hypoxaemic, by breathing an N2/O2 mixture for 20 min to achieve an SaO2 of 85-90% adjusted for a further 20 min to achieve an SaO2 of 75-80%. Pulsed wave doppler echocardiography was used to measure mean pulmonary artery pressure, cardiac output and hence pulmonary vascular resistance (PVR). RESULTS Plasma renin activity (PRA) was significantly (P < 0.01) increased after prior treatment with frusemide compared with placebo at all time points. Prior treatment with frusemide significantly (P < 0.05) increased PVR compared with placebo at baseline: 185 +/- 17 vs 132 +/- 10 dyn s cm-5 at an SaO2 of 85-90%: 291 +/- 18 vs 229 +/- 16 dyn s cm-5 and at SaO2 of 75-80%: 356 +/- 12 vs 296 +/- 17 dyn s cm-5 respectively. However, the delta-PVR response to hypoxaemia was not significantly altered by frusemide compared with placebo. In contrast to its effect on the pulmonary vasculature prior treatment with frusemide did not significantly alter systemic haemodynamic parameters either at baseline or during hypoxia. CONCLUSIONS Thus, prior treatment with frusemide increased baseline pulmonary vascular resistance and significantly augmented the hypoxaemic pulmonary vascular response in additive fashion. It is hypothesised that this effect of frusemide may be due to RAS activation with ANG II mediated pulmonary vasoconstriction.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, UK
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Abstract
OBJECTIVES Endothelin-1 levels are elevated in a number of conditions characterised by impaired cardiovascular performance and abnormal vasoconstriction such as congestive cardiac failure and primary and secondary pulmonary hypertension. The aim of the present study was to assess the effects of the vasoconstrictor peptide endothelin-1 on pulmonary and systemic haemodynamics and cardiovascular performance in normal man. METHODS Ten healthy male volunteers were studied on two occasions in a randomised, double-blind, placebo-controlled, cross-over study and received systemic infusions of either endothelin-1 (0.75, 1.5 and 3 pmol.kg-1.min-1 for 30 min each) or saline placebo. Systemic and pulmonary haemodynamic parameters were monitored non-invasively by pulsed-wave Doppler, as were parameters of left and right ventricular diastolic filling and inotropic state. Effects on renin-angiotensin and natriuretic peptide system activity were also measured. RESULTS Endothelin-1 infusion produced dose-related falls in heart rate, stroke volume and cardiac output. Systemic vascular resistance (SVR) increased from 1156 +/- 57 to 1738 +/- 115 dyn.s.cm-5, and total pulmonary vascular resistance (TPR) increased from 142 +/- 12 to 329 +/- 22 dyn.s.cm-5. Endothelin-1 caused significant impairment of left and right ventricular diastolic filling, even at a low dose which had no pulmonary or systemic pressor effects. Electromechanical and Doppler acceleration indices of inotropic state were also significantly impaired. Activity of the renin-angiotensin system was suppressed by endothelin-1 whilst plasma levels of atrial natriuretic peptide (ANP) were unchanged. CONCLUSIONS Thus, in addition to systemic and pulmonary pressor effects our results suggest that endothelin-1 impairs overall cardiovascular performance by causing diastolic dysfunction and acting as a negatively inotropic agent. These effects were associated with compensatory changes in the renin-angiotensin system.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK
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Kiely DG, Cargill RI, Wheeldon NM, Coutie WJ, Lipworth BJ. Haemodynamic and endocrine effects of type 1 angiotensin II receptor blockade in patients with hypoxaemic cor pulmonale. Cardiovasc Res 1997; 33:201-8. [PMID: 9059545 DOI: 10.1016/s0008-6363(96)00180-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [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: 02/03/2023] Open
Abstract
OBJECTIVES Angiotensin II (ANG II) is known to be a potent vasoconstrictor agent in the pulmonary circulation. Furthermore, type 1 ANG II receptor blockade with losartan attenuates acute hypoxic pulmonary vasoconstriction in normal subjects. The aim of this study was therefore to evaluate the haemodynamic and endocrine sequelae of type 1 ANG II receptor blockade in patients with hypoxaemic cor pulmonale. METHODS Nine patients with chronic obstructive pulmonary disease (COPD) age 67 +/- 3 years with pulmonary hypertension and normal left ventricular systolic function were studied on two separate occasions in a double-blind, placebo-controlled, crossover study. They were randomised to receive either 50 mg of oral losartan or matched placebo. Pulsed wave Doppler echocardiography was used to measure cardiac output (CO), mean pulmonary artery pressure (MPAP) and hence systemic vascular resistance (SVR) and total pulmonary vascular resistance (TPR). Haemodynamic measurements and venous blood samples were taken at baseline and after 2 and 4 h. RESULTS Maximal effects were observed at 4 h where losartan compared to placebo resulted in a significant reduction in both MPAP (28.6 +/- 2.0 vs 32.4 +/- 1.5 mmHg) and TPR (428 +/- 40 vs 510 +/- dyn.s.cm-5), respectively. Similarly losartan compared to placebo resulted in a significant reduction in MAP (87 +/- 4.5 vs 93 +/- 3.2 mmHg) and SVR (1293 +/- 94 vs 1462 +/- 112 dyn.s.cm-5), and significantly increased CO (5.58 +/- 0.43 vs 5.31 +/- 0.42 l/min). In addition, plasma aldosterone was significantly lower after treatment with losartan compared to placebo: 76 +/- 23 vs 164 +/- 43 pg/ml respectively. CONCLUSIONS Thus, selective type 1 ANG II receptor blockade appears to have beneficial pulmonary and endocrine effects, suggesting a possible therapeutic role in the management of hypoxaemic cor pulmonale.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
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Kiely DG, Cargill RI, Lipworth BJ. Angiotensin II receptor blockade and effects on pulmonary hemodynamics and hypoxic pulmonary vasoconstriction in humans. Chest 1996; 110:698-703. [PMID: 8797414 DOI: 10.1378/chest.110.3.698] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
STUDY OBJECTIVE We examined the hypothesis that angiotensin II (ANG II) is a modulator of pulmonary vascular tone by examining the effects of ANG II blockade on pulmonary hemodynamics during normoxemia and hypoxemia in normal volunteers with an activated renin angiotensin system (RAS). PARTICIPANTS AND INTERVENTIONS Eight normal volunteers, pretreated with furosemide, were studied on two separate occasions and received either an infusion of saralasin, 5 micrograms/kg/min, or placebo. After 20 min, they were rendered hypoxemic, by breathing N2/O2 mixture for 20 min to achieve arterial oxygen saturation (SaO2) of 85 to 90% adjusted for a further 20 min to achieve SaO2 of 75 to 80%. Doppler echocardiography was used to measure mean pulmonary artery pressure (MPAP), cardiac output, and hence total pulmonary vascular resistance (TPR). RESULTS Saralasin compared with placebo resulted in a significant (p < 0.05) reduction in MPAP during normoxemia, 6.70 +/- 1.0 vs 11.7 +/- 1.3 mm Hg; at SaO2 of 85 to 90%, 14.7 +/- 1.4 vs 20.5 +/- 1.0 mm Hg; and at SaO2 of 75 to 80%, 18.1 +/- 1.9 vs 27.8 +/- 1.9 mm Hg, respectively. Likewise saralasin compared with placebo resulted in a significant reduction in TPR during normoxemia, 104 +/- 14 vs 180 +/- 20 dyne.s.cm-5; at SaO2 of 85 to 90%, 222 +/- 24 vs 295 +/- 21 dyne.s.cm-5; and at SaO2 of 75 to 80%, 238 +/- 21 vs 362 +/- 11 dyne.s.cm-5, respectively. The delta MPAP response to hypoxemia was likewise significantly (p < 0.01) attenuated by saralasin infusion compared with placebo: mean difference 5.0 mm Hg, 95% confidence interval (CI) 1.9 to 8.08, and there was a trend toward attenuation of the delta TPR response to hypoxemia (0.05 < p < 0.10): mean difference 47 dyne.s.cm-5, 95% CI, -10 to 105. CONCLUSION In addition to causing pulmonary vasodilatation in the presence of an activated RAS, our results suggest that ANG II receptor blockade attenuates acute hypoxic pulmonary vasoconstriction and that ANG II may play a role in modulating this response in normal man.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital, Dundee, Scotland
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Abstract
STUDY OBJECTIVE The inotropic, lusitropic, and electrophysiologic effects of acute hypercapnia in humans are not known. Although the effects of hypercapnia on the systemic circulation have been well documented, there is still some debate as to whether hypercapnia causes true pulmonary vasoconstriction in vivo. We have therefore evaluated the effects of acute hypercapnia on these cardiac indices and the interaction of hypercapnia with the systemic and pulmonary vascular beds in humans. PARTICIPANTS AND INTERVENTIONS Eight healthy male volunteers were studied using Doppler echocardiography. After resting for at least 30 min to achieve baseline hemodynamic parameters (T(0)), they were rendered hypercapnic to achieve an end-tidal carbon dioxide (CO2) of 7 kPa for 30 min by breathing a variable mixture of CO2/air (T1). They were restudied after 30 min recovery breathing air (T2). Hemodynamic, diastolic, and systolic flow parameters, QT dispersion (maximum-minimum QT interval measured in a 12-lead ECG), and venous blood samples for plasma renin activity (PRA), angiotensin II (ANG II), and aldosterone (ALDO) were measured at each time point. RESULTS Hypercapnia compared with placebo significantly increased mean pulmonary artery pressure 14 +/- 1 vs 9 +/- 1 mm Hg and pulmonary vascular resistance 171 +/- 17 vs 129 +/- 17 dyne.s.cm-5, respectively. Heart rate, stroke volume, cardiac output, and mean arterial BP were increased by hypercapnia. Indexes of systolic function, namely peak aortic velocity and aortic mean and peak acceleration, were unaffected by hypercapnia. Similarly, hypercapnia had no effect on lusitropic indexes reflected by its lack of effect on isovolumic relaxation time, mitral E-wave deceleration time, and mitral E/A wave ratio. Hypercapnia was found to significantly increase both QTc interval and QT dispersion: 428 +/- 8 vs 411 +/- 3 ms and 48 +/- 2 vs 33 +/- 4 ms, respectively. There was no significant effect of hypercapnia on PRA, ANG II, or ALDO. CONCLUSION Thus, acute hypercapnia appears to have no adverse inotropic or lusitropic effects on cardiac function, although repolarization abnormalities, reflected by an increase in QT dispersion, and its effects on pulmonary vasoconstriction may have important sequelae in man.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
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Kiely DG, Cargill RI, Lipworth BJ. Acute hypoxic pulmonary vasoconstriction in man is attenuated by type I angiotensin II receptor blockade. Cardiovasc Res 1995; 30:875-80. [PMID: 8746201] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES We examined the hypothesis that angiotensin II (ANG II) is a modulator of acute hypoxic pulmonary vasoconstriction (HPV) by looking at the effect of losartan, a selective type 1 ANG II receptor antagonist, on acute HPV in man. METHODS Ten normal volunteers were studied on two separate days. They either received pre-treatment with losartan 25, 50, 100, 100 mg respectively on four consecutive days or matched placebo. They were then rendered hypoxaemic, by breathing an N2/O2 mixture for 20 min to achieve an SaO2 of 85-90% adjusted for a further 20 min to achieve an SaO2 of 75-80%. Pulsed wave Doppler echocardiography was used to measure mean pulmonary artery pressure (MPAP), cardiac output and hence pulmonary vascular resistance (PVR). RESULTS Baseline MPAP and PVR (during normoxaemia) were unaffected by losartan pre-treatment compared with placebo. However, losartan significantly reduced MPAP at both levels of hypoxaemia compared with placebo: 14.7 +/- 0.7 vs 19.0 +/- 0.7 mmHg at an SaO2 85-90% (P < 0.01) and 20.0 +/- 0.7 vs 25.7 +/- 0.8 mmHg at an SaO2 75-80% (P < 0.05) respectively. Similarly losartan significantly reduced PVR compared to placebo: 191 +/- 9 vs 246 +/- 10 dyne.s.cm-5 at an SaO2 85-90% (P < 0.005) and 233 +/- 12 vs 293 +/- 18 dyne.s.cm-5 at an SaO2 75-80% (P < 0.05), respectively. Pre-treatment with losartan, however, had no significant effect on systemic vascular resistance although losartan compared to placebo resulted in a significant (P < 0.05) reduction in mean arterial pressure at an SaO2 75-80%: 78 +/- 2 vs 87 +/- 2 mmHg. CONCLUSIONS Losartan had no effect on baseline pulmonary haemodynamics but significantly attenuated acute hypoxic pulmonary vasoconstriction, suggesting that angiotensin II plays a role in modulating this response in man via its effects on the type 1 angiotensin II receptor.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, University of Dundee, UK
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Abstract
BACKGROUND Secretion of the vasoconstrictor peptide endothelin-1 from vascular endothelium is increased by various stimuli. Whether hypoxaemia affects plasma levels of endothelin-1 in humans is unknown, but this may be important in the haemodynamic response to hypoxaemia. The plasma endothelin-1 concentrations in hypoxaemic humans has therefore been measured. METHODS Plasma levels of endothelin-1 were measured by specific radioimmunoassay in 10 control subjects at rest and following 30 minutes of acute hypoxaemia (SaO2 75-80%) induced by breathing a nitrogen/oxygen mixture, and in 10 patients with hypoxaemic cor pulmonale. RESULTS The plasma endothelin-1 concentration in control subjects was increased from a mean (SE) of 0.90 (0.11) pmol/l at baseline to 2.34 (0.34) pmol/l during hypoxaemia. In patients with cor pulmonale the plasma endothelin-1 concentration was 2.96 (0.34) pmol/l, raised in comparison with control subjects at rest but similar to levels in controls during hypoxaemia. CONCLUSIONS Plasma levels of endothelin-1 were increased by hypoxaemia in humans. The raised levels observed in patients with cor pulmonale may largely be attributable to the effects of hypoxaemia, although the pathophysiological significance of these observations remains to be established.
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Affiliation(s)
- R I Cargill
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK
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38
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Abstract
BACKGROUND Prolongation of the QTc interval has been associated with cardiac dysrhythmias and sudden death. QTc dispersion (interlead variability in QTc interval) has recently been proposed as being a more sensitive marker of repolarisation abnormalities and shown to be a more specific index of arrhythmia risk. Although hypoxaemia and fenoterol have previously been shown to prolong the QTc interval, this does not reflect regional myocardial repolarisation abnormalities. METHODS Electrophysiological effects were measured at baseline and after 30 minutes steady state hypoxaemia at an arterial oxygen saturation (SaO2) of 75-80% (study 1) and at baseline then 30 minutes after inhaled fenoterol 2.4 mg (study 2). From the ECG, lead II corrected QT interval (QTc) and overall corrected QT dispersion were measured using a computer linked digitising tablet according to standard criteria. RESULTS QTc dispersion was increased during hypoxia compared with baseline values (mean (SE) 69 (6) ms v 50 (5) ms) and after fenoterol compared with baseline (79 (13) v 46 (4) ms), respectively. There was also an increase in QTc interval and heart rate after fenoterol (493 (23) v 420 (6) ms and 98 (3) v 71 (6) bpm, respectively). The heart rate was increased during hypoxaemia compared with baseline (78 (3) v 64 (2) bpm), but no change occurred in the QTc interval. CONCLUSIONS Both hypoxaemia and fenoterol cause myocardial repolarisation abnormalities in man in terms of increased QTc dispersion, but only fenoterol increased the QTc interval. This may be relevant in the aetiology of arrhythmias in patients with acute severe asthma where beta agonist therapy and hypoxaemia coexist.
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, UK
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39
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Abstract
STUDY OBJECTIVE Although some of the cardiovascular responses to hypoxemia are well described, effects on myocardial contractility have not been defined. Such effects are readily assessed by noninvasive techniques and we have therefore evaluated Doppler-phonocardiographic parameters of systolic left ventricular contractility in normal humans rendered hypoxemic. DESIGN Eight healthy male volunteers were studied. Parameters were measured after resting to achieve baseline haemodynamics, after 20 min moderate hypoxemia (SaO2 85 to 90%), and after a further 20 min of severe hypoxemia (SaO2 75 to 80%). Hypoxemia was induced by breathing a variable N2/O2 mixture. MEASUREMENTS Pulsed-wave Doppler analysis of ascending aortic blood flow was combined with phonocardiography to measure indices of systolic left ventricular function at baseline and at the end of each period of hypoxemia. RESULTS There was a significant, dose-related increase in cardiac output in response to hypoxemia, from 5.5 +/- 0.26 L/min at baseline to 6.1 +/- 0.08 L/min during moderate hypoxemia and to 7.0 +/- 0.23 L/min during severe hypoxemia. Likewise, heart rate increased significantly in dose-related fashion although stroke volume was not affected by either level of hypoxemia. Hypoxemia had no significant effects on systolic or diastolic blood pressures, but caused a significant reduction in systemic vascular resistance. Aortic peak and mean acceleration and acceleration time were not affected by moderate or severe hypoxemia. Although the systolic time intervals measured shortened significantly during severe hypoxemia, these were no longer significant when appropriate corrections were made for heart rate. CONCLUSIONS Although cardiac output increases during hypoxemia, this is due to increases in heart rate but not to any effect on stroke volume. Parameters of left ventricular systolic function and myocardial inotropic state were also not affected by severe hypoxemia. Systolic left ventricular function and myocardial contractility are thus well preserved in normal humans during hypoxemia.
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Affiliation(s)
- R I Cargill
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, Scotland
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40
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Abstract
1. Nebulised salbutamol is frequently used in the treatment of asthma and chronic obstructive pulmonary disease. Its effects on the cardiovascular system have been extensively investigated although as yet little is known concerning its effects on the pulmonary circulation, particularly during hypoxaemia. We have therefore examined the effects of nebulised salbutamol on pulmonary haemodynamics to see if it modifies hypoxic pulmonary vasoconstriction. 2. Eight healthy normal volunteers were studied on two separate occasions. After resting to achieve baseline haemodynamics patients were randomised to receive 5 mg salbutamol or placebo via a nebuliser. They were restudied after 30 min and then rendered hypoxaemic by breathing an N2/O2 mixture to achieve an SaO2 of 75-80%. Doppler echocardiography was used to measure mean pulmonary artery pressure (MPAP), cardiac output (CO) and hence pulmonary vascular resistance (PVR). 3. Treatment with salbutamol significantly increased MPAP during normoxaemia and hypoxaemia compared with placebo at 12.0 +/- 1.2 vs 8.0 +/- 0.7 mm Hg and 28.6 +/- 0.9 vs 25.2 +/- 1.0 mm Hg, respectively (P < 0.05). Salbutamol caused a significant increase in heart rate compared with placebo and effects were additive to those of hypoxia at 74 +/- 2 vs 67 +/- 3 beats min-1 during normoxaemia and 84 +/- 3 vs 77 +/- 4 beats min-1 during hypoxaemia, respectively (P < 0.05). Whilst systemic vascular resistance fell in response to salbutamol, PVR was unchanged by salbutamol during either normoxaemia or hypoxaemia. Cardiac output was increased by salbutamol and by hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D G Kiely
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
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41
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Abstract
1. Abnormalities of myocardial relaxation may occur as a consequence of myocyte hypoxia. We have therefore examined the effects of hypoxaemia on right and left ventricular diastolic function in 10 healthy male subjects. 2. After resting to reach baseline haemodynamics, subjects were rendered hypoxaemic by breathing a variable nitrogen/oxygen mixture. Oxygen saturation (SaO2) was maintained at 85-90% for 20 min and then at 75-80% for a further 20 min. Haemodynamic and diastolic filling parameters were measured noninvasively at baseline and at the end of each period of hypoxaemia. 3. Diastolic filling of both ventricles was significantly impaired by hypoxaemia. In comparison with baseline, left ventricular isovolumic relaxation time and transmitral E-wave deceleration time corrected for heart rate were significantly prolonged at SaO2 75-80%: mean difference in corrected relaxation time, 9.8 ms (95% confidence interval 1-19); mean difference in corrected deceleration time, 34 ms (95% confidence interval 11-56). Similarly, right ventricular isovolumic relaxation time and transtricuspid E-wave deceleration time were significantly prolonged at SaO2 values of 75-80% compared with baseline: mean difference in relaxation time, 20.3 ms (95% confidence interval 3-38); mean difference in deceleration time, 33 ms (95% confidence interval 11-55). 4. During hypoxaemia there were dose-related increases in heart rate, cardiac output and mean pulmonary artery pressure, but no effects on mean arterial pressure. 5. Hypoxaemia significantly impairs relaxation of left and right ventricles in normal humans. These changes may reflect impairment of intracellular calcium transport secondary to the effects of myocyte hypoxia.
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Affiliation(s)
- R I Cargill
- Department of Clinical Pharmacology, Ninewells Hospital, Scotland, U.K
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42
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Affiliation(s)
- R I Cargill
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK
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