1
|
Impact of rapid sequential combination therapy on distinct haemodynamic measures in newly diagnosed pulmonary arterial hypertension. ESC Heart Fail 2024; 11:1540-1552. [PMID: 38224960 PMCID: PMC11098663 DOI: 10.1002/ehf2.14611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/16/2023] [Accepted: 11/16/2023] [Indexed: 01/17/2024] Open
Abstract
AIMS In pulmonary arterial hypertension (PAH), upfront combination therapy with ERA and PDE5i is associated with a reduction in morbidity and mortality events and improves standard haemodynamics, but data remain limited. Aims of this study were (i) to capture detailed haemodynamic effects of rapid sequential dual combination therapy in patients with newly diagnosed PAH; (ii) to monitor the impact of treatment initiation on clinical variables and patients' risk status, and (iii) to compare the treatment effect in patients with 'classical PAH' and 'PAH with co-morbidities'. METHODS Fifty patients (median age 57 [42-71] years, 66% female) with newly diagnosed PAH (76% idiopathic) were treated with a PD5i/sGC-S or ERA, followed by addition of the respective other drug class within 4 weeks. All patients underwent repeat right heart catheterization (RHC) during early follow-up. RESULTS At early repeat RHC (7 ± 2 months), there were substantial reductions in mean pulmonary artery pressure (mPAP: 52.2 ± 13.5 to 39.0 ± 10.6 mmHg; -25.3%), and pulmonary vascular resistance (PVR: 12.1 ± 5.7 to 5.8 ± 3.1 WU; -52.1%), and an increase in cardiac index (2.1 ± 0.4 to 2.7 ± 0.7 mL/min/m2; +32.2%) (all P < 0.05). Haemodynamic improvements correlated with improved clinical parameters including 6-min walking distance (336 ± 315 to 389 ± 120 m), NTproBNP levels (1.712 ± 2.024 to 506 ± 550 ng/L, both P < 0.05) and WHO-FC at 12 months, resulting in improved risk status, and were found in patients with few (n = 37) or multiple cardiovascular co-morbidities (BMI > 30 kg/m2, hypertension, diabetes, coronary artery disease [≥3]; n = 13), albeit baseline PVR in PAH patients with multiple co-morbidities was lower (9.3 ± 4.4 vs. 13.1 ± 5.9 WU) and PVR reduction less pronounced compared with those with few co-morbidities (-42.7% vs. -54.7%). However, comprehensive haemodynamic assessment considering further variables of prognostic relevance such as stroke volume index and pulmonary artery compliance showed similar improvements among the two groups (SVI: +50.0% vs. +49.2%; PAC: 91.7% vs. 100.0%). Finally, the 4-strata risk assessment approach was better able to capture treatment response as compared with other approaches, particularly in patients with co-morbidities. CONCLUSIONS Rapid sequential combination therapy with PDE5i/sGC-S and ERA substantially ameliorates cardiopulmonary haemodynamics at early follow-up in patients without, and to a lesser extent, with cardiovascular co-morbidities. This occurs in line with improvements of clinical parameters and risk status.
Collapse
|
2
|
Positive Vasoreactivity Testing in Pulmonary Arterial Hypertension: Therapeutic Consequences, Treatment Patterns, and Outcomes in the Modern Management Era. Circulation 2024; 149:1549-1564. [PMID: 38606558 DOI: 10.1161/circulationaha.122.063821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/21/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Among patients with pulmonary arterial hypertension (PAH), acute vasoreactivity testing during right heart catheterization may identify acute vasoresponders, for whom treatment with high-dose calcium channel blockers (CCBs) is recommended. However, long-term outcomes in the current era remain largely unknown. We sought to evaluate the implications of acute vasoreactivity response for long-term response to CCBs and other outcomes. METHODS Patients diagnosed with PAH between January 1999 and December 2018 at 15 pulmonary hypertension centers were included and analyzed retrospectively. In accordance with current guidelines, acute vasoreactivity response was defined by a decrease of mean pulmonary artery pressure by ≥10 mm Hg to reach <40 mm Hg, without a decrease in cardiac output. Long-term response to CCBs was defined as alive with unchanged initial CCB therapy with or without other initial PAH therapy and World Health Organization functional class I/II and/or low European Society of Cardiology/European Respiratory Society risk status at 12 months after initiation of CCBs. Patients were followed for up to 5 years; clinical measures, outcome, and subsequent treatment patterns were captured. RESULTS Of 3702 patients undergoing right heart catheterization for PAH diagnosis, 2051 had idiopathic, heritable, or drug-induced PAH, of whom 1904 (92.8%) underwent acute vasoreactivity testing. A total of 162 patients fulfilled acute vasoreactivity response criteria and received an initial CCB alone (n=123) or in combination with another PAH therapy (n=39). The median follow-up time was 60.0 months (interquartile range, 30.8-60.0), during which overall survival was 86.7%. At 12 months, 53.2% remained on CCB monotherapy, 14.7% on initial CCB plus another initial PAH therapy, and the remaining patients had the CCB withdrawn and/or PAH therapy added. CCB long-term response was found in 54.3% of patients. Five-year survival was 98.5% in long-term responders versus 73.0% in nonresponders. In addition to established vasodilator responder criteria, pulmonary artery compliance at acute vasoreactivity testing, low risk status and NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels at early follow-up correlated with long-term response and predicted survival. CONCLUSIONS Our data display heterogeneity within the group of vasoresponders, with a large subset failing to show a sustained satisfactory clinical response to CCBs. This highlights the necessity for comprehensive reassessment during early follow-up. The use of pulmonary artery compliance in addition to current measures may better identify those likely to have a good long-term response.
Collapse
|
3
|
Reply to: The puzzles surrounding the impact of face masks on 6-minute walking distance in pulmonary hypertension. Eur Respir J 2024; 63:2400529. [PMID: 38754949 DOI: 10.1183/13993003.00529-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 05/18/2024]
|
4
|
Dual-layer dual-energy CT-derived pulmonary perfusion for the differentiation of acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eur Radiol 2024; 34:2944-2956. [PMID: 37921925 PMCID: PMC11126515 DOI: 10.1007/s00330-023-10337-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/18/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVES To evaluate dual-layer dual-energy computed tomography (dlDECT)-derived pulmonary perfusion maps for differentiation between acute pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This retrospective study included 131 patients (57 patients with acute PE, 52 CTEPH, 22 controls), who underwent CT pulmonary angiography on a dlDECT. Normal and malperfused areas of lung parenchyma were semiautomatically contoured using iodine density overlay (IDO) maps. First-order histogram features of normal and malperfused lung tissue were extracted. Iodine density (ID) was normalized to the mean pulmonary artery (MPA) and the left atrium (LA). Furthermore, morphological imaging features for both acute and chronic PE, as well as the combination of histogram and morphological imaging features, were evaluated. RESULTS In acute PE, normal perfused lung areas showed a higher mean and peak iodine uptake normalized to the MPA than in CTEPH (both p < 0.001). After normalizing mean ID in perfusion defects to the LA, patients with acute PE had a reduced average perfusion (IDmean,LA) compared to both CTEPH patients and controls (p < 0.001 for both). IDmean,LA allowed for a differentiation between acute PE and CTEPH with moderate accuracy (AUC: 0.72, sensitivity 74%, specificity 64%), resulting in a PPV and NPV for CTEPH of 64% and 70%. Combining IDmean,LA in the malperfused areas with the diameter of the MPA (MPAdia) significantly increased its ability to differentiate between acute PE and CTEPH (sole MPAdia: AUC: 0.76, 95%-CI: 0.68-0.85 vs. MPAdia + 256.3 * IDmean,LA - 40.0: AUC: 0.82, 95%-CI: 0.74-0.90, p = 0.04). CONCLUSION dlDECT enables quantification and characterization of pulmonary perfusion patterns in acute PE and CTEPH. Although these lack precision when used as a standalone criterion, when combined with morphological CT parameters, they hold potential to enhance differentiation between the two diseases. CLINICAL RELEVANCE STATEMENT Differentiating between acute PE and CTEPH based on morphological CT parameters is challenging, often leading to a delay in CTEPH diagnosis. By revealing distinct pulmonary perfusion patterns in both entities, dlDECT may facilitate timely diagnosis of CTEPH, ultimately improving clinical management. KEY POINTS • Morphological imaging parameters derived from CT pulmonary angiography to distinguish between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension lack diagnostic accuracy. • Dual-layer dual-energy CT reveals different pulmonary perfusion patterns between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. • The identified parameters yield potential to enable more timely identification of patients with chronic thromboembolic pulmonary hypertension.
Collapse
|
5
|
CT-derived lung vessel morphology correlates with prognostic markers in precapillary pulmonary hypertension. J Heart Lung Transplant 2024; 43:54-65. [PMID: 37619642 DOI: 10.1016/j.healun.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/30/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND While computed tomography pulmonary angiography (CTPA) is an integral part of the work-up in patients with suspected pulmonary hypertension (PH), there is no established CTPA-derived prognostic marker. We aimed to assess whether quantitative readouts of lung vessel morphology correlate with established prognostic indicators in PH. METHODS We applied a fully-automatic in-house developed algorithm for segmentation of arteries and veins to determine lung vessel morphology in patients with precapillary PH who underwent right heart catheterization and CTPA between May 2016 and May 2019. Primary endpoint of this retrospective study was the calculation of receiver operating characteristics for identifying low and high mortality risk according to the 3-strata risk assessment model presented in the current guidelines. RESULTS We analyzed 73 patients, median age 65 years (interquartile range (IQR): 54-76), female/male ratio 35/38, median mean pulmonary arterial pressure 37 mm Hg (IQR: 30-46), and found significant correlations with important prognostic factors in pulmonary arterial hypertension. N-terminal pro-brain natriuretic peptide, cardiac index, mixed venous oxygen saturation, and 6-minute walking distance were correlated with the ratio of the number of arteries over veins with vessel diameters of 6-10 mm (Spearman correlation coefficients ρ = 0.64, p < 0.001; ρ = -0.60, p < 0.001; ρ = -0.47, p = 0.005; ρ = -0.45, p = 0.001, respectively). This ratio predicted a low- and high-risk score with an area under the curve of 0.73 (95% confidence interval (CI): 0.56-0.90) and 0.86 (95% CI: 0.74-0.97), respectively. CONCLUSIONS The ratio of the number of arteries over veins with diameters between 6 and 10 mm is significantly correlated with prognostic markers in pulmonary hypertension and predicts low and high mortality risk.
Collapse
|
6
|
Impact of face masks on the 6-minute walk distance in pulmonary hypertension patients during the COVID-19 pandemic: a prospective, randomised cross-over study. Eur Respir J 2023; 62:2201454. [PMID: 37827573 PMCID: PMC10627309 DOI: 10.1183/13993003.01454-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
In patients with pulmonary hypertension (PH) or with other pulmonary or cardiac diseases, the 6-minute walking test – accompanied by the Borg dyspnea score – is frequently utilised as a semi-quantitative measure of exercise capacity [1]. The 6-minute walking distance (6 MWD) also serves as primary or key secondary endpoint in numerous clinical trials assessing the efficacy of pharmacotherapies in various forms of PH [2, 3]. Furthermore, the 6MWD is among the key non-invasive measures of multi-modal risk assessment in pulmonary arterial hypertension (PAH) [4–6]. In this context, cut-off values of 440 m and 165 m have been validated to indicate low, intermediate and high mortality risk, respectively, in the 3-strata model proposed by the current ESC/ERS guidelines [1], with an additional cut-off of 320 m to discriminate between intermediate-high and intermediate-low risk in the recently introduced 4-strata approach [7, 8].
Collapse
|
7
|
Preexisting Chronic Thromboembolic Pulmonary Hypertension in Acute Pulmonary Embolism. Chest 2023; 163:923-932. [PMID: 36621756 DOI: 10.1016/j.chest.2022.11.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. RESEARCH QUESTION Which radiologic findings on CT pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of preexisting CTEPH? STUDY DESIGN AND METHODS This study included unselected patients with acute PE who were prospectively followed up for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for preexisting CTEPH; in case of disagreement, a decision was reached by a 2:1 majority with a third expert radiologist. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. RESULTS Signs of chronic PE or CTEPH at baseline were identified in 46 of 303 included patients (15%). Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days following acute PE) were found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of preexisting CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. INTERPRETATION Searching for predefined radiologic parameters suggesting preexisting CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis.
Collapse
|
8
|
Automatische Segmentierung der peripheren Pulmonalarterien und -venen für die Diagnose der Pulmonalen Hypertonie. ROFO-FORTSCHR RONTG 2022. [DOI: 10.1055/s-0042-1749934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Profiles and treatment patterns of patients with pulmonary arterial hypertension on monotherapy at experienced centres. ESC Heart Fail 2022; 9:2873-2885. [PMID: 35706353 DOI: 10.1002/ehf2.13804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Guideline recommendations highlight the critical role of combination therapy for the treatment of pulmonary arterial hypertension (PAH). Conversely, registry data demonstrate that a considerable number of PAH patients remain on monotherapy. The reasons for this discrepancy remain elusive. The aim of this study was to assess the patient profiles, treatment patterns, and disease characteristics of patients diagnosed with PAH who were kept on monotherapy at experienced pulmonary hypertension (PH) centres and to capture potential reasons for monotherapy. METHODS AND RESULTS We analysed the patient profiles of 182 patients on monotherapy with PAH-targeted drugs, managed at experienced PH expert centres (Cologne, Giessen, Heidelberg, and Dresden). Patients were identified based on their latest follow-up visit and analysed retrospectively from the time of PAH diagnosis to last follow-up. Patients were dichotomized by age, and patient characteristics, treatment patterns, response to therapy, change in risk status, and drug tolerability were recorded during the course of their disease. Patients' mean age was 69.1 ± 13.1 years at the most recent follow-up (Key Time Point 1) and 64.5 ± 14.9 years at the time of diagnosis (Key Time Point 2). The mean time on monotherapy was 60.7 ± 53.8 months; 35.7/64.3% of patients were male/female. The majority (66.5%) had idiopathic PAH, followed by PAH associated with connective tissue disease (17.0%) and portopulmonary PH (8.2%). Among patients on monotherapy, there were five main clusters: (i) patients with failed escalation attempts mostly because of intolerability (26.9%); (ii) low risk on monotherapy, favourable response, and no reason for escalation (24.2%); (iii) patients with mild PAH (36.3%); (iv) elderly patients with PAH and multiple co-morbidities (38.5%); and (v) patients with associated forms of PAH where the level of evidence for combination therapies is considered low (16.5%). There were substantial differences between patients above or below the median age (68 years). The most frequently used monotherapy for PAH was phosphodiesterase type 5 inhibitors (75.3%). CONCLUSIONS A considerable number of PAH patients are on monotherapy at large PH expert centres, characterized by specific reasons that justify this kind of treatment. Nevertheless, as comprehensive treatment strategies have shown improved long-term outcomes even in mildly symptomatic patients, each case of monotherapy should be justified.
Collapse
|
10
|
Spectral Detector CT-Derived Pulmonary Perfusion Maps and Pulmonary Parenchyma Characteristics for the Semiautomated Classification of Pulmonary Hypertension. Front Cardiovasc Med 2022; 9:835732. [PMID: 35391852 PMCID: PMC8982082 DOI: 10.3389/fcvm.2022.835732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTo evaluate the usefulness of spectral detector CT (SDCT)-derived pulmonary perfusion maps and pulmonary parenchyma characteristics for the semiautomated classification of pulmonary hypertension (PH).MethodsA total of 162 consecutive patients with right heart catheter (RHC)-proven PH of different aetiologies as defined by the current ESC/ERS guidelines who underwent CT pulmonary angiography (CTPA) on SDCT and 20 patients with an invasive rule-out of PH were included in this retrospective study. Semiautomatic lung segmentation into normal and malperfused areas based on iodine density (ID) as well as automatic, virtual non-contrast-based emphysema quantification were performed. Corresponding volumes, histogram features and the ID SkewnessPerfDef-Emphysema-Index (δ-index) accounting for the ratio of ID distribution in malperfused lung areas and the proportion of emphysematous lung parenchyma were computed and compared between groups.ResultsPatients with PH showed a significantly greater extent of malperfused lung areas as well as stronger and more homogenous perfusion defects. In group 3 and 4 patients, ID skewness revealed a significantly more homogenous ID distribution in perfusion defects than in all other subgroups. The δ-index allowed for further subclassification of subgroups 3 and 4 (p < 0.001), identifying patients with chronic thromboembolic PH (CTEPH, subgroup 4) with high accuracy (AUC: 0.92, 95%-CI, 0.85–0.99).ConclusionAbnormal pulmonary perfusion in PH can be detected and quantified by semiautomated SDCT-based pulmonary perfusion maps. ID skewness in malperfused lung areas, and the δ-index allow for a classification of PH subgroups, identifying groups 3 and 4 patients with high accuracy, independent of reader expertise.
Collapse
|
11
|
Detection of patients with chronic thromboembolic pulmonary hypertension by volumetric iodine quantification in the lung-a case control study. Quant Imaging Med Surg 2022; 12:1121-1129. [PMID: 35111609 DOI: 10.21037/qims-21-229] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023]
Abstract
Background To evaluate whether volumetric iodine quantification of the lung allows for the automatic identification of patients with chronic thromboembolic pulmonary hypertension (CTEPH) and whether the extent of pulmonary malperfusion correlates with invasive hemodynamic parameters. Methods Retrospective data base search identified 30 consecutive patients with CTEPH who underwent CT pulmonary angiography (CTPA) on a spectral-detector CT scanner. Thirty consecutive patients who underwent an identical CT examination for evaluation of suspected acute pulmonary embolism and had no signs of pulmonary embolism or PH, served as control cohort. Lungs were automatically segmented for all patients and normal and malperfused volumes were segmented based on iodine density thresholds. Results were compared between groups. For correlation analysis between the extent of malperfused volume and mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) 3 patients were excluded because of a time span of more than 30 days between CTPA and right heart catheterization. Results Patients with CTEPH had a higher percentage of malperfused lung compared to controls (43.25%±24.72% vs. 21.82%±20.72%; P=0.001) and showed reduced mean iodine density in malperfused and normal-perfused lung areas, as well as in the vessel volume. Controls showed a left-tailed distribution of iodine density in malperfused lung areas while patients with CTEPH had a more symmetrical distribution (Skew: -0.382±0.435 vs. -0.010±0.396; P=0.004). Patients with CTEPH showed a significant correlation between the percentage of malperfused lung volume and the PVR (r=0.57, P=0.001). Conclusions Volumetric iodine quantification helps to identify patients with CTEPH by showing increased areas of malperfusion. The extent of malperfusion might provide a measurement for disease severity in patients with CTEPH.
Collapse
|
12
|
|
13
|
Ferric carboxymaltose in patients with pulmonary arterial hypertension and iron deficiency: a long-term study. J Cachexia Sarcopenia Muscle 2021; 12:1501-1512. [PMID: 34498427 PMCID: PMC8718050 DOI: 10.1002/jcsm.12764] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/03/2021] [Accepted: 07/02/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease with limited survival. Iron deficiency (ID) correlates with disease severity and mortality. While oral iron supplementation was shown to be insufficient in such patients, the potential impact of parenteral iron on clinical measures warrants further investigation. METHODS We retrospectively analysed the long-term effects of intravenous ferric carboxymaltose (FCM) on iron status and clinical measures in patients with PAH and ID [ferritin < 100 μg/L or ferritin 100-300 μg/L and transferrin saturation (TSAT) < 20%] who were on stable targeted PAH therapy, compared with matched controls without ID. Patients with ID received a single infusion of FCM (500 to 1000 mg). Clinical measures monitored included exercise capacity, World Health Organization (WHO) functional class, ESC/ERS risk status, and hospitalizations. The observation period was up to 18 months. RESULTS One hundred and seventeen patients (mean age 60.9 ± 16.1 years; 64.1% females) with confirmed PAH and on stable targeted therapy for ≥3 months were included (58 with and 59 patients without ID who did not receive FCM). In patients with ID, iron supplementation with FCM resulted in an immediate and sustained improvement of iron status for up to 18 months (serum iron, ferritin, TSAT, all P < 0.01). Fourteen patients in the FCM group received a second FCM infusion after 9.6 ± 4.8 months due to recurrent ID. At 6 and 18 months after FCM infusion, 6 min walk distance improved from 377.5 ± 15.9 at baseline to 412.5 ± 15.1 and 400.8 ± 14.5 m, respectively (both P < 0.05). WHO functional class (P < 0.05) and ESC/ERS risk status also improved, and there was a reduction of hospitalizations for worsening PAH in the 12 months post vs. prior to iron repletion (P = 0.029). No significant changes were observed in the control group. FCM was well tolerated in all patients, with no severe adverse events. CONCLUSIONS In addition to targeted therapy, correction of ID by parenteral iron supplementation with FCM appears feasible and safe, has sustained effects on iron status, and may improve the clinical status and hospitalization rates in patients with PAH. Larger controlled studies are required to confirm this finding.
Collapse
|
14
|
Selonsertib in adults with pulmonary arterial hypertension (ARROW): a randomised, double-blind, placebo-controlled, phase 2 trial. THE LANCET RESPIRATORY MEDICINE 2021; 10:35-46. [PMID: 34425071 DOI: 10.1016/s2213-2600(21)00032-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data obtained in human lung tissue and preclinical models suggest that oxidative stress and increased apoptosis signal-regulating kinase 1 (ASK1) activity might have a prominent role in the pathobiology of pulmonary arterial hypertension (PAH). The purpose of this study was to determine the efficacy, safety, and tolerability of the ASK1 inhibitor selonsertib compared with placebo in patients with PAH. METHODS We did a randomised, double-blind, placebo-controlled, phase 2 trial at 46 centres located in Canada, France, Germany, Italy, the Netherlands, Spain, the UK, and the USA. Participants were aged 18-75 years and had an established diagnosis of idiopathic or hereditary PAH, or PAH associated with connective tissue disease, drugs or toxins, human immunodeficiency virus, or repaired congenital heart defects. Patients were stratified by PAH aetiology and background therapy, and randomly assigned (1:1:1:1) using an interactive voice-response or web-response system to placebo or selonsertib 2 mg, 6 mg, or 18 mg administered orally once daily. Both placebo and selonsertib were in tablet form. The primary efficacy endpoint was change in pulmonary vascular resistance, measured by right heart catheterisation, from baseline to week 24 in the full analysis set. Pair-wise comparisons between each of the selonsertib groups and the placebo group were made with a stratified Wilcoxon (van Elteren) rank sum test for participants without major protocol deviations who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT02234141. FINDINGS Between Dec 3, 2014, and Nov 13, 2015, 151 patients were enrolled and randomly assigned. Of 150 participants who received selonsertib or placebo, 134 (89%) completed 24 weeks of the randomly assigned treatment; all were on background PAH therapy (138 [92%] on combination therapy). 90 (60%) patients were in functional class II and 60 (40%) in functional class III. Mean baseline pulmonary vascular resistance was 772 (SD 334) dyn·s/cm5. Change in pulmonary vascular resistance was 6·0 dyn·s/cm5 (SD 28·0; n=31) for placebo, and 35·0 (35·4) dyn·s/cm5 (n=35; p=0·21 vs placebo) for 2 mg selonsertib, -28·0 (30·2) dyn·s/cm5 (n=34; p=0·27 vs placebo) for 6 mg selonsertib, and -21·0 (37·9) dyn·s/cm5 (n=36; p=0·60 vs placebo) for 18 mg selonsertib. The most frequent adverse events were headache (17 [15%]), abnormal dreams (eight [7%]), nausea (seven [6%]), and diarrhoea (seven [6%]) in the selonsertib groups, and headache (six [16%]), nausea (five [14%]), and diarrhoea (two [5%]) in the placebo group. Serious adverse events occurred in 23 (20%) of 113 selonsertib-treated patients and seven (19%) of 37 patients who received placebo. INTERPRETATION Selonsertib once daily for 24 weeks did not lead to a significant reduction in pulmonary vascular resistance or to clinical improvement in patients with PAH, but appeared to be safe and well tolerated. Although these data do not support the clinical use of selonsertib in PAH, further study of the potential of targeting the ASK1-p38 pathway in PAH is warranted. FUNDING Gilead Sciences.
Collapse
|
15
|
Quality of life 3 and 12 months after acute pulmonary embolism: analysis of 617 patients from the prospective multicentre FOCUS study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Few data are available on the long-term course and predictors of quality of life (QoL) after acute pulmonary embolism (PE).
Aims
To evaluate the kinetics and determinants of QoL at 3 and 12 months after acute PE.
Methods
The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively followed consecutive adult patients with objectively diagnosed PE. For this analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at two predefined visits 3 and 12 months after PE. PEmb-QoL, studied as total score and in its six dimensions, ranges from 0% (best QoL) to 100% (worst QoL). We studied the course of PEmb-QoL and the impact of baseline characteristics using multivariable linear regression.
Results
In 617 included patients (44% women, median age 62 years), overall QoL improved from 3 to 12 months, with a decrease of the mean PEmb-QoL score from 25.3% to 21.5% (p-value <0.001). Intra-individual correlation between PEmb-QoL score at 3 and 12 months was high; Figure A. The improvement was consistent across all PEmb-QoL dimensions; Figure B. Female sex, cardiopulmonary diseases, and higher body mass index were the main factors associated with a worse QoL; Table. Age and smoking affected QoL only at 12 months. The improvement in QoL was faster in patients without cardiopulmonary diseases (−4.2%; 95% CI: −5.2% to −3.1%), without previous VTE (−4.3%; −5.5% to −3.2%), and in non-smokers (−4.2%; −5.3% to −3.1%).
Conclusions
In a large cohort of patients with pulmonary embolism, we quantified the improvement of QoL between 3 and 12 months after diagnosis. We identified factors independently associated with lower QoL and slower recovery of QoL that may reflect special patient needs. These estimates may facilitate the planning and interpretation of clinical trials with QoL as a study outcome.
Figure 1
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research
Collapse
|
16
|
Flow rate variance of a fully implantable pump for the delivery of intravenous treprostinil in pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020910136. [PMID: 32206306 PMCID: PMC7074510 DOI: 10.1177/2045894020910136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/07/2020] [Indexed: 01/31/2023] Open
Abstract
Implantable infusion pumps might improve the convenience and safety of intravenous treprostinil for pulmonary arterial hypertension. The LENUS Pro® pump (approved in Europe) has a fixed flow rate. Based on 126 pumps and 2853 refills, we retrospectively analyzed the actual flow rate from 09/2010 to 09/2018. A relevant flow rate variance is evident after three years; therefore, flow rate monitoring and dose adjustment are mandatory.
Collapse
|
17
|
Abstract
Pulmonary hypertension (PH) is a frequent hemodynamic condition that is highly prevalent in patients with heart failure and reduced (HFrEF) or preserved ejection fraction (HFpEF). Irrespective of left ventricular EF, the presence of PH and right ventricular (RV) dysfunction are highly relevant for morbidity and mortality in patients with heart failure. While elevated left-sided filling pressures and functional mitral regurgitation primarily lead to post-capillary PH, current guidelines and recommendations distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH), the latter being defined by a pulmonary vascular resistance (PVR) of ≥3 Wood units. Here, we describe the pathophysiology and clinical relevance of these distinct entities, and report on the diagnostic work-up including remote pulmonary artery pressure (PAP) monitoring. Furthermore, we highlight strategies to manage PH and improve RV function in heart failure, which may include optimized management of HFrEF and HFpEF (medical and interventional), sufficient volume control, catheter-based mitral valve repair, and-in selected cases-targeted PH therapy. In this context, we also highlight gaps in evidence and the need for further research.
Collapse
|
18
|
Abstract
Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.
Collapse
|
19
|
P4511Characteristic hemodynamic and metabolic response patterns differ between patients with stable chronic left vs right heart failure. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Patients with chronic left and right heart failure show a reduction in peak oxygen uptake (VO2), even with optimal medical therapy. A non-invasive determination whether the mechanism of exercise limitation is primarily due to left or right-heart failure may be a challenge in clinical practice. The simultaneous analysis of metabolic and hemodynamic responses during exercise may allow an improved differentiation of exercise limitation. However, only little is known about the combined hemodynamic/metabolic exercise response patterns in these patients.
OBJECTIVES
We sought to characterize the simultaneous hemodynamic and metabolic response to exercise in stable patients with chronic, isolated left vs right heart failure.
Methods
We analyzed a cohort of highly selected patients with isolated right heart failure (group 1) and isolated left heart failure (group 2). All patients were in functional class II and III, and under stable medical Treatment. All patients had received right heart catheterization before enrollment. All of the patients in group 1 and none of the patients in group 2 showed an elevated pulmonary vascular resistance (PVR). All patients received a cardiopulmonary exercise test (CPET) with a ramp protocol up to maximal exercise tolerance. During a second visit, a combined CPET/stress echocardiography was performed with a two step constant work rate protocol. For step 1, a workrate below the patients' anaerobic threshold was chosen. For step 2, 80% of the patients' maximum workrate from the ramp test was chosen. Each step was performed until a complete echocardiographic image acquisition was obtained. Echocardiographic parameters, including stroke volume measurements, were obtained once at rest and for each of the two exercise steps.
Results
We recruited 18 patients (n=9 in group 1, n=9 in group 2). There were no significant differences in demographic baseline characteristics. There were no adverse events. In the inital ramp CPET, both groups showed a moderate reduction in peak VO2 (53,0±12,4 vs 63,3±12,8% of predicted). The absolute peak VO2 values, corrected for body weight, showed no significant difference (16,7±4,5 vs 16,5±5,1 ml/min/kg). While the increase in VO2 (Figure 1A) and cardiac index (Figure 1B) during step 1 and step 2 of the simultaneous CPET/stress echocardiography was similar between both groups, the increase of stroke volume index with exercise was significantly reduced in the group with right heart failure, while the group with left heart failure increased stroke volume index during exercise (Figure 1C).
Figure 1
Conclusions
The simultaneous evaluation of hemodynamic and metabolic parameters by CPET/stress echocardiography is safe and may reveal characteristic response patterns to exercise in patients with chronic left vs right heart failure. Patients with right heart failure seem to be less able to increase stroke volume during exercise than patients with left heart failure.
Acknowledgement/Funding
This project was partly funded by Actelion Pharmaceuticals
Collapse
|
20
|
P6325Gas exchange improvements during exercise correlate with hemodynamic changes in heart failure patients with a left ventricular assist device. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure.
Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven.
There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation.
To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times.
Methods
We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively.
Results
Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p<0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p<0,001), PAP mean (40 vs 22 mmHg, p<0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p<0,001). However, there was no significant increase in peak VO2 after 6 months.
12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1).
Conclusion
Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.
Collapse
|
21
|
High-risk pregnancy in a patient with pulmonary arterial hypertension due to congenital heart disease (PAH-CHD) with temporary shunt inversion and deoxygenation. Pulm Circ 2019; 9:2045894019835649. [PMID: 30767601 PMCID: PMC6429658 DOI: 10.1177/2045894019835649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Atrial septal defect (ASD) is one of the most frequent congenital heart diseases (CHD). Up to 10% of adults with an ASD develop pulmonary arterial hypertension (PAH, PAH-CHD) in their lifetime. Despite improved therapy options, gravidity remains a substantial risk for both maternal and neonatal mortality in PAH-CHD patients. In our patient, gravidity remained uncomplicated until week 32, under specific monotherapy with tadalafil, before onset of dyspnea and markedly increase of systolic pulmonary arterial pressure (PAP) was observed in echocardiography. Urgent Caesarian delivery was performed without any complications and a healthy baby was born. However, immediately afterwards, the patient desaturated (SpO2 65%, PaO2 37 mmHg) due to a shunt inversion with now right-to-left shunt through the residual ASD. She was admitted to our intensive care unit and specific PH therapy was escalated to a triple combination of tadalafil, ambrisentan, and iloprost. Hereafter, in a slow process of approximately three weeks, the patient's condition improved to baseline. This rare case of a young woman with high-risk pregnancy in PAH-CHD highlights the hemodynamic changes and treatment options during pregnancy in these patients and emphasizes the urgency of a close monitoring at specialized GUCH/PAH centers with experience in managing PAH under these circumstances.
Collapse
|
22
|
Diagnosis of pulmonary hypertension using spectral-detector CT. Int J Cardiol 2019; 285:80-85. [PMID: 30905521 DOI: 10.1016/j.ijcard.2019.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/04/2019] [Accepted: 03/11/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the value of spectral-detector CT (SDCT) in the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), its differentiation against other etiologies of pulmonary hypertension (PH) and in the prediction of disease severity. MATERIALS AND METHODS 60 patients with suspected PH underwent SDCT. Additional diagnostic tests in accordance with the ESC guidelines including right heart catherization and VQ-SPECT were performed. After full diagnostic work-up patients were classified as: 21 precapillary PH, 5 postcapillary PH, 6 combined pre- and postcapillary PH, 19 CTEPH, 9 no PH. SDCT examinations were analyzed by two blinded readers deciding on the diagnosis of CTEPH and scoring the extent of perfusion abnormalities on iodine density images. An additional reading was performed using conventional CTPA images only. RESULTS With access to SDCT data, both readers reached a sensitivity of 100% for the diagnosis of CTEPH with a specificity of 95.1% and 87.8%. On analysis of conventional CTPA images alone, specificity and diagnostic confidence decreased for both readers (Specificity 90.2 and 85.3%) while sensitivity dropped for the less experienced reader only (Sensitivity 78.9%). Patients with PH showed significantly more perfusion abnormalities than patients without PH (16.6 ± 8.4 vs. 9.5 ± 8.9 p < 0.001) and the extent of perfusion abnormalities correlated with the mean pulmonary artery pressure (r = 0.37 p = 0.008). CONCLUSIONS SDCT offers confident identification of patients with CTEPH and enables a comprehensive analysis of pulmonary vasculature, pulmonary perfusion and the lung parenchyma in a single examination for patients with suspected PH.
Collapse
|
23
|
Chronic thromboembolic pulmonary hypertension (CTEPH): Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:69-78. [PMID: 30195840 DOI: 10.1016/j.ijcard.2018.08.079] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.
Collapse
|
24
|
General measures and supportive therapy for pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:30-36. [PMID: 30190156 DOI: 10.1016/j.ijcard.2018.08.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to general measures (i.e. physical activity/supervised rehabilitation, pregnancy/contraception, elective surgery, infection prevention, psychological support, travel) and supportive therapy (i.e. anticoagulants, diuretics, oxygen, cardiovascular medications, anaemia/iron deficiency, arrhythmias) for PAH. While the European guidelines provide detailed recommendations for the use of targeted PAH therapies as well as supportive care, detailed treatment decisions in routine clinical care may be challenging, and the relevance of supportive care is often not sufficiently considered. In addition, new evidence became available, thus requiring a thorough reevaluation of specific recommendations. The detailed results and recommendations of the working group on general measures and supportive therapy for PAH, which were last updated in the spring of 2018, are summarized in this article.
Collapse
|
25
|
P1624Intravenous iron substitution improves pulmonary diffusion capacity in patients with iron deficiency and precapillary pulmonary hypertension. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
26
|
Influence of spectral detector CT based monoenergetic images on the computer-aided detection of pulmonary artery embolism. Eur J Radiol 2017; 95:242-248. [DOI: 10.1016/j.ejrad.2017.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/28/2017] [Indexed: 11/26/2022]
|
27
|
P2587Therapeutic effects of phosphodiesterase 5 inhibitors in patients with heart failure with preserved ejection fraction (HFpEF) and combined post- and pre-capillary pulmonary hypertension (Cpc-PH). Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p2587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
P3531Improvement of pulmonary diffusion capacity after intravenous iron substitution in patients with iron deficiency and pulmonary hypertension. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
29
|
Late outcomes after acute pulmonary embolism: rationale and design of FOCUS, a prospective observational multicenter cohort study. J Thromb Thrombolysis 2017; 42:600-9. [PMID: 27577542 PMCID: PMC5040729 DOI: 10.1007/s11239-016-1415-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute pulmonary embolism (PE) is a frequent cause of death and serious disability. The risk of PE-associated mortality and morbidity extends far beyond the acute phase of the disease. In earlier follow-up studies, as many as 30 % of the patients died during a follow-up period of up to 3 years, and up to 50 % of patients continued to complain of dyspnea and/or poor physical performance 6 months to 3 years after the index event. The most feared ‘late sequela’ of PE is chronic thromboembolic pulmonary hypertension (CTEPH), the true incidence of which remains obscure due to the large margin of error in the rates reported by mostly small, single-center studies. Moreover, the functional and hemodynamic changes corresponding to early, possibly reversible stages of CTEPH, have not been systematically investigated. The ongoing Follow-Up after acute pulmonary embolism (FOCUS) study will prospectively enroll and systematically follow, over a 2-year period and with a standardized comprehensive program of clinical, echocardiographic, functional and laboratory testing, a large multicenter prospective cohort of 1000 unselected patients (all-comers) with acute symptomatic PE. FOCUS will possess adequate power to provide answers to relevant remaining questions regarding the patients’ long-term morbidity and mortality, and the temporal pattern of post-PE abnormalities. It will hopefully provide evidence for future guideline recommendations regarding the selection of patients for long-term follow-up after PE, the modalities which this follow-up should include, and the findings that should be interpreted as indicating progressive functional and hemodynamic post-PE impairment, or the development of CTEPH.
Collapse
|
30
|
Oscillatory whole-body vibration improves exercise capacity and physical performance in pulmonary arterial hypertension: a randomised clinical study. Heart 2017; 103:592-598. [PMID: 28100544 PMCID: PMC5529961 DOI: 10.1136/heartjnl-2016-309852] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 09/23/2016] [Accepted: 09/29/2016] [Indexed: 01/11/2023] Open
Abstract
Objective In patients with pulmonary arterial hypertension (PAH), supportive therapies may be beneficial in addition to targeted medical treatment. Here, we evaluated the effectiveness and safety of oscillatory whole-body vibration (WBV) in patients on stable PAH therapy. Methods Twenty-two patients with PAH (mean PAP≥25 mm Hg and pulmonary arterial wedge pressure (PAWP)≤15 mm Hg) who were in world health organization (WHO)-Functional Class II or III and on stable PAH therapy for≥3 months, were randomised to receive WBV (16 sessions of 1-hour duration within 4 weeks) or to a control group, that subsequently received WBV. Follow-up measures included the 6-min walking distance (6MWD), cardiopulmonary exercise testing (CPET), echocardiography, muscle-power, and health-related quality of life (HRQoL; SF-36 and LPH questionnaires). Results When compared to the control group, patients receiving WBV exhibited a significant improvement in the primary endpoint, the 6MWD (+35.4±10.9 vs −4.4±7.6 m), resulting in a net benefit of 39.7±7.8 m (p=0.004). WBV was also associated with substantial improvements in CPET variables, muscle power, and HRQoL. The combined analysis of all patients (n=22) indicated significant net improvements versus baseline in the 6MWD (+38.6 m), peakVO2 (+65.7 mL/min), anaerobic threshold (+40.9 mL VO2/min), muscle power (+4.4%), and HRQoL (SF-36 +9.7, LPH −11.5 points) (all p<0.05). WBV was well tolerated in all patients, and no procedure-related severe adverse events (SAEs) occurred. Conclusions WBV substantially improves exercise capacity, physical performance, and HRQoL in patients with PAH who are on stable targeted therapy. This methodology may be utilised in structured training programmes, and may be feasible for continuous long-term physical exercise in these patients. Trial registration number NCT01763112; Results.
Collapse
|
31
|
Safety, Tolerability and Clinical Effects of a Rapid Dose Titration of Subcutaneous Treprostinil Therapy in Pulmonary Arterial Hypertension: A Prospective Multi-Centre Trial. Respiration 2016; 92:362-370. [DOI: 10.1159/000450759] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/13/2016] [Indexed: 11/19/2022] Open
|
32
|
[Chronic thromboembolic pulmonary hypertension: Recommendations of the Cologne Consensus Conference 2016]. Dtsch Med Wochenschr 2016; 141:S62-S69. [PMID: 27760452 DOI: 10.1055/s-0042-114529] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The 2015 European Guidelines on Pulmonary Hypertension did not cover only pulmonary arterial hypertension (PAH), but also other significant subgroups of pulmonary hypertension (PH). In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany to discuss open and controversial issues surrounding the practical implementation of the European Guidelines. Several working groups were initiated, one of which was dedicated to the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). In every patient with PH of unknown cause CTEPH should be excluded. The primary treatment option is surgical pulmonary endarterectomy (PEA) in a specialized multidisciplinary CTEPH center. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. For balloon pulmonary angioplasty (BPA), there is currently only limited experience. This option - as PEA - is reserved to specialized centers with expertise for this treatment method. In addition, a brief overview is given on pulmonary artery sarcoma, since its surgical treatment is often analogous to PEA. The recommendations of this working group are summarized in the present paper.
Collapse
|
33
|
Allgemeine und supportive Therapie der pulmonal arteriellen Hypertonie: Empfehlungen der Kölner Konsensus Konferenz 2016. Dtsch Med Wochenschr 2016; 141:S26-S32. [DOI: 10.1055/s-0042-114525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
34
|
Prognostic Relevance of Cardiopulmonary Exercise Testing in the Long-term Follow-up of Scleroderma Patients With and Without PAH. Chest 2016. [DOI: 10.1016/j.chest.2016.08.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
35
|
Safety, tolerability and clinical effects of a rapid dose titration of subcutaneous treprostinil therapy in pulmonary arterial hypertension: a prospective multi-centre trial. Pneumologie 2016. [DOI: 10.1055/s-0036-1572125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
36
|
Case report: Subjective loss of performance after pulmonary embolism in an athlete- beyond normal values. BMC Pulm Med 2016; 16:21. [PMID: 26821715 PMCID: PMC4730648 DOI: 10.1186/s12890-016-0180-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/13/2016] [Indexed: 11/16/2022] Open
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease. For patients with operable CTEPH, there is a clear recommendation for surgical removal of persistent thrombi by pulmonary endarterectomy (PEA). However, without the presence of PH, therapeutic management of chronic thromboembolic disease (CTED) is challenging - especially in highly trained subjects exceeding predicted values of maximal exercise capacity. Case presentation A 43-year-old male athlete reported with progressive exercise limitation since 8 months. Six months earlier, pulmonary embolism had occurred, and was treated since with oral anticoagulation. A pulmonary ventilation/perfusion scan showed severe ventilation/perfusion mismatch: chest CT and pulmonary angiography revealed bilateral wall-adherent thrombotic material, but pulmonary hemodynamics were completely normal. His peak oxygen uptake exceeded predicted values, however exercise ventilatory efficiency was abnormal, compared to a matching athlete. After thoroughly discussing therapeutic options with the patient, he successfully underwent pulmonary endarterectomy at an expert center. Five and twelve months after surgery, his maximal exercise capacity and ventilatory efficiency profoundly improved beyond preoperative values, and his subjective exercise tolerance had returned to normal. Conclusions Significant CTED may be present without relevant pathologic changes in pulmonary hemodynamics at rest. Reaching normal values of maximal exercise capacity does not exclude pulmonary vascular disease in highly trained subjects. More data are needed to evaluate the risk-/benefit ratio of PEA in patients with CTED and normal pulmonary hemodynamics. A thorough discussion with the patient as well as shared decision making regarding therapy are mandatory. Cardiopulmonary exercise testing may add important clinical information in the non-invasive diagnostic evaluation at baseline and during follow-up.
Collapse
|
37
|
Ferric carboxymaltose improves exercise capacity and quality of life in patients with pulmonary arterial hypertension and iron deficiency: A pilot study. Int J Cardiol 2014; 175:233-9. [DOI: 10.1016/j.ijcard.2014.04.233] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 04/16/2014] [Accepted: 04/22/2014] [Indexed: 01/10/2023]
|
38
|
Effect of intravenous iron on exercise capacity and quality of life in iron deficient pulmonary arterial hypertension patients. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
39
|
Fully reversible pulmonary arterial hypertension associated with dasatinib treatment for chronic myeloid leukaemia. Eur Respir J 2012; 38:218-20. [PMID: 21719499 DOI: 10.1183/09031936.00154210] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
40
|
[70-year-old woman with cardiac hypertrophy and severe pulmonary hypertension: pre- or postcapillary?]. Dtsch Med Wochenschr 2011; 136:2594-8. [PMID: 22160952 DOI: 10.1055/s-0031-1292855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
HISTORY AND ADMISSION FINDINGS A 70-year-old female patient was admitted with progressive dyspnea and peripheral edema. The patient had a medical history of myocardial hypertrophy, diastolic dysfunction and concomitant pulmonary hypertension (PH). INVESTIGATIONS The physical exam was suggestive of cardiac decompensation. Echocardiography showed myocardial hypertrophy, an enlarged left atrium as well as enlarged right-sided heart chambers. A prominent tricuspid regurgitation jet was present, and the estimated systolic right ventricular pressure was 65 mmHg. Invasive hemodynamic measurements showed a marked pressure elevation in the pulmonary circulation (mean PAP 51 mmHg), combined with an elevated left ventricular end-diastolic pressure (LVEDP) of 30 mmHg and a profound increase in the transpulmonary gradient (TPG, 21 mmHg). TREATMENT AND COURSE The synopsis of these findings led to the diagnosis of postcapillary PH with a prominent precapillary involvement and cardiac decompensation. Due to signs of volume overload, an adequate diuretic therapy was initiated. The patient was recompensated and lost 7 kg of weight, which was associated with substantial clinical improvement. At invasive follow-up hemodynamic measurement, the patient's PAP was substantially decreased and almost reached normal values. The previously diagnosed precapillary involvement had disappeared. CONCLUSION PH is a frequent phenomenon in patients with systolic and diastolic heart failure, and might initially appear as a combination of pre- and postcapillary involvement. The patients' volume status has a major influence on pulmonary hemodynamics. An adequate therapy of the underlying heart failure, especially an adequate diuresis, may have marked beneficial effects on pulmonary hemodynamics. Hemodynamic measurements should always be performed in compensated status.
Collapse
|
41
|
Treatment of pulmonary arterial hypertension (PAH): Updated Recommendations of the Cologne Consensus Conference 2011. Int J Cardiol 2011; 154 Suppl 1:S20-33. [DOI: 10.1016/s0167-5273(11)70490-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
42
|
Relevanz der maximalen Sauerstoffaufnahme und des endexpiratorischen CO 2-Partialdrucks in der Diagnostik der Sklerodermie-assoziierten pulmonal-arteriellen Hypertonie. Pneumologie 2011. [DOI: 10.1055/s-0030-1256821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
|
43
|
Afterload-related cardiac performance: a hemodynamic parameter with prognostic relevance in patients with sepsis in the Emergency Department. Crit Care 2011. [PMCID: PMC3061701 DOI: 10.1186/cc9491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
44
|
Extensive hepatic portal venous gas and gastric emphysema after successful resuscitation. Resuscitation 2011; 82:238-9. [DOI: 10.1016/j.resuscitation.2010.10.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/06/2010] [Indexed: 10/18/2022]
|
45
|
|
46
|
Abstract
The maltose regulon consists of 10 genes encoding an ABC transporter for maltose and maltodextrins as well as enzymes necessary for their degradation. MalK, the energy-transducing subunit of the transport system, acts phenotypically as a repressor of MalT, the transcriptional activator of the mal genes. Using MacConkey maltose indicator plates we isolated an insertion mutation that strongly reduced the repressing effect of overproduced MalK. The insertion had occurred in treR encoding the repressor of the trehalose system. The loss of TreR function led to derepression of treB encoding an enzymeIITre of the PTS for trehalose and of treC encoding TreC, the cytoplasmic trehalose-6-phosphate hydrolase. Further analysis revealed that maltose can enter the cell by facilitated diffusion through enzymeIITre, thus causing induction of the maltose system. In addition, derepression of TreC by itself caused induction of the maltose system, and a mutant lacking TreC was reduced in the uninduced level of mal gene expression indicating synthesis of endogenous inducer by TreC. Extracts containing TreC transformed [14C]-maltose into another 14C-labelled compound (preliminarily identified as maltose 1-phosphate) that is likely to be an alternative inducer of the maltose system.
Collapse
|
47
|
|
48
|
EFFECT OF ACID AND ALKALINE HYDROLYSIS ON THE ESTIMATION OF HEMICELLULOSE AND ASSOCIATED GROUPS IN YOUNG APPLE WOOD. PLANT PHYSIOLOGY 1929; 4:373-83. [PMID: 16652622 PMCID: PMC440071 DOI: 10.1104/pp.4.3.373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
|
49
|
SOME CHEMICAL CHANGES INCIDENT TO RIPENING AND STORAGE IN THE GRIMES APPLE. PLANT PHYSIOLOGY 1926; 1:251-64. [PMID: 16652482 PMCID: PMC439918 DOI: 10.1104/pp.1.3.251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
|