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Klose H, Harbaum L, Richter MJ, Lichtblau M, Marra AM, Kabitz HJ, Harutyunova S, Milger-Kneidinger K, Lange TJ. [Targeted therapy for pulmonary arterial hypertension in patients without comorbidities]. Pneumologie 2023; 77:890-900. [PMID: 37963478 DOI: 10.1055/a-2145-4711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The 2022 guidelines on pulmonary hypertension from the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) provide therapeutic strategies that account for the variability in the clinical presentation of newly diagnosed patients. We summarize treatment recommendations for pulmonary arterial hypertension (PAH) in patients without significant comorbidities, particularly for idiopathic, hereditary, drug/toxin-induced, or connective tissue disease-associated PAH. In this group of patients, multidimensional assessments for short-term mortality risk guide initial treatment decisions and treatment decisions during follow-up. Upfront dual combination therapy (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) is recommended for low- and intermediate-risk patients, and triple therapy including a parenteral prostacyclin should be considered in high- or intermediate-high-risk patients. If a low or intermediate-low-risk profile cannot be achieved during therapy, sequential add-on therapy escalation with parenteral prostacyclin or a prostacyclin receptor agonist should be considered, and switching from a phosphodiesterase type-5 inhibitor to a guanylate cyclase stimulator may also be considered.
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Affiliation(s)
- Hans Klose
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Lars Harbaum
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, zzt. Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Mona Lichtblau
- Klinik für Pneumologie, Zentrum für Pulmonale Hypertonie, Universitätsspital Zürich, Zürich, Schweiz
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University of Naples, Napoli, Italy
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Aarau, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik an der Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Katrin Milger-Kneidinger
- Medizinische Klinik und Poliklinik V, Ludwig-Maximilians-Universität (LMU) Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Bad Reichenhall, Deutschland
- Fakultät für Medizin, Lehrstuhl für Innere Medizin II, Universität Regensburg, Regensburg, Deutschland
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Lichtblau M, Harutyunova S, Nechwatal R, Mayer L, Kabitz HJ, Wilkens FM, Uiker S, Grünig E, Ritter D, Florea A, Benjamin N. [General measures and management of pulmonary arterial hypertension]. Pneumologie 2023; 77:907-915. [PMID: 37963480 DOI: 10.1055/a-2145-4741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Care of patients with pulmonary arterial hypertension (PAH) needs a multi-facetet concept and measures, including management of adverse reactions, right heart insufficiency as well as information on pregnancy, travels by air, psychosocial support, physical exercise training and prophylaxis by vaccination.Positive study results led to an higher recommendation of specialized exercise training in pulmonary hypertension. Also, the recommendation on iron substitution was amended according to the current evidence.In the current guidelines, special focus was given to the elaboration of recommendations regarding pregnancy, including patient information, contraception and patient management in case of pregnancy.This article aims to provide an overview on the recommendations of general measuremes, special circumstances and patient management according to the ESC/ERS guidelines. Amendments to the guideline recommendations are given as comments from the authors of this article.
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Affiliation(s)
- Mona Lichtblau
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | | | - Laura Mayer
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Schweiz
| | - Finn Moritz Wilkens
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Sören Uiker
- Rehaklinik Heidelberg Königstuhl, Heidelberg, Deutschland
| | - Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Daniel Ritter
- Klinikum Würzburg Mitte, Standort Missionsärztliche Klinik, Würzburg, Deutschland
| | - Andreea Florea
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Harutyunova S, Benjamin N, Eichstaedt C, Marra AM, Xanthouli P, Nagel C, Grünig E, Egenlauf B. Long-Term Safety, Outcome, and Clinical Effects of Subcutaneous and Intravenous Treprostinil Treatment in Patients with Severe Chronic Pulmonary Arterial Hypertension. Respiration 2023; 102:579-590. [PMID: 37544296 DOI: 10.1159/000531169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Current guidelines recommend treatment with parenteral prostacyclin analogs in patients with severe pulmonary arterial hypertension (PAH), who have insufficient response to treatment. Real-life data are sought to help physicians in treatment decisions and clinical care of patients. OBJECTIVE This study analyzed safety, clinical effects, and long-term outcomes of subcutaneous (sc) and/or intravenous (iv) treprostinil via different pump systems in consecutive patients with PAH. METHODS Thirty-seven patients with severe progressive PAH despite dual combination therapy (20 female, mean age: 52.3 ± 15 years, mean pulmonary vascular resistance: 12.1 ± 5.1 WU) were initiated with add-on treprostinil sc and were routinely clinically assessed. Changes in clinical parameters, adverse events, and outcome were analyzed retrospectively. RESULTS In 24 of 37 patients, treprostinil administration was continued iv via implantation of LENUS Pro® pump after 3 ± 1.3 months, 6 patients continued with sc therapy, and 7 discontinued treatment. After 3, 6, 9, and 12 months of treprostinil treatment, patients showed a significant improvement in mean 6-min walk distance and tricuspid annular plane systolic excursion compared to baseline. In 8 of the 24 patients, iv pumps required surgical revision. During a mean follow-up of 2.82 ± 1.95 years, 12 patients died, four received lung transplantation. Transplant-free survival after 1, 2, and 3 years was 85.7%, 69.2%, and 65.3%, respectively. CONCLUSION sc treprostinil as add-on to double combination treatment significantly improved exercise capacity and right heart function. In most patients, treprostinil could be continued via more tolerable iv administration approach (LENUS Pro® pump), showing reasonable overall survival with respect to the severity of PAH.
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Affiliation(s)
- Satenik Harutyunova
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany,
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany,
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina Eichstaedt
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Institute of Human Genetics, Laboratory for Molecular Genetic Diagnostics, Heidelberg University, Heidelberg, Germany
| | - Alberto M Marra
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Internal Medicine Section, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Panagiota Xanthouli
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology, Clinic Baden-Baden, Baden-Baden, Germany
- Practice of Pneumology, Max Grundig Clinic Bühlerhöhe, Bühl, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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Theobald V, Grünig E, Benjamin N, Seyfarth H, Halank M, Schneider MA, Richtmann S, Kazdal D, Hinderhofer K, Xanthouli P, Egenlauf B, Harutyunova S, Hoeper MM, Jonigk D, Sparla R, Muckenthaler MU, Eichstaedt CA. Is iron deficiency caused by BMPR2 mutations or dysfunction in pulmonary arterial hypertension patients? Pulm Circ 2023; 13:e12242. [PMID: 37292089 PMCID: PMC10247310 DOI: 10.1002/pul2.12242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
Iron deficiency is common in idiopathic and heritable pulmonary arterial hypertension patients (I/HPAH). A previous report suggested a dysregulation of the iron hormone hepcidin, which is controlled by BMP/SMAD signaling involving the bone morphogenetic protein receptor 2 (BMPR-II). Pathogenic variants in the BMPR2 gene are the most common cause of HPAH. Their effect on patients' hepcidin levels has not been investigated. The aim of this study was to assess whether iron metabolism and regulation of the iron regulatory hormone hepcidin was disturbed in I/HPAH patients with and without a pathogenic variant in the gene BMPR2 compared to healthy controls. In this explorative, cross-sectional study hepcidin serum levels were quantified by enzyme-linked immunosorbent assay. We measured iron status, inflammatory parameters and hepcidin modifying proteins such as IL6, erythropoietin, and BMP2, BMP6 in addition to BMPR-II protein and mRNA levels. Clinical routine parameters were correlated with hepcidin levels. In total 109 I/HPAH patients and controls, separated into three groups, 23 BMPR2 variant-carriers, 56 BMPR2 noncarriers and 30 healthy controls were enrolled. Of these, 84% had iron deficiency requiring iron supplementation. Hepcidin levels were not different between groups and corresponded to the degree of iron deficiency. The levels of IL6, erythropoietin, BMP2, or BMP6 showed no correlation with hepcidin expression. Hence, iron homeostasis and hepcidin regulation was largely independent from these parameters. I/HPAH patients had a physiologically normal iron regulation and no false elevation of hepcidin levels. Iron deficiency was prevalent albeit independent of pathogenic variants in the BMPR2 gene.
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Affiliation(s)
- Vivienne Theobald
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Ekkehard Grünig
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Nicola Benjamin
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Hans‐Jürgen Seyfarth
- Department of Pneumology, Medical Clinic IIUniversity Hospital of LeipzigLeipzigGermany
| | - Michael Halank
- Medical Clinic IUniversity Hospital of DresdenDresdenGermany
| | - Marc A. Schneider
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Translational Research UnitThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
| | - Sarah Richtmann
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Translational Research UnitThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
| | - Daniel Kazdal
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Institute of PathologyHeidelberg University HospitalHeidelbergGermany
| | - Katrin Hinderhofer
- Laboratory for Molecular Diagnostics, Institute of Human GeneticsHeidelberg UniversityHeidelbergGermany
| | - Panagiota Xanthouli
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Benjamin Egenlauf
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Satenik Harutyunova
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Marius M. Hoeper
- Department of Pneumology, Hannover Medical School, Biomedical Research in End‐stage and Obstructive Lung Disease Hannover (BREATH)German Center for Lung Research (DZL)HannoverGermany
| | - Danny Jonigk
- Hannover Medical School, Institute for Pathology, German Center for Lung Research (DZL)Biomedical Research in End‐stage and Obstructive Lung Disease Hannover (BREATH)HannoverGermany
- Institute of PathologyRWTH Aachen University HospitalAachenGermany
| | - Richard Sparla
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Centre for Translational Biomedical Iron Research, Hematology, Immunology and PulmonologyUniversity Hospital HeidelbergHeidelbergGermany
| | - Martina U. Muckenthaler
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Centre for Translational Biomedical Iron Research, Hematology, Immunology and PulmonologyUniversity Hospital HeidelbergHeidelbergGermany
- German Centre for Cardiovascular Research (DZHK)Partner Site Heidelberg/MannheimHeidelbergGermany
| | - Christina A. Eichstaedt
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Laboratory for Molecular Diagnostics, Institute of Human GeneticsHeidelberg UniversityHeidelbergGermany
- German Centre for Cardiovascular Research (DZHK)Partner Site Heidelberg/MannheimHeidelbergGermany
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Xanthouli P, Gordjani O, Benjamin N, Harutyunova S, Egenlauf B, Marra AM, Haas S, Milde N, Blank N, Lorenz HM, Fiehn C, Ulrich S, Distler O, Grünig E, Eichstaedt CA. Hypochromic red cells as a prognostic indicator of survival among patients with systemic sclerosis screened for pulmonary hypertension. Arthritis Res Ther 2023; 25:38. [PMID: 36895026 PMCID: PMC9997012 DOI: 10.1186/s13075-023-03020-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/26/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Patients with systemic sclerosis (SSc) are frequently affected by iron deficiency, particularly those with pulmonary hypertension (PH). The first data indicate the prognostic importance of hypochromic red cells (% HRC) > 2% among patients with PH. Hence, the objective of our study was to investigate the prognostic value of % HRC in SSc patients screened for PH. METHODS In this retrospective, single-center cohort study, SSc patients with a screening for PH were enrolled. Clinical characteristics and laboratory and pulmonary functional parameters associated with the prognosis of SSc were analyzed using uni- and multivariable analysis. RESULTS From 280 SSc patients screened, 171 could be included in the analysis having available data of iron metabolism (81% female, 60 ± 13 years of age, 77% limited cutaneous SSc, 65 manifest PH, and 73 pulmonary fibrosis). The patients were followed for 2.4 ± 1.8 (median 2.4) years. HRC > 2% at baseline was significantly associated with worse survival in the uni- (p = 0.018) and multivariable (p = 0.031) analysis independent from the presence of PH or pulmonary parenchymal manifestations. The combination of HRC > 2% and low diffusion capacity for carbon monoxide (DLCO) ≤ 65% predicted was significantly associated with survival (p < 0.0001). CONCLUSION This is the first study reporting that HRC > 2% is an independent prognostic predictor of mortality and can possibly be used as a biomarker among SSc patients. The combination of HRC > 2% and DLCO ≤ 65% predicted could serve in the risk stratification of SSc patients. Larger studies are required to confirm these findings.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ojan Gordjani
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University and School of Medicine, Naples, Italy
| | - Simon Haas
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Nicklas Milde
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Norbert Blank
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Fiehn
- Unit for Rheumatology and Clinical Immunology, Medical Centre Baden-Baden, Baden-Baden, Germany
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
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Grünig E, Benjamin N, Xanthouli P, Jordan S, Milde N, Marra A, Blank N, Egenlauf B, Gorenflo M, Harutyunova S, Lorenz HM, Nagel C, Theobald V, Lichtblau M, Berlier C, Ulrich S, Distler O. Response to: ' Correspondence on 'Haemodynamic phenotypes and survival in patients with systemic sclerosis: the impact of the new definition of pulmonary arterial hypertension'' by Iudici et al. Ann Rheum Dis 2023; 82:e66. [PMID: 33328252 DOI: 10.1136/annrheumdis-2020-219597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Suzana Jordan
- Department of Rheumatology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Nicklas Milde
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | | | - Norbert Blank
- Department of Internal Medicine 5: Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Matthias Gorenflo
- Department of Pediatric Cardiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine 5: Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany.,Lung Centre, Klinikum Mittelbaden gGmbH, Baden-Baden, Baden-Württemberg, Germany
| | - Vivienne Theobald
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
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7
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Xanthouli P, Gordjani O, Benjamin N, Trudzinski FC, Egenlauf B, Harutyunova S, Marra AM, Milde N, Nagel C, Blank N, Lorenz HM, Grünig E, Eichstaedt CA. Oxygenated hemoglobin as prognostic marker among patients with systemic sclerosis screened for pulmonary hypertension. Sci Rep 2023; 13:1839. [PMID: 36725894 PMCID: PMC9892512 DOI: 10.1038/s41598-023-28608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/20/2023] [Indexed: 02/03/2023] Open
Abstract
Oxygenated hemoglobin (OxyHem) in arterial blood may reflect disease severity in patients with systemic sclerosis (SSc). The aim of this study was to analyze the predictive value of OxyHem in SSc patients screened for pulmonary hypertension (PH). OxyHem (g/dl) was measured by multiplying the concentration of hemoglobin with fractional oxygen saturation in arterialized capillary blood. Prognostic power was compared with known prognostic parameters in SSc using uni- and multivariable analysis. A total of 280 SSc patients were screened, 267 were included in the analysis. No signs of pulmonary vascular disease were found in 126 patients, while 141 patients presented with mean pulmonary arterial pressure ≥ 21 mmHg. Interstitial lung disease (ILD) was identified in 70 patients. Low OxyHem ≤ 12.5 g/dl at baseline was significantly associated with worse survival (P = 0.046). In the multivariable analysis presence of ILD, age ≥ 60 years and diffusion capacity for carbon monoxide (DLCO) ≤ 65% were negatively associated with survival. The combination of low DLCO and low OxyHem at baseline could predict PH at baseline (sensitivity 76.1%). This study detected for the first time OxyHem ≤ 12.5 g/dl as a prognostic predictor in SSc patients. Further studies are needed to confirm these results.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany.,Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ojan Gordjani
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franziska C Trudzinski
- Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University and School of Medicine, Naples, Italy
| | - Nicklas Milde
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany
| | - Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany.,Department of Respiratory Care Medicine and Thoracic Surgery, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Norbert Blank
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany. .,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
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Grünig E, Egenlauf B, Benjamin N, Braun M, Harutyunova S, Winterbauer M, Klose H. Gezielte medikamentöse Therapie der pulmonalarteriellen Hypertonie nach den aktuellen Leitlinien. Aktuelle Kardiologie 2023. [DOI: 10.1055/a-1968-9470] [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] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
ZusammenfassungDieser Artikel stellt die gezielte Therapie der pulmonalarteriellen Hypertonie (PAH) vor. Die medikamentöse Therapie der PAH hat sich in den letzten Jahren entscheidend verbessert und
ermöglicht heute vielen Patienten eine deutliche Verbesserung der körperlichen Belastbarkeit, Lebensqualität und des Langzeitüberlebens. Die neuen ESC/ERS-Leitlinien zur pulmonalen
Hypertonie haben die aus vielen neuen Studien entstandenen Evidenzen zusammengetragen, bewertet und den therapeutischen Algorithmus und die Therapieempfehlungen entsprechend angepasst. In
dem folgenden Artikel werden die neuen Empfehlungen zur medikamentösen Therapie der PAH zusammengefasst und eingeordnet. Die PAH-Therapie wird wie bisher am Schweregrad der Erkrankung
orientiert, der bei Diagnose nach einem 3-Risikostufen-Modell abgeschätzt wird. Neu ist die Anwendung eines 4-stufigen Risikomodells bei der Therapieanpassung im Krankheitsverlauf. In den
neuen Leitlinien werden erstmals auch Therapieempfehlungen für Patienten mit PAH und Komorbiditäten gegeben.
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Affiliation(s)
- Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Moritz Braun
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Marc Winterbauer
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg; Translational Lung Research Center Heidelberg (TLRC), Deutsches Zentrum für
Lungenforschung (DZL), Heidelberg, Deutschland
| | - Hans Klose
- Zentrum für pulmonal-arterielle Hypertonie Hamburg, Sektion Pneumologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Degering J, Egenlauf B, Harutyunova S, Benjamin N, Salkić A, Xanthouli P, Eichstaedt CA, Seeger R, Sitbon O, Grünig E. Tolerability, safety and survival in patients with severe pulmonary arterial hypertension treated with intravenous epoprostenol (Veletri ®): a prospective, 6-months, open label, observational, non-interventional study. Respir Res 2023; 24:18. [PMID: 36653855 PMCID: PMC9847036 DOI: 10.1186/s12931-022-02296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Epoprostenol AS (Veletri®), a thermostable epoprostenol formulation, provides better drug stability and improved clinical use compared to previous epoprostenol formulations. This study aims to expand clinical experience in the use of Veletri®, especially regarding tolerability, safety and survival. METHODS Pulmonary arterial hypertension (PAH) patients at high risk despite pretreatment with at least double oral combination therapy and with clinical indication for epoprostenol (Veletri®) treatment were consecutively included in this prospective, open label, observational, non-interventional study. Clinical data were assessed at baseline, after 3 and 6 months. Adverse events (AEs) and serious adverse events (SAEs) were documented. Survival from initiation of Veletri® was assessed at last patient out. RESULTS Fifteen patients (60 ± 13.7 years, WHO functional class III (n = 10) or IV (n = 5), severely impaired right ventricular function, mean pulmonary arterial pressure 54.8 ± 8.9 mmHg, mean pulmonary vascular resistance 4.4 ± 0.7 (median 3.8) Wood Units) were enrolled and treated with a mean dosage of 7.9 ± 3.9 (median 7.5) ng/kg/min. Eleven patients completed the study (treatment withdrawal n = 1, death n = 3). After a mean follow-up of 19.1 ± 13.5 (median 18.0) months, seven patients died and three were listed for lung transplantation. Seven AEs (nausea n = 3, diarrhea n = 1, flushing n = 2, headaches n = 1) and three SAEs (catheter infection n = 2, catheter occlusion n = 1) were related to Veletri®. The 1- and 2-year survival rates were 73.3% and 52.4%, respectively. CONCLUSIONS The study showed that safety and tolerability of epoprostenol AS (Veletri®) was comparable to previous prostacyclin formulations and was feasible for most patients. The maximum tolerable dosage was lower than dosages reported in the literature. In future applications/trials the up-titration process should be pushing for higher dosages of epoprostenol in the occurrence of side effects, as the achievement of a high and effective dosage is crucial for the clinical benefit of the patients. Survival was as expected in these prevalent severely impaired patients. Trial registration The study was registered in the EUPAS registry (EUPAS32492).
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Affiliation(s)
- Julia Degering
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany
| | - Benjamin Egenlauf
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Amina Salkić
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Panagiota Xanthouli
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Division of Rheumatology, Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christina A. Eichstaedt
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany ,grid.7700.00000 0001 2190 4373Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Rebekka Seeger
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Olivier Sitbon
- grid.460789.40000 0004 4910 6535Department of Respiratory Diseases, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Ekkehard Grünig
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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Nagel C, Olschewski H, Sorichter S, Uezgoer G, Diehm C, Huppert P, Iber T, Herth F, Harutyunova S, Marra AM, Benjamin N, Salkić A, Grünig E, Egenlauf B. Impairment of Inspiratory Muscle Function after COVID-19. Respiration 2022; 101:981-989. [DOI: 10.1159/000527361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 09/07/2022] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Persistent symptoms after acute coronavirus-disease-2019 (COVID-19) are common, and there is no significant correlation with the severity of the acute disease. In long-COVID (persistent symptoms >4 weeks after acute COVID-19), respiratory symptoms are frequent, but lung function testing shows only mild changes that do not explain the symptoms. Although COVID-19 may lead to an impairment of the peripheral nervous system and skeletal muscles, respiratory muscle function has not been examined in this setting. <b><i>Methods:</i></b> In this study, we assessed the severity of dyspnea (NYHA-function class) in long-COVID patients and analyzed its association with body mass index (BMI), FEV1, forced vital capacity, other parameters of body plethysmography, diffusing capacity for carbon monoxide (DLCO), arterial blood gases, and inspiratory muscle function, assessed by airway occlusion pressure (P0.1) and maximal inspiratory pressure (PImax) in two respiratory clinics in Germany between Oct 2020 and Aug 2021. <b><i>Results:</i></b> A total of 116 patients were included in the study. The mean age was 50.2 ± 14.5 years; BMI, 26.7 ± 5.87 kg/m<sup>2</sup>; NYHA class I, 19%; II, 27%; III, 41%; and IV, 14%. While lung function values and computed tomography or conventional X-ray of the chest were in the normal range, inspiratory muscle function was markedly impaired. P01 was elevated to 154 ± 83%predicted and PImax was reduced to 41 ± 25%predicted. PImax reduction was strongly associated with the severity of dyspnea but independent of BMI, time after acute COVID-19 and most of the other parameters. <b><i>Conclusions:</i></b> This study shows that in long-COVID patients, respiratory symptoms may be mainly caused by reduced inspiratory muscle strength. Assessment of PImax and P0.1 might better explain dyspnea than classical lung function tests and DLCO. A prospective study is needed to confirm these results.
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Xanthouli P, Miazgowski J, Benjamin N, Gordjani O, Egenlauf B, Harutyunova S, Seeger R, Marra AM, Blank N, Lorenz HM, Grünig E, Eichstaedt CA. Prognostic meaning of right ventricular function and output reserve in patients with systemic sclerosis. Arthritis Res Ther 2022; 24:173. [PMID: 35864554 PMCID: PMC9306074 DOI: 10.1186/s13075-022-02863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study was to investigate the prognostic impact of right ventricular (RV) function at rest and during exercise in patients with systemic sclerosis (SSc) presenting for a screening for pulmonary hypertension (PH). Methods In this study, data from SSc patients who underwent routinely performed examinations for PH screening including echocardiography and right heart catheterization at rest and during exercise were analysed. Uni- and multivariable analyses were performed to identify prognostic parameters. Results Out of 280 SSc patients screened for PH, 225 were included in the analysis (81.3% female, mean age 58.1±13.0 years, 68% limited cutaneous SSc, WHO-FC II–III 74%, 24 manifest PH). During the observation period of 3.2±2.7 (median 2.6) years 35 patients died. Tricuspid annular plane systolic excursion (TAPSE) at rest <18 mm (p=0.001), RV output reserve as increase of cardiac index (CI) during exercise <2 l/min (p<0.0001), RV pulmonary vascular reserve (Δ mean pulmonary artery pressure/Δ cardiac output) ≥3 mmHg/l/min (p<0.0001), peak CI <5.5 l/min/m2 (p=0.001), pulmonary arterial compliance <2 ml/mmHg (p=0.002), TAPSE/systolic pulmonary arterial pressure (sPAP) ratio ≤0.6 ml/mmHg (p<0.0001) and echocardiographic qualitative RV function at rest (p<0.0001) significantly predicted worse survival. In the multivariable analysis TAPSE/sPAP ratio and diffusion capacity for carbon monoxide ≤65% were identified as independent prognostic predictors and had 75% sensitivity and 69% specificity to predict future development of pulmonary vascular disease (PVD) during follow-up. Conclusions This study demonstrates that assessment of RV function at rest and during exercise may provide crucial information to identify SSc patients who are at a high risk of poor outcome and for the development of PH and/or PVD.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Miazgowski
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Ojan Gordjani
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Rebekka Seeger
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University and School of Medicine, Naples, Italy
| | - Norbert Blank
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany. .,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany. .,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
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Xanthouli P, Gordjani O, Eichstaedt C, Benjamin N, Egenlauf B, Harutyunova S, Marra A, Theobald V, Milde N, Nagel C, Blank N, Lorenz HM, Grünig E. POS0885 HYPOCHROMIC ERYTHROCYTES AS PROGNOSTIC INDICATOR OF SURVIVAL AMONG PATIENTS WITH SYSTEMIC SCLEROSIS SCREENED FOR PULMONARY HYPERTENSION. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.2936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundIron deficiency is frequent among patients with systemic sclerosis (SSc), particularly among those with pulmonary hypertension (PH). First data indicate prognostic importance of hypochromic erythrocytes (HRC) >2% among patients with PH1. Hence, the aim of this study was to investigate the predictive value of HRC in SSc patients screened for PH.ObjectivesThe objective of this study was to investigate the predictive value of HRC in SSc patients screened for PH.MethodsIn this retrospective, single-center cohort study SSc patients screened for PH were included. Clinical characteristics, laboratory and pulmonary functional parameters associated with the prognosis of SSc were analysed using uni- and multivariable analysis.ResultsA total of 280 SSc patients were screened, 171 were included in the analysis having complete data of iron metabolism (79% female, 61.0±12.9 years of age, 73.2% limited cutaneous SSc, 56 manifest PH and 112 pulmonary fibrosis). The patients were followed for 2.4±1.8 (median 2.4) years. HRC >2% at baseline was significantly associated with worse survival in the uni- (p=0.018) and multivariable analysis (p<0.0001). Overall 34.5% of the patients suffered from iron deficiency and 22% received iron substitution during follow-up. HRC >2% was identified as independent predictor of mortality, for patients with and without pulmonary manifestations of SSc.ConclusionThis study detected for the first time that HRC >2% is an independent prognostic predictor and can possibly be used as a biomarker among SSc-patients. Further studies are needed to confirm these results.References[1]Xanthouli P, Theobald V, Benjamin N, Marra AM, D’Agostino A, Egenlauf B, Shaukat M, Ding C, Cittadini A, Bossone E, Kögler M, Grünig E, Muckenthaler MU, Eichstaedt CA. Prognostic impact of hypochromic erythrocytes in patients with pulmonary arterial hypertension. Respir Res. 2021 Nov 9;22(1):288. doi: 10.1186/s12931-021-01884-9.Disclosure of InterestsPanagiota Xanthouli Speakers bureau: MSD and OMT, outside the submitted work, Ojan Gordjani: None declared, Christina Eichstaedt: None declared, Nicola Benjamin Speakers bureau: Actelion pharmaceuticals, Bayer HealthCare and MSD., Benjamin Egenlauf Speakers bureau: Actelion, MSD, Bayer and OMT outside the submitted work, Satenik Harutyunova Speakers bureau: Bayer, MSD, Actelion and GSK, outside the submitted work., Alberto Marra Speakers bureau: Bayer/MSD outside the submitted work, Vivienne Theobald: None declared, Nicklas Milde: None declared, Christian Nagel Speakers bureau: Actelion, MSD, Boehringer, Novartis, Bayer, and AstraZeneca, Norbert Blank Speakers bureau: MSD, GSK, Actelion and Bayer Vital., Consultant of: MSD, GSK, Actelion and Bayer Vital., Hanns-Martin Lorenz Speakers bureau: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Consultant of: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Ekkehard Grünig Speakers bureau: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House, Consultant of: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House
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Xanthouli P, Miazgowski J, Benjamin N, Gordjani O, Egenlauf B, Harutyunova S, Seeger R, Marra A, Blank N, Lorenz HM, Grünig E, Eichstaedt C. AB0687 Prognostic meaning of right ventricular function and reserve in patients with systemic sclerosis. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.2945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundThe delay of the diagnosis of pulmonary hypertension (PH) in patients with systemic sclerosis (SSc) leads to severe impairment of survival.ObjectivesThe objective of this study was to investigate the prognostic impact of right ventricular (RV) function at rest and during exercise on survival in patients with SSc presenting for screening for PH.MethodsData from SSc patients who underwent routinely performed examinations for PH screening including echocardiography and right heart catheterization at rest and during exercise were analyzed. Uni- and multivariable analyses were performed to identify prognostic parameters in SSc and to compare them to known prognostic predictors.ResultsOut of 285 SSc patients screened for PH, 225 patients (81.3% female, mean age 58.1±13.0 years, 68% limited cutaneous SSc, WHO-FC II-III 74%, 24 manifest PH) were included in the analysis. During an observation period of 3.2±2.7 (median 2.6) years 35 patients died. Tricuspid annular plane systolic excursion ≤18 mm (p=0.0004), increase of cardiac index (CI) during exercise ≤ 2 l/min (p=0.0002), RV output reserve >3 mmHg/l/min (p=0.001), peak CI ≤ 5.5l/min (p=0.01), pulmonary arterial compliance >2 ml/mmHg (p=0.0005) and qualitative RV function at rest (p<0.0001) significantly predicted survival. In the multivariable analysis, RV function at rest, diffusion capacity for carbon monoxide < 65% predicted and CI increase <2 l/min/m2 were identified as independent prognostic predictors and had >70% sensitivity and specificity to predict development of pulmonary vascular disease (PVD) during follow-up.ConclusionThis study demonstrates that assessment of RV function at rest and during exercise may provide crucial information to identify SSc patients who are at a high risk of an impaired survival and development of PVD.References[1]Brown ZR, et al. Screening for pulmonary arterial hypertension in systemic sclerosis: Now or never!. Eur J Rheumatol. 2020;7(Suppl 3):S187-S192.Disclosure of InterestsPanagiota Xanthouli Speakers bureau: MSD and OMT, outside the submitted work, Julia Miazgowski: None declared, Nicola Benjamin Speakers bureau: Actelion pharmaceuticals, Bayer HealthCare and MSD outside the submitted work., Ojan Gordjani: None declared, Benjamin Egenlauf Speakers bureau: Actelion, MSD, Bayer and OMT (less than $10,000 each)., Satenik Harutyunova Speakers bureau: Bayer, MSD, Actelion and GSK, outside the submitted work., Rebekka Seeger: None declared, Alberto Marra Speakers bureau: MSD, Norbert Blank Speakers bureau: MSD, GSK, Actelion and Bayer Vital., Hanns-Martin Lorenz Speakers bureau: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Consultant of: AbbVie, BMS, Pfizer, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, and Lilly (less than $10,000 each) and research support from AbbVie, MSD, BMS, Cellgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, AstraZeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, and Thermo Fisher, Ekkehard Grünig Speakers bureau: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House, Consultant of: Actelion, Bayer AG, and MSD; grants from GSK, Novartis, and United Therapeutics; and personal fees from SCOPE, OrPha Swiss GmbH, and Zurich Heart House, Christina Eichstaedt: None declared
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Nagel C, Benjamin N, Egenlauf B, Eichstaedt CA, Fischer C, Palevičiūtė E, Čelutkienė J, Harutyunova S, Mayer E, Nasereddin M, Marra AM, Grünig E, Guth S. Effect of Supervised Training Therapy on Pulmonary Arterial Compliance and Stroke Volume in Severe Pulmonary Arterial Hypertension and Inoperable or Persistent Chronic Thromboembolic Pulmonary Hypertension. Respiration 2021; 100:369-378. [PMID: 33765679 DOI: 10.1159/000512316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary arterial compliance (PAC) is a prognostic parameter in pulmonary arterial hypertension (PAH) reflecting the elasticity of the pulmonary vessels. OBJECTIVES The objective of this post hoc analysis of a prospective randomized controlled trial (RCT) was to assess the effect of exercise training on PAC and stroke volume (SV) in patients with PAH and persistent/inoperable chronic thromboembolic pulmonary hypertension (CTEPH). METHOD From the previous RCT, 43 out of 87 patients with severe PAH (n = 29) and CTEPH (n = 14) had complete haemodynamic examinations at baseline and after 15 weeks by right heart catheterization and were analysed (53% female, 79% World Health Organization functional class III/IV, 58% combination therapy, 42% on supplemental oxygen therapy, training group n = 24, and control group n = 19). Medication remained unchanged for all patients. RESULTS Low-dose exercise training at 4-7 days/week significantly improved PAC (training group 0.33 ± 0.65 mL/mm Hg vs. control group -0.06 ± 1.10 mL/mm Hg; mean difference 0.39 mL/mm Hg, 95% confidence interval [CI] 0.15-0.94 mL/mm Hg; p = 0.004) and SV (training group 9.9 ± 13.4 mL/min vs. control group -4.2 ± 11.0 mL/min; mean difference 14.2 mL, 95% CI 6.5-21.8 mL; p < 0.001) in the training versus control group. Furthermore, exercise training significantly improved cardiac output and pulmonary vascular resistance at rest, peak oxygen consumption, and oxygen pulse. CONCLUSIONS Our findings suggest that supervised exercise training may improve right ventricular function and PAC at the same time. Further prospective studies are needed to evaluate these findings.
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Affiliation(s)
- Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Department of Respiratory Care Medicine and Thoracic Surgery, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Christine Fischer
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Eglė Palevičiūtė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Mohammed Nasereddin
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Alberto M Marra
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University Hospital and School of Medicine, Naples, Italy
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
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Nagel C, Nasereddin M, Benjamin N, Egenlauf B, Harutyunova S, Eichstaedt CA, Xanthouli P, Mayer E, Grünig E, Guth S. Supervised Exercise Training in Patients with Chronic Thromboembolic Pulmonary Hypertension as Early Follow-Up Treatment after Pulmonary Endarterectomy: A Prospective Cohort Study. Respiration 2020; 99:577-588. [PMID: 32726793 DOI: 10.1159/000508754] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 03/25/2020] [Accepted: 05/19/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Data on exercise training in chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) as well as data on clinical and haemodynamic changes shortly after PEA are lacking. OBJECTIVE The objective of this prospective study was to analyse the safety, feasibility, and the effectiveness of combined supervised inpatient rehabilitation in patients with CTEPH directly after PEA. METHODS CTEPH patients started a 19-week rehabilitation program (3 weeks as inpatients and continued at home for another 16 weeks) with supervised exercise training as follow-up treatment shortly after PEA. Haemodynamics were assessed by right heart catheterisation before PEA and 22 weeks after PEA. Non-invasive assessments as transthoracic echocardiography and 6-min walking distance (6MWD) were performed before PEA and after 3 (that is, beginning of rehabilitation), 6, and 22 weeks following PEA. Adverse events were recorded throughout the study. RESULTS Forty-five CTEPH patients were included (49% female, 57.6 ± 12.4 years old, 60% WHO functional class III). Rehabilitation was started 3.3 ± 0.9 weeks after PEA. Exercise training was well tolerated in all patients without severe side effects. Haemodynamics measured by right heart catheterisation significantly improved from pre-PEA to 22 weeks post-PEA in cardiac output (+1.2 ± 1.5 L/min, 33.4%, p = 0.001) and mean pulmonary arterial pressure (-19 ± 13 mm Hg, -39.6%, p < 0.0001). Right heart size measured by echocardiography, 6MWD, quality of life, and oxygen saturation significantly improved not only within the first 3 weeks after PEA but also during the following 19 weeks of exercise training. CONCLUSIONS Supervised exercise training was feasible as early follow-up treatment after PEA. Further controlled studies are needed to discriminate the effects of PEA and early follow-up rehabilitation. TRIAL REGISTRATION The study was registered at clinicaltrials.gov (NCT01393327) on July 13, 2011. The study start date was January 2010, and completion date was December 2013.
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Affiliation(s)
- Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany, .,Department for Respiratory Care Medicine and Thoracic Surgery, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany, .,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany,
| | - Mohammed Nasereddin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
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Xanthouli P, Koegler M, Marra AM, Benjamin N, Fischer L, Eichstaedt CA, Harutyunova S, Nagel C, Grünig E, Egenlauf B. Risk stratification and prognostic factors in patients with pulmonary arterial hypertension and comorbidities a cross-sectional cohort study with survival follow-up. Respir Res 2020; 21:127. [PMID: 32448256 PMCID: PMC7245826 DOI: 10.1186/s12931-020-01393-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The objective of this study was to analyze prognostic factors and risk stratification in patients with pulmonary arterial hypertension (PAH) and comorbidities. METHODS Patients with invasively diagnosed PAH were included in the analysis. Comorbidities were clinically diagnosed as proposed in the 6th World Symposium of pulmonary hypertension. Uni- and multivariate analysis were employed for identification of factors predicting survival and time to first clinical worsening (TTCW). Risk stratification was based on parameters from ESC/ERS-guidelines 2015. RESULTS In total 142 patients were enrolled in the study, 90 of them were diagnosed as PAH without and 52 with comorbidities. All patients received targeted PAH therapy and were followed for 3.3 ± 2.4 years. In PAH patients without comorbidities survival and TTCW were significantly associated with reduced 6-min walking distance (6MWD), elevated N-terminal pro brain natriuretic peptide (NT-proBNP), WHO-functional class (WHO-FC) and right atrial (RA) area. In the multivariate analysis, 6MWD was an independent predictor for survival (p = 0.002) and WHO-FC for TTCW (p = 0.001). In patients with PAH and comorbidities these parameters had no significant association with survival and TTCW. Average risk score was significantly associated with survival (p = 0.001) and TTCW (p = 0.013) in PAH but not in PAH with comorbidities (both p > 0.05; figure 1). CONCLUSION Risk stratification based on ESC/ERS-guidelines could only be confirmed in patients without comorbidities, but not in patients with PAH and comorbidities. The data of this study suggest, that a different risk stratification needs to be applied to PAH patients with comorbidities. Further studies are needed to confirm these results. TRIAL REGISTRATION Not applicable, retrospective registry.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Maria Koegler
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | | | - Nicola Benjamin
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Lukas Fischer
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Christian Nagel
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.,Lung Centre, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.
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Eichstaedt CA, Verweyen J, Halank M, Benjamin N, Fischer C, Mayer E, Guth S, Wiedenroth CB, Egenlauf B, Harutyunova S, Xanthouli P, Marra AM, Wilkens H, Ewert R, Hinderhofer K, Grünig E. Myeloproliferative Diseases as Possible Risk Factor for Development of Chronic Thromboembolic Pulmonary Hypertension-A Genetic Study. Int J Mol Sci 2020; 21:ijms21093339. [PMID: 32397294 PMCID: PMC7246715 DOI: 10.3390/ijms21093339] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease which is often caused by recurrent emboli. These are also frequently found in patients with myeloproliferative diseases. While myeloproliferative diseases can be caused by gene defects, the genetic predisposition to CTEPH is largely unexplored. Therefore, the objective of this study was to analyse these genes and further genes involved in pulmonary hypertension in CTEPH patients. A systematic screening was conducted for pathogenic variants using a gene panel based on next generation sequencing. CTEPH was diagnosed according to current guidelines. In this study, out of 40 CTEPH patients 4 (10%) carried pathogenic variants. One patient had a nonsense variant (c.2071A>T p.Lys691*) in the BMPR2 gene and three further patients carried the same pathogenic variant (missense variant, c.1849G>T p.Val617Phe) in the Janus kinase 2 (JAK2) gene. The latter led to a myeloproliferative disease in each patient. The prevalence of this JAK2 variant was significantly higher than expected (p < 0.0001). CTEPH patients may have a genetic predisposition more often than previously thought. The predisposition for myeloproliferative diseases could be an additional risk factor for CTEPH development. Thus, clinical screening for myeloproliferative diseases and genetic testing may be considered also for CTEPH patients.
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Affiliation(s)
- Christina A. Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
- Correspondence: ; Tel.: +49-6221-396-1221; Fax: +49-6221-396-1222
| | - Jeremias Verweyen
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Michael Halank
- Department of Internal Medicine I, Carl Gustav Carus University Hospital, Technical University of Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Christine Fischer
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Christoph B. Wiedenroth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Alberto M. Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
- IRCCS SDN Research Institute, Via F. Crispi 8, 80121 Naples, Italy
| | - Heinrike Wilkens
- Department of Internal Medicine V—Pneumology, Allergology and Critical Care Medicine, University Hospital of Saarland, Kirrberger Str., 66424 Homburg, Saar, Germany;
| | - Ralf Ewert
- Department of Internal Medicine B—Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany;
| | - Katrin Hinderhofer
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
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18
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Richter MJ, Harutyunova S, Bollmann T, Classen S, Fuge J, Gall H, Gerhardt F, Ghofrani HA, Gunkel H, Grünig E, Halank M, Heine A, Klose H, Lange TJ, Neurohr C, Nickolaus K, Opitz CF, Rosenkranz S, Seyfarth HJ, Tello K, Ewert R, Olsson KM. 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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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.
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Affiliation(s)
- Manuel J Richter
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - Tom Bollmann
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Simon Classen
- Department of Vascular Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Jan Fuge
- German Center for Lung Research (DZL), Giessen, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Felix Gerhardt
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Hossein A Ghofrani
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany.,Department of Medicine, Imperial College London, London, UK
| | | | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Halank
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Alexander Heine
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Hans Klose
- Department of Pneumology, University of Hamburg, Hamburg, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Claus Neurohr
- Department for Pneumology and Respiratory Medicine, Robert-Bosch-Hospital, Gerlingen, Germany
| | - Kai Nickolaus
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | | | - Stephan Rosenkranz
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | | | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Ralf Ewert
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Karen M Olsson
- German Center for Lung Research (DZL), Giessen, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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19
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Xanthouli P, Jordan S, Milde N, Marra A, Blank N, Egenlauf B, Gorenflo M, Harutyunova S, Lorenz HM, Nagel C, Theobald V, Lichtblau M, Berlier C, Ulrich S, Grünig E, Benjamin N, Distler O. Haemodynamic phenotypes and survival in patients with systemic sclerosis: the impact of the new definition of pulmonary arterial hypertension. Ann Rheum Dis 2020; 79:370-378. [PMID: 31818805 DOI: 10.1136/annrheumdis-2019-216476] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [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: 10/15/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND In this study, we investigated the impact of the new haemodynamic definition of pulmonary arterial hypertension (PAH) as proposed by the 6th PH World Symposium on phenotypes and survival in patients with systemic sclerosis (SSc). METHODS In SSc patients who were prospectively and consecutively screened for PAH including right heart catheterisation in Heidelberg or Zurich, haemodynamic and clinical variables have been reassessed according to the new PAH definition. Patients have been followed for 3.7±3.7 (median 3.4) years; Kaplan-Meier survival analysis was performed. Patients with significant lung or left heart disease were excluded from comparative analyses. RESULTS The final dataset included 284 SSc patients, 146 patients (49.2%) had mean pulmonary arterial pressure (mPAP) ≤20 mm Hg, 19.3% had mPAP 21-24 mm Hg and 29.4% had mPAP ≥25 mm Hg. In the group of mildly elevated mPAP, only four patients (1.4% of the whole SSc cohort) had pulmonary vascular resistance (PVR) values ≥3 Wood Units (WU) and could be reclassified as manifest SSc-APAH. Twenty-eight (9.8%) patients with mPAP of 21-24 mm Hg and PVR ≥2 WU already presented with early pulmonary vascular disease with decreased 6 min walking distance (6MWD) (p<0.001), TAPSE (p=0.004) and pulmonary arterial compliance (p<0.001). A PVR ≥2 WU was associated with reduced long-term survival (p=0.002). PVR and 6MWD were independent prognostic predictors in multivariate analysis. CONCLUSION The data of this study show that a PVR threshold ≥3 WU is too high to enable an early diagnosis of PAH. A PVR threshold ≥2 WU was already associated with pulmonary vascular disease, significantly reduced survival and would be more appropriate in SSc patients with mild PAH.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Suzana Jordan
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Nicklas Milde
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Norbert Blank
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Matthias Gorenflo
- Department of Pediatric Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Lung centre, Klinikum Mittelbaden gGmbH, Baden-Baden Balg, Germany
| | - Vivienne Theobald
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
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20
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Pan Z, Marra AM, Benjamin N, Eichstaedt CA, Blank N, Bossone E, Cittadini A, Coghlan G, Denton CP, Distler O, Egenlauf B, Fischer C, Harutyunova S, Xanthouli P, Lorenz HM, Grünig E. Early treatment with ambrisentan of mildly elevated mean pulmonary arterial pressure associated with systemic sclerosis: a randomized, controlled, double-blind, parallel group study (EDITA study). Arthritis Res Ther 2019; 21:217. [PMID: 31655622 PMCID: PMC6815440 DOI: 10.1186/s13075-019-1981-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023] Open
Abstract
Objective The objective of this randomized, placebo-controlled, double-blind, parallel group, trial was to assess the effect of ambrisentan on mean pulmonary arterial pressure (mPAP) in patients with systemic sclerosis (SSc) and mildly elevated pulmonary hypertension (PH). Methods Thirty-eight SSc patients with mildly elevated mPAP at rest between 21 and 24 mmHg and/or > 30 mmHg during low-dose exercise were randomly assigned to treatment with either ambrisentan 5–10 mg/day or placebo. Right heart catheterization and further clinical parameters were assessed at baseline and after 6 months. The primary endpoint was the difference of mPAP change at rest between groups. Results After 6 months, the two groups did not differ in the primary endpoint (ambrisentan mPAP − 1 ± 6.4 mmHg vs. placebo − 0.73 ± 3.59 mmHg at rest, p = 0.884). However, three patients from the placebo group but none of the ambrisentan group progressed to SSc-associated pulmonary arterial hypertension. Furthermore, ambrisentan treatment showed significant improvements in the secondary endpoints cardiac index (CI) and pulmonary vascular resistance (PVR) at rest (CI 0.36 ± 0.66 l/min/m2 vs. − 0.31 ± 0.71 l/min/m2, p = 0.010; PVR − 0.70 ± 0.78 WU vs. 0.01 ± 0.71 WU, p = 0.012) and during exercise (CI 0.7 ± 0.81 l/min/m2 vs. − 0.45 ± 1.36 l/min/m2, p = 0.015; PVR − 0.84 ± 0.48 WU vs. − 0.0032 ± 0.34 WU, p < 0.0001). Conclusion This is the first randomized, double-blind, placebo-controlled study testing the effect of ambrisentan in patients with mildly elevated mPAP and/or exercise PH. The primary endpoint change in mPAP did only tendentially improve in the ambrisentan group, but the significant improvement of other hemodynamic parameters points to a possible benefit of ambrisentan and will be helpful to design future trials. Trial registration www.ClinicalTrials.gov, unique identifier NCT: NCT02290613, registered 14th of November 2014.
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Affiliation(s)
- Zixuan Pan
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Norbert Blank
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Eduardo Bossone
- Division of Cardiology, U.O.C. Rehabilitazione Cardiovascolare, A Cardarelli, Naples, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University Federico II of Naples, Naples, Italy
| | - Gerry Coghlan
- Cardiology Department, Royal Free Hospital, London, UK
| | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Department of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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21
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Xanthouli P, Milde N, Marra AM, Benjamin N, Nagel C, Eichstaedt C, Blank N, Egenlauf B, Harutyunova S, Lorenz HM, Grunig E. P3676Hemodynamic phenotypes in systemic sclerosis patients screened for pulmonary hypertension (PH): impact of the new definition of PH. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with systemic sclerosis (SSc) are at high risk of developing concomitant pulmonary hypertension (PH) which has a crucial impact on the patients' symptoms, quality of life and prognosis.
Purpose
The aim of this study was to analyse the impact of the new hemodynamic definition of precapillary PH as proposed at the 2018 World Symposium on PH in Nice in patients with SSc. Although recent data suggest that PVR >2 WU could be considered as abnormal in the new definition a conservative cut-off value of PVR ≥3 WU has been used.
Methods
SSc-patients were screened for PH using clinical assessments as WHO-functional class, 6 minute walking distance and right heart catheterisation. Patients were divided into hemodynamic subgroups according to their mean pulmonary arterial pressure (mPAP) values with mPAP ≤20 mmHg, 21–24 mmHg and ≥25 mmHg. These subgroups were further divided according to their pulmonary vascular resistance (PVR) with PVR <3 WU or ≥3 WU.
Results
One-hundred-twenty-two patients (79% female, age 57.6±12.7 years, 6MWD 439.5±98.1 meters, 70% diffuse cutaneous SSc, 30% limited cutaneous SSc, 53% WHO-FC II, 25% WHO-FC III) who were prospectively screened for PH were included in the analysis (Figure 1). Among them 26 had a symptomatic manifest PH using the cut-off value of mPAP ≥25 mmHg. Only half of this group presented with PVR ≥3 WU, the others had PVR <3 WU. Eight of these 26 PH-patients presented with PH due to left heart disease. Out of 21 patients with mildly elevated mPAP 21–24 mmHg, two (10%) met the new definition criteria of PH (pulmonary arterial wedge pressure <15 mmHg, mPAP 23 and 24 mmHg, PVR 3.0 and 3.2 WU, CI 2.2 L/min/m2 both, WHO-FC II both, respectively). Out of 75 patients with mPAP <21 mmHg, three presented with PVR ≥3 WU.
Overview of systemic sclerosis patients
Conclusions
The new definition of precapillary pulmonary hypertension may on the one hand allow detecting an additional 10% of PH patients with mild elevated mPAP. On the other hand, eight of 13 patients (62%), who met the former definition of pulmonary arterial hypertension, would be classified as “normal” due to a lack of increase in PVR according to the new definition. The data of this study suggest that for SSc-patients the cut-off value of mPAP >20 mmHg is useful, but the criteria of PVR ≥3 WU may be too strict.
Further studies with larger sample sizes will be needed to better characterise these hemodynamic subgroups and to define the extent of pulmonary vascular disease and treatability.
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Affiliation(s)
- P Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - N Milde
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - A M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - N Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - C Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - C Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - N Blank
- University of Heidelberg, Department of Rheumatology, Heidelberg, Germany
| | - B Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - S Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - H M Lorenz
- University of Heidelberg, Department of Rheumatology, Heidelberg, Germany
| | - E Grunig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
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22
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Nagel C, Marra AM, Benjamin N, Blank N, Cittadini A, Coghlan G, Distler O, Denton CP, Egenlauf B, Fiehn C, Fischer C, Harutyunova S, Hoeper MM, Lorenz HM, Xanthouli P, Bossone E, Grünig E. Reduced Right Ventricular Output Reserve in Patients With Systemic Sclerosis and Mildly Elevated Pulmonary Artery Pressure. Arthritis Rheumatol 2019; 71:805-816. [PMID: 30615302 DOI: 10.1002/art.40814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This prospective study was undertaken to evaluate right ventricular function and pulmonary arterial compliance (PAC; ratio of stroke volume to pulse pressure) at rest and during exercise in patients with systemic sclerosis (SSc) with normal mean pulmonary artery pressure (PAP), patients with SSc with mildly elevated mean PAP, and patients with SSc with manifest pulmonary hypertension (PH). METHODS Patients with SSc (n = 112) underwent clinical assessment and right-sided heart catheterization at rest and during exercise and were divided into 3 groups according to their resting mean PAP values: normal mean PAP (≤20 mm Hg), mildly elevated mean PAP (21-24 mm Hg), and PH (mean PAP ≥25 mm Hg). Results were compared between groups by analysis of variance followed by post hoc Student's t-test. RESULTS Compared to patients with normal mean PAP, patients with mildly elevated mean PAP had a lower 6-minute walking distance (P = 0.008), lower cardiac index (P = 0.027) and higher pulmonary vascular resistance (P = 0.0002) during exercise, and lower PAC at rest (P = 0.016) and different stages of exercise (P = 0.033 for 25W and P = 0.024 for 75W). CONCLUSION The results of this study suggest that impaired 6-minute walking distance in SSc patients with mildly elevated mean PAP might be caused by reduced PAC during exercise and reduced right ventricular output reserve, presumably due to impaired coupling between the right ventricle and the pulmonary vasculature. These findings provide further evidence of the clinical relevance of mildly elevated mean PAP in patients with SSc.
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Affiliation(s)
- Christian Nagel
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany, and Klinikum Mittelbaden Baden-Baden Balg, Baden-Baden, Germany
| | - Alberto M Marra
- SDN Scientific Institute for Research and Healthcare, Naples, Italy
| | - Nicola Benjamin
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | | | | | | | - Benjamin Egenlauf
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Satenik Harutyunova
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Panagiota Xanthouli
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | - Ekkehard Grünig
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
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23
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Marra AM, Halank M, Benjamin N, Bossone E, Cittadini A, Eichstaedt CA, Egenlauf B, Harutyunova S, Fischer C, Gall H, Ghofrani HA, Hoeper MM, Lange TJ, Olsson KM, Klose H, Grünig E. Right ventricular size and function under riociguat in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (the RIVER study). Respir Res 2018; 19:258. [PMID: 30567595 PMCID: PMC6299931 DOI: 10.1186/s12931-018-0957-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/29/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Riociguat is a soluble guanylate cyclase stimulator approved for pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTPEH). The objective of this study was to evaluate right heart size and function assessed by echocardiography during long term treatment with riociguat. METHODS Patients who started riociguat treatment (1.0-2.5 mg tid) within the trials phase II, PATENT, PATENTplus, EAS, CHEST and continued treatment for 3-12 months were included in this study. Echocardiography was analysed off-line at baseline, after 3, 6 and 12 months by investigators who were blinded to clinical data. Last and baseline observation carried forward method (LOCF, BOCF) were performed as sensitivity analysis. RESULTS Seventy-one patients (45% PAH, 55% CTEPH; 53.5% female; 60 ± 13 years, mean pulmonary arterial pressure 46 ± 10 mmHg, mean PVR 700 ± 282dynes·sec·cm-5) were included. After 6 months, RA and RV area, RV thickness tricuspid regurgitation velocity showed a significant reduction. After 12 months, patients receiving riociguat therapy showed a significant reduction in right atrial (- 2.6 ± 4.4 cm2, 95% CI -3.84, - 1.33; p < 0.001, n = 49) and right ventricular (RV) area (- 3.5 ± 5.2 cm2, 95% CI -5.1, - 1.9; p < 0.001; n = 44), RV thickness (- 0.76 ± 2.2 mm, 95% CI -1.55, 0.03; n = 32), and a significant increase in TAPSE (2.95 ± 4.78 mm, 95% CI 1.52, 4.39; n = 45) and RV fractional area change (8.12 ± 8.87 mm, 95% CI 4.61, 11.62; n = 27). Both LOCF and BOCF showed similar results but lower effect sizes. CONCLUSION Patients under long-term treatment with riociguat show significantly reduced right heart size and improved RV function in PAH and CTEPH. Further controlled prospective studies are needed to confirm these results.
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Affiliation(s)
- Alberto M Marra
- IRCCS SDN, Research Institute, Naples, Italy.,Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Michael Halank
- Department of Internal Medicine I, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Antonio Cittadini
- Department of Translational Medical Sciences, "Federico" University, Naples, Italy
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Hans Klose
- Department of Pneumology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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Fischer L, Benjamin N, Blank N, Egenlauf B, Fischer C, Harutyunova S, Koegler M, Lorenz HM, Marra AM, Nagel C, Xanthouli P, Bossone E, Grünig E. Right heart size and function significantly correlate in patients with pulmonary arterial hypertension - a cross-sectional study. Respir Res 2018; 19:216. [PMID: 30409145 PMCID: PMC6225631 DOI: 10.1186/s12931-018-0913-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/16/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The objective of this study was to assess, whether right atrial (RA) and ventricular (RV) size is related to RV pump function at rest and during exercise in patients with pulmonary arterial hypertension (PAH). METHODS We included 54 patients with invasively diagnosed PAH that had been stable on targeted medication. All patients underwent clinical assessments including right heart catheterization and echocardiography at rest and during exercise. RV output reserve was defined as increase of cardiac index (CI) from rest to peak exercise (∆CIexercise). Patients were classified according to the median of RA and RV-area. RV pump function and further clinical parameters were compared between groups by student's t-test. Uni- and multivariate Pearson correlation analyses were performed. RESULTS Patients with larger RA and/or RV-areas (above a median of 16 and 20cm2, respectively) showed significantly lower ∆CIexercise, higher mean pulmonary arterial pressure, pulmonary vascular resistance at rest and NT-proBNP levels. Furthermore, patients with higher RV-areas presented with a significantly lower RV stroke volume and pulmonary arterial compliance at peak exercise than patients with smaller RV-size. RV area was identified as the only independent predictor of RV output reserve. CONCLUSION RV and RA areas represent valuable and easily accessible indicators of RV pump function at rest and during exercise. Cardiac output reserve should be considered as an important clinical parameter. Prospective studies are needed for further evaluation.
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Affiliation(s)
- Lukas Fischer
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Norbert Blank
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Maria Koegler
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,IRCCS SDN Research Institute, Naples, Italy
| | - Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Lung Centre, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Eduardo Bossone
- Heart Department, Cardiology Division, "Cava de' Tirreni and Amalfi Coast" Hospital, University of Salerno, Salerno, Italy
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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Grünig E, Benjamin N, Krüger U, Kaemmerer H, Harutyunova S, Olsson KM, Ulrich S, Gerhardt F, Neurohr C, Sablotzki A, Halank M, Marra AM, Kabitz HJ, Thimm G, Fliegel KG, Klose H. 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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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.
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Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany.
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Ulrich Krüger
- Department of Cardiology, Heart Centre Duisburg, Germany
| | - Harald Kaemmerer
- Department of Paediatric Cardiology and Congenital Heart Disease Munich, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, German Centre for Lung Research (DZL), Hannover, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich, Switzerland
| | - Felix Gerhardt
- Department of Cardiology, University Hospital Cologne, Germany
| | - Claus Neurohr
- Dept. of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Armin Sablotzki
- Clinic for Anesthesiology St. Georg Hospital, Leipzig, Germany
| | - Michael Halank
- Department of Pneumology, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany; IRCCS S.D.N., Via Gianturco 113, 80143 Naples, Italy
| | - Hans-Joachim Kabitz
- Department of Pneumology and Intensive Care Medicine, Academic Teaching Hospital, Klinikum Konstanz, Germany
| | - Günther Thimm
- Patientenvereinigung Pulmonale Hypertonie e.V., Rheinstetten, Germany
| | | | - Hans Klose
- Department of Pneumology, University Hospital Hamburg-Eppendorf, Germany
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Coghlan JG, Wolf M, Distler O, Denton CP, Doelberg M, Harutyunova S, Marra AM, Benjamin N, Fischer C, Grünig E. Incidence of pulmonary hypertension and determining factors in patients with systemic sclerosis. Eur Respir J 2018; 51:13993003.01197-2017. [PMID: 29563168 DOI: 10.1183/13993003.01197-2017] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 02/15/2018] [Indexed: 11/05/2022]
Abstract
The objective of this study was to evaluate the incidence of pulmonary hypertension (PH) and determining factors in patients with systemic sclerosis (SSc) and a diffusing capacity of the lung for carbon monoxide (DLCO) <60% predicted.In this bicentric, prospective cohort study, patients with SSc were clinically assessed at baseline and after 3 years, including right heart catheterisation (RHC). Analysis of determining factors for the development of PH was performed using univariate and multivariate analyses.96 patients with a mean pulmonary arterial pressure (mPAP) <25 mmHg at baseline were followed for 2.95±0.7 years (median 3 years). Of these, 71 had a second RHC; 18 of these 71 patients (25.3%) developed PH, and five (7%) developed SSc-associated pulmonary arterial hypertension. For patients with an mPAP of 21-24 mmHg at baseline, the likelihood of presenting with PH as opposed to normal pressures on follow-up was significantly higher (p=0.026). Pulmonary vascular resistance, tricuspid regurgitation velocity, diffusion capacity and the size of the inferior vena cava at baseline were independent predictors for the development of PH during follow-up.In a selected cohort of SSc patients with a DLCO <60%, pulmonary pressures appeared to rise progressively during follow-up. In this population, it was possible to identify manifest PH in almost 25% of patients using prospective RHC during follow-up. Therefore, regular clinical assessment including RHC might be useful in patients with SSc.
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Affiliation(s)
- J Gerry Coghlan
- Cardiology Dept, Royal Free Hospital, London, UK.,Both authors contributed equally
| | - Matthias Wolf
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany.,Both authors contributed equally
| | - Oliver Distler
- Dept of Rheumatology, Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | | | | | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | | | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - Christine Fischer
- Dept of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany.,Translational Lung Research Center (TLRC) of the German Center for Lung Research (DZL), Heidelberg, Germany
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Egenlauf B, Marra A, Nagel C, Harutyunova S, Lorenz HM, Blank N, Fiehn C, Hadaschik E, Benjamin N, Fischer C, Grünig E. Patients with systemic sclerosis and borderline pulmonary arterial pressures display reduced right ventricular contractile reserve. Pneumologie 2018. [DOI: 10.1055/s-0037-1619134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- B Egenlauf
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
| | - A Marra
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
| | - C Nagel
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
| | - S Harutyunova
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
| | - HM Lorenz
- Department of Rheumatology, University Hospital Heidelberg
| | - N Blank
- Department of Rheumatology, University Hospital Heidelberg
| | - C Fiehn
- Praxis für Rheumatologie und Klinische Immunologie, Baden-Baden
| | - E Hadaschik
- Department of Dermatology, University of Heidelberg
| | - N Benjamin
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
| | - C Fischer
- Institute of Human Genetics, University of Heidelberg
| | - E Grünig
- Centre for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg
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Coghlan G, Wolf M, Distler O, Denton CP, Doelberg M, Harutyunova S, Marra A, Benjamin N, Fischer C, Grünig E. Incidence of pulmonary hypertension and determining factors in patients with systemic sclerosis after negative right heart catheterisation. Pneumologie 2018. [DOI: 10.1055/s-0037-1619133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- G Coghlan
- Cardiology Department, Royal Free Hospital, London
| | - M Wolf
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg
| | - O Distler
- Department of Rheumatology, Faculty of Medicine, University of Zurich
| | - CP Denton
- Centre of Rheumatology, Royal Free Hospital, London
| | - M Doelberg
- Actelion Pharmaceuticals Ltd., Switzerland
| | - S Harutyunova
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg
| | - A Marra
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg
| | - N Benjamin
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg
| | - C Fischer
- Institute of Biostatistics Heidelberg
| | - E Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg; Translational Lung Research Center (TLRC) of the German Center for Lung Research (DZL), Heidelberg
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Grünig E, Ohnesorge J, Benjamin N, Burhenne J, Enderle Y, Egenlauf B, Fischer C, Harutyunova S, Huppertz A, Klose H, Haefeli WE. Plasma Drug Concentrations in Patients with Pulmonary Arterial Hypertension on Combination Treatment. Respiration 2017; 94:26-37. [PMID: 28494463 DOI: 10.1159/000470916] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 02/25/2017] [Accepted: 03/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Combination therapy with the phosphodiesterase type 5 inhibitors (PDE-5i) sildenafil or tadalafil and the endothelin receptor antagonists (ERA) bosentan, ambrisentan, or macitentan may cause mutual pharmacokinetic interactions in patients with pulmonary arterial hypertension (PAH). OBJECTIVE The objective of this study was to analyze plasma drug concentrations in PAH patients receiving different combination treatments. METHODS PAH patients receiving a stable combination treatment with ERA and PDE-5i with targeted dosage for at least 1 month were routinely assessed, including clinical parameters and plasma drug concentrations. Concentrations were normalized considering dose and time from last medication intake and presented as multiples of the expected mean (MoM) of the respective monotherapies. RESULTS A total of 125 PAH patients (84 female, 41 male, 57% idiopathic/heritable) were included. Sildenafil and tadalafil concentrations were lowest in combination with bosentan (MoM 0.44 ± 0.42, 95% confidence interval [CI] 0.30-0.57, and MoM 0.89 ± 0.53, 95% CI 0.50-1.28, respectively) compared to the combination with ambrisentan (MoM 1.3 ± 0.97, 95% CI 0.86-1.73, and MoM 1.67 ± 0.63, 95% CI 1.40-1.94, respectively) and macitentan (MoM 1.16 ± 0.87, 95% CI 0.86-1.46, and MoM 1.59 ± 0.99, 95% CI 0.80-2.38, respectively). The combination of sildenafil and bosentan led to more than twice the expected bosentan concentrations in 53.8%. Patients switching from sildenafil-bosentan to macitentan showed a significant increase in sildenafil concentrations (p < 0.001). CONCLUSIONS Only the combination with macitentan or ambrisentan led to targeted mean PDE-5i plasma concentrations and should therefore be preferred to combination with bosentan. Sildenafil-bosentan showed the strongest interaction, with low sildenafil and high bosentan concentrations. The study was not powered to analyze whether lower PDE-5i concentrations cause unsatisfying clinical response. However, plasma concentrations within a targeted range are desirable and may become of increasing importance.
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Affiliation(s)
- Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
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Harutyunova S, Ehlken N, Egenlauf B, Grünig E, Nagel C. Mischform einer pulmonal arterieller Hypertonie und pulmonal venoocclusiver Erkrankung (PVOD): ein Fallbericht. Pneumologie 2017. [DOI: 10.1055/s-0037-1598401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- S Harutyunova
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg
| | - N Ehlken
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg
| | - B Egenlauf
- Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg; Zentrum für Pulmonale Hypertonie
| | - E Grünig
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg
| | - C Nagel
- Lungenzentrum, Klinikum Baden-Baden
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Eichstaedt CA, Song J, Benjamin N, Harutyunova S, Fischer C, Grünig E, Hinderhofer K. EIF2AK4 mutation as "second hit" in hereditary pulmonary arterial hypertension. Respir Res 2016; 17:141. [PMID: 27809840 PMCID: PMC5095976 DOI: 10.1186/s12931-016-0457-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/24/2016] [Indexed: 01/08/2023] Open
Abstract
Background Mutations in the eukaryotic translation initiation factor 2α kinase 4 (EIF2AK4) gene have recently been identified in recessively inherited veno-occlusive disease. In this study we assessed if EIF2AK4 mutations occur also in a family with autosomal dominantly inherited pulmonary arterial hypertension (HPAH) and incomplete penetrance of bone morphogenic protein receptor 2 (BMPR2) mutations. Methods Clinical examinations in a family with 10 members included physical examination, electrocardiogram, (stress)-echocardiography and lung function. Manifest PAH was confirmed by right heart catheterisation in three affected subjects. Genetic analysis was performed using a new PAH-specific gene panel analysis with next generation sequencing of all known PAH and further candidate genes. Identified variants were confirmed by Sanger sequencing. Results All living family members with manifest HPAH carried two pathogenic heterozygous mutations: a frame shift mutation in the BMPR2 gene and a novel splice site mutation in the EIF2AK4 gene. Two family members who carried the BMPR2 mutation only did not develop manifest HPAH. Conclusions This is the first study suggesting that EIF2AK4 can also contribute to autosomal dominantly inherited HPAH. Up to now it has only been identified in a recessive form of HPAH. Only those family members with a co-occurrence of two mutations developed manifest HPAH. Thus, the EIF2AK4 and BMRPR2 mutations support the “second hit” hypothesis explaining the variable penetrance of HPAH in this family. Hence, the assessment of all known PAH genes in families with a known mutation might assist in predictions about the clinical manifestation in so far non-affected mutation carriers.
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Affiliation(s)
- Christina A Eichstaedt
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Jie Song
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Katrin Hinderhofer
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.
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Grünig E, Benjamin N, Krüger U, Kaemmerer H, Harutyunova S, Olsson K, Ulrich S, Gerhardt F, Neurohr C, Sablotzki A, Halank M, Kabitz HJ, Thimm G, Fliegel KG, Klose H. 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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Grünig E, Ohnesorge J, Benjamin N, Burhenne J, Song J, Egenlauf B, Fischer C, Harutyunova S, Huppertz A, Klose H, Haefeli WE. Plasma drug-concentrations in patients with pulmonary arterial hypertension on combination treatment. Pneumologie 2016. [DOI: 10.1055/s-0036-1584623] [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: 10/19/2022]
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Song J, Eichstaedt CA, Rodríguez Viales R, Benjamin N, Harutyunova S, Fischer C, Grünig E, Hinderhofer K. A new fast molecular genetic diagnostic approach for pulmonary arterial hypertension. Pneumologie 2016. [DOI: 10.1055/s-0036-1584632] [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: 10/19/2022]
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35
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Egenlauf B, Ohnesorge J, Benjamin N, Harutyunova S, Fischer C, Enderle Y, Burhenne J, Nagel C, Huppertz A, Carls A, Haefeli WE, Grünig E. Pharmacokinetic interactions in different combinations of specific pulmonary arterial hypertension treatment. Pneumologie 2016. [DOI: 10.1055/s-0036-1572031] [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: 10/22/2022]
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