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Sato T, Furukawa T, Teramachi R, Fukihara J, Yamano Y, Yokoyama T, Matsuda T, Kataoka K, Kimura T, Sakamoto K, Ishii M, Kondoh Y. Mild elevation of pulmonary vascular resistance predicts mortality regardless of mean pulmonary artery pressure in mild interstitial lung disease. Thorax 2024; 79:422-429. [PMID: 38316550 DOI: 10.1136/thorax-2023-220179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/08/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Pulmonary hypertension (PH) is defined by elevated mean pulmonary arterial pressure (MPAP), and elevated pulmonary vascular resistance (PVR) reflects pulmonary vascular abnormalities. The clinical significance of non-severe PH in patients with various interstitial lung diseases (ILDs) has not been fully elucidated. We aimed to investigate the clinical significance of MPAP and PVR for mortality in patients with newly diagnosed ILD. METHODS We retrospectively analysed consecutive patients with ILD at initial evaluations that included right heart catheterisation from 2007 to 2018. These patients were classified by MPAP and PVR using the 2022 the European Society of Cardiology (ESC)/the European Respiratory Society (ERS) guidelines for PH. The clinical significance of MPAP and PVR for mortality was analysed. RESULTS Among 854 patients, 167 (19.6%) had MPAP>20 mm Hg. The proportion of patients with PVR>2 Wood units (WU) among those with MPAP≤20 mm Hg, 202 WU was associated with a higher mortality rate (HR 1.61, 95% CI 1.28 to 2.02, p<0.0001) even in a group with MPAP≤20 mm Hg. CONCLUSIONS Mild elevation of PVR was associated with a higher mortality rate in patients with newly diagnosed ILD, even in those with MPAP≤20 mm Hg.
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Affiliation(s)
- Tomonori Sato
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taiki Furukawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Medical IT Center, Nagoya University Hospital, Nagoya, Japan
| | - Ryo Teramachi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Medical IT Center, Nagoya University Hospital, Nagoya, Japan
| | - Jun Fukihara
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Toshiki Yokoyama
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Toshiaki Matsuda
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Koji Sakamoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Makoto Ishii
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
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Ameri P, Mercurio V, Pollesello P, Anker MS, Backs J, Bayes-Genis A, Borlaug BA, Burkhoff D, Caravita S, Chan SY, de Man F, Giannakoulas G, González A, Guazzi M, Hassoun PM, Hemnes AR, Maack C, Madden B, Melenovsky V, Müller OJ, Papp Z, Pullamsetti SS, Rainer PP, Redfield MM, Rich S, Schiattarella GG, Skaara H, Stellos K, Tedford RJ, Thum T, Vachiery JL, van der Meer P, Van Linthout S, Pruszczyk P, Seferovic P, Coats AJS, Metra M, Rosano G, Rosenkranz S, Tocchetti CG. A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function. Eur J Heart Fail 2024; 26:707-729. [PMID: 38639017 DOI: 10.1002/ejhf.3236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiac, Thoracic, and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Piero Pollesello
- Content and Communication, Branded Products, Orion Pharma, Espoo, Finland
| | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin (Campus CBF), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, University of Heidelberg and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milan, Italy
| | - Stephen Y Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Frances de Man
- PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aránzazu González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Marco Guazzi
- University of Milan, Milan, Italy
- Cardiology Division, San Paolo University Hospital, Milan, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristoph Maack
- Comprehensive Heart Failure Center (CHFC) and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | | | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Oliver J Müller
- Department of Internal Medicine V, University Hospital Schleswig-Holstein, and German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Soni Savai Pullamsetti
- Department of Internal Medicine and Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig University, Giessen, Germany
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | | | - Stuart Rich
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gabriele G Schiattarella
- Max-Rubner Center (CMR), Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Hall Skaara
- Pulmonary Hypertension Association Europe, Vienna, Austria
| | - Kostantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site, Heidelberg and Mannheim, Germany
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Jean Luc Vachiery
- Department of Cardiology, Hopital Universitaire de Bruxelles Erasme, Brussels, Belgium
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, University of Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK, partner site Berlin), Berlin, Germany
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade University Medical Center, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
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3
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Vaidy A, Vahdatpour CA, Mazurek J. Exercise Testing in Patients with Pulmonary Hypertension. J Clin Med 2024; 13:795. [PMID: 38337493 PMCID: PMC10855991 DOI: 10.3390/jcm13030795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Pulmonary hypertension (PH), defined by a mean pulmonary artery pressure of >20 mm Hg, often presents with non-specific symptoms such as dyspnea and exercise intolerance, making it difficult to diagnose early before the onset of right heart dysfunction. Therefore, exercise testing can be of great utility for clinicians who are evaluating patients with an unclear etiology of exercise intolerance by helping identify the underlying mechanisms of their disease. The presence of PH is associated with adverse clinical outcomes, with distinct differences and patterns in the cardiovascular and ventilatory responses to exercise across various PH phenotypes. We discuss the role of exercise-invasive hemodynamic testing, cardiopulmonary exercise testing, and exercise stress echocardiography modalities across the spectrum of PH.
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Affiliation(s)
- Anika Vaidy
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Cyrus A. Vahdatpour
- Division of Pulmonary Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Jeremy Mazurek
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Torbicki A, Kurzyna M. The Diagnostic Approach to Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:728-737. [PMID: 37487526 DOI: 10.1055/s-0043-1770116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
The clinical presentation of pulmonary hypertension (PH) is nonspecific, resulting in significant delays in its detection. In the majority of cases, PH is a marker of the severity of other cardiopulmonary diseases. Differential diagnosis aimed at the early identification of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) who do require specific and complex therapies is as important as PH detection itself. Despite all efforts aimed at the noninvasive assessment of pulmonary arterial pressure, the formal confirmation of PH still requires catheterization of the right heart and pulmonary artery. The current document will give an overview of strategies aimed at the early diagnosis of PAH and CTEPH, while avoiding their overdiagnosis. It is not intended to be a replica of the recently published European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines on Diagnosis and Treatment of Pulmonary Hypertension, freely available at the Web sites of both societies. While promoting guidelines' recommendations, including those on new definitions of PH, we will try to bring them closer to everyday clinical practice, benefiting from our personal experience in managing patients with suspected PH.
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Affiliation(s)
- Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre for Postgraduate Medical Education at ECZ-Otwock, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre for Postgraduate Medical Education at ECZ-Otwock, Otwock, Poland
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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6
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), 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
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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Caravita S, Baratto C, Filippo A, Soranna D, Dewachter C, Zambon A, Perego GB, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Fudim M. Shedding Light on Latent Pulmonary Vascular Disease in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1427-1438. [PMID: 37115127 DOI: 10.1016/j.jchf.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Among patients with heart failure with preserved ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, ie, latent pulmonary vascular disease (HFpEF-latentPVD), defined by exercise pulmonary vascular resistance (PVR) >1.74 WU. OBJECTIVES This study aims to explore the pathophysiological significance of HFpEF-latentPVD. METHODS The authors analyzed a cohort of patients who had undergone supine exercise right heart catheterization with cardiac output (CO) measured by direct Fick method, between 2016 and 2021. HFpEF-latentPVD patients were compared with HFpEF control patients. RESULTS Out of 86 HFpEF patients, 21% qualified as having HFpEF-latentPVD, 78% of whom had PVR >2 WU at rest. Patients with HFpEF-latentPVD were older, with a higher pretest probability of HFpEF, and more frequently experienced atrial fibrillation and at least moderate tricuspid regurgitation (P < 0.05). PVR trajectories differed between HFpEF-latentPVD patients and HFpEF control patients (Pinteraction = 0.008), slightly increasing in the former and reducing in the latter. HFpEF-latentPVD patients displayed more frequent hemodynamically significant tricuspid regurgitation during exercise (P = 0.002) and had more impaired CO and stroke volume reserve (P < 0.05). Exercise PVR was correlated with mixed venous O2 tension (R2 = 0.33) and stroke volume (R2 = 0.31) in HFpEF-latentPVD patients. The HFpEF-latentPVD patients had had higher dead space ventilation during exercise and higher PaCO2 (P < 0.05), which correlated with resting PVR (R2 = 0.21). Event-free survival was reduced in HFpEF-latentPVD patients (P < 0.05). CONCLUSIONS The results suggest that when CO is measured by direct Fick, few HFpEF patients have isolated latent PVD (ie, normal PVR at rest, becoming abnormal during exercise). HFpEF-latentPVD patients present with CO limitation to exercise, associated with dynamic tricuspid regurgitation, altered ventilatory control, and pulmonary vascular hyperreactivity, portending a poor prognosis.
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Affiliation(s)
- Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy; Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.
| | - Aurora Filippo
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milano, Italy
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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8
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Pezzuto B, Agostoni P. The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension. J Clin Med 2023; 12:5465. [PMID: 37685532 PMCID: PMC10487723 DOI: 10.3390/jcm12175465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.
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Affiliation(s)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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9
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Goda A, Yanagisawa Y, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Kohno T, Satoh T, Soejima K. Characteristics of cardiopulmonary exercise testing in patients with combined post- and pre-capillary pulmonary hypertension due to left heart disease. PLoS One 2023; 18:e0286057. [PMID: 37216326 DOI: 10.1371/journal.pone.0286057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common and morbid complication of left heart disease (LHD), comprising two subtypes: (1) isolated post-capillary pulmonary hypertension (Ipc-PH) and (2) combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH). Knowledge regarding the physiological characteristics that distinguish Cpc-PH, which has a worse prognosis, from Ipc-PH remains limited. Therefore, this study aimed to assess the utility of cardiopulmonary exercise testing (CPET) variables in detecting Cpc-PH. METHODS AND RESULTS Among 105 consecutive patients with LHD (age: 55 ± 13 years; male/female = 79/26) who underwent right heart catheterization and CPET, 45 (43%) were classified as PH-LHD (mean pulmonary artery pressure >20 mmHg). Ipc-PH (n = 24) was defined as pulmonary vascular resistance (PVR) ≤ 3 WU and Cpc-PH (n = 21) as PVR > 3 WU. Patients with Cpc-PH had a significantly lower peak partial pressure of carbon dioxide (PETCO2) (Non-PH/Ipc-PH/Cpc-PH = 38.2 ± 6.6 vs. 38.3 ± 6.0 vs 33.0 ± 4.4 mmHg, p = 0.006), higher VE vs. VCO2 slope (Non-PH/Ipc-PH/Cpc-PH = 33.0 [28.3, 36.6] vs. 32.5 [28.1, 37.8] vs. 40.6 [33.6, 46.1], p = 0.007), and lower ΔVO2/ΔWR (Non-PH/Ipc-PH/Cpc-PH = 8.5 ± 1.4 vs. 8.0 ± 1.7 vs. 6.8 ± 2.0 mL/min/watt, p = 0.001) than those with Ipc-PH and non-PH. Using multivariable logistic regression analysis, CPET variables were found to be independent predictors of Cpc-PH (lower peak PETCO2: odds ratio, 0.728 [95% confidence interval {CI}: 0.616-0.840], p = 0.003 and lower ΔVO2/ΔWR: odds ratio, 0.747 [95% CI: 0.575-0.872], p = 0.003). CONCLUSION From our exploratory analysis, CPET variables, especially in the lower peak PETCO2 and lower ΔVO2/ΔWR, were associated with Cpc-PH in patients with left heart disease.
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Affiliation(s)
- Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Yoshiaki Yanagisawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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10
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Verwerft J, Bertrand PB, Claessen G, Herbots L, Verbrugge FH. Cardiopulmonary Exercise Testing With Simultaneous Echocardiography: Blueprints of a Dyspnea Clinic for Suspected HFpEF. JACC. HEART FAILURE 2023; 11:243-249. [PMID: 36754531 DOI: 10.1016/j.jchf.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/09/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jan Verwerft
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Philippe B Bertrand
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Guido Claessen
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
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11
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 394] [Impact Index Per Article: 394.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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12
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Joseph P, Savarimuthu S, Zhao J, Yan X, Oakland HT, Cullinan M, Heerdt PM, Singh I. Noninvasive determinants of pulmonary hypertension in interstitial lung disease. Pulm Circ 2023; 13:e12197. [PMID: 36814586 PMCID: PMC9939578 DOI: 10.1002/pul2.12197] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/04/2022] [Accepted: 01/23/2023] [Indexed: 01/30/2023] Open
Abstract
Pulmonary hypertension (PH) in interstitial lung disease (ILD) is associated with increased mortality and impaired exertional capacity. Right heart catheterization is the diagnostic standard for PH but is invasive and not readily available. Noninvasive physiologic evaluation may predict PH in ILD. Forty-four patients with PH and ILD (PH-ILD) were compared with 22 with ILD alone (non-PH ILD). Six-min walk distance (6MWD, 223 ± 131 vs. 331 ± 125 m, p = 0.02) and diffusing capacity for carbon monoxide (DLCO, 33 ± 14% vs. 55 ± 21%, p < 0.001) were lower in patients with PH-ILD. PH-ILD patients exhibited a lower gas-exchange derived pulmonary vascular capacitance (GXCAP, 251 ± 132 vs. 465 ± 282 mL × mmHg, p < 0.0001) and extrapolated maximum oxygen uptake (VO2max) (56 ± 32% vs. 84 ± 37%, p = 0.003). Multivariate analysis was performed to determine predictors of VO2 max. GXCAP was the only variable that predicted extrapolated VO2 max among PH-ILD and non-PH ILD patients. Receiver operating characteristic curve analysis assessed the ability of individual noninvasive variables to distinguish between PH-ILD and non-PH ILD patients. GXCAP (area under the curve [AUC] 0.85 ± 0.04, p < 0.0001) and delta ETCO2 (AUC 0.84 ± 0.04, p < 0.0001) were the strongest predictors of PH-ILD. A CART analysis selected GXCAP, estimated right ventricular systolic pressure (eRVSP) by echocardiogram, and FVC/DLCO ratio as predictive variables for PH-ILD. With this analysis, the AUC improved to 0.94 (sensitivity of 0.86 and sensitivity of 0.93). Patients with a GXCAP ≤ 416 mL × mmHg had an 82% probability of PH-ILD. Patients with GXCAP ≤ 416 mL × mmHg and high FVC/DLCO ratio >1.7 had an 80% probability of PH-ILD. Patients with GXCAP ≤ 416 mL × mmHg and an elevated eRVSP by echocardiogram >43 mmHg had 100% probability of PH-ILD. The incorporation of GXCAP with either eRVSP or FVC/DLCO ratio distinguishes between PH-ILD and non-PH-ILD with high probability and may therefore assist in determining the need to proceed with a diagnostic right heart catheterization and potential initiation of pulmonary arterial hypertension-directed therapy in PH-ILD patients.
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Affiliation(s)
- Phillip Joseph
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Stella Savarimuthu
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Jiayi Zhao
- Department of BiostatisticsYale School of Public HealthNew HavenConnecticutUSA
| | - Xiting Yan
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Hannah T. Oakland
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Marjorie Cullinan
- Department of Respiratory CareYale New Haven HospitalNew HavenConnecticutUSA
| | - Paul M. Heerdt
- Department of AnaesthesiologyYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Inderjit Singh
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
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13
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Baratto C, Caravita S, Corbetta G, Soranna D, Zambon A, Dewachter C, Gavazzoni M, Heilbron F, Tomaselli M, Radu N, Perelli FP, Perego GB, Vachiéry JL, Parati G, Badano LP, Muraru D. Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction. Front Cardiovasc Med 2023; 10:1061118. [PMID: 36937944 PMCID: PMC10014840 DOI: 10.3389/fcvm.2023.1061118] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Background Both secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problems in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified. Aim To explore the impact of STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF. Methods We analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age-, sex-, and body mass index (BMI)- matched HFpEF patients with mild or no STR (HFpEF-controls). Results Twelve HFpEF with atrial-STR (mean age 72 years, 92% females, BMI 28 Kg/m2) and 12 HFpEF-controls patients were analyzed. HFpEF-STR had higher (p < 0.01) right atrial pressure than HFpEF-controls both at rest (10 ± 1 vs. 5 ± 1 mmHg) and during exercise (23 ± 2 vs. 14 ± 2 mmHg). Despite higher pulmonary artery wedge pressure (PAWP) at rest in HFpEF-STR than in HFpEF-controls (17 ± 2 vs. 11 ± 2, p = 0.04), PAWP at peak exercise was no more different (28 ± 2 vs. 29 ± 2). Left ventricular transmural pressure and cardiac output (CO) increased less in HFpEF-STR than in HFpEF-controls (interaction p-value < 0.05). This latter was due to lower stroke volume (SV) values both at rest (48 ± 9 vs. 77 ± 9 mL, p < 0.05) and at peak exercise (54 ± 10 vs. 93 ± 10 mL, p < 0.05). Despite these differences, the two groups of patients laid on the same oxygen consumption isophlets because of the increased peripheral oxygen extraction in HFpEF-STR (p < 0.01). We found an inverse relationship between pulmonary vascular resistance and SV, both at rest and at peak exercise (R 2 = 0.12 and 0.19, respectively). Conclusions Severe STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, undermining the typical HFpEF pathophysiology.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
- *Correspondence: Sergio Caravita
| | - Giorgia Corbetta
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Mara Gavazzoni
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Noela Radu
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Paolo Perelli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Gianfranco Parati
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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14
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Dzikowska-Diduch O, Kurnicka K, Lichodziejewska B, Dudzik-Niewiadomska I, Machowski M, Roik M, Wiśniewska M, Siwiec J, Staniszewska IM, Pruszczyk P. Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism. J Clin Med 2022; 11:jcm11247369. [PMID: 36555985 PMCID: PMC9784264 DOI: 10.3390/jcm11247369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/31/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.
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Affiliation(s)
- Olga Dzikowska-Diduch
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-502-11-44; Fax: +48-22-502-21-42
| | - Katarzyna Kurnicka
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Iwona Dudzik-Niewiadomska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Michał Machowski
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Marek Roik
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Małgorzata Wiśniewska
- 1st Department of Radiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Jan Siwiec
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | | | - Piotr Pruszczyk
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
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15
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 942] [Impact Index Per Article: 471.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Caravita S, Faini A, Vignati C, Pelucchi S, Salvioni E, Cattadori G, Baratto C, Torlasco C, Contini M, Villani A, Malfatto G, Perger E, Lombardi C, Piperno A, Agostoni P, Parati G. Intravenous iron therapy improves the hypercapnic ventilatory response and sleep disordered breathing in chronic heart failure. Eur J Heart Fail 2022; 24:1940-1949. [PMID: 35867685 PMCID: PMC9804720 DOI: 10.1002/ejhf.2628] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 01/09/2023] Open
Abstract
AIMS Intravenous iron therapy can improve symptoms in patients with heart failure, anaemia and iron deficiency. The mechanisms underlying such an improvement might involve chemoreflex sensing and nocturnal breathing patterns. METHODS AND RESULTS Patients with heart failure, reduced left ventricular ejection fraction, anaemia (haemoglobin <13 g/dl in men; <12 g/dl in women) and iron deficiency (ferritin <100 or 100-299 μg/L with transferrin saturation <20%) were 2:1 randomized to patient-tailored intravenous ferric carboxymaltose dose or placebo. Chemoreflex sensitivity cardiorespiratory sleep study, symptom assessment and cardiopulmonary exercise test were performed before and 2 weeks after the last treatment dose. Fifty-eight patients (38 active arm/20 placebo arm) completed the study. Intravenous iron was associated with less severe symptoms, higher haemoglobin (12.5 ± 1.4 vs. 11.7 ± 1.0 mg/dl, p < 0.05) and improved haematinic parameters. Ferric carboxymaltose improved the central hypercapnic ventilatory response (-25.8%, p < 0.05 vs. placebo), without changes in peripheral chemosensitivity. In particular, the central hypercapnic ventilatory responses passed from 4.6 ± 6.5 to 2.9 ± 2.9 L/min/mmHg after ferric carboxymaltose and from 4.4 ± 4.6 to 4.6 ± 3.9 L/min/mmHg after placebo (ptreatment*condition = 0.046). In patients presenting with sleep-related breathing disorder, apnoea-hypopnoea index was reduced with active treatment as compared to placebo (12 ± 11 vs. 19 ± 13 events/h, p < 0.05). After ferric carboxymaltose, but not after placebo, both peak oxygen uptake (VO2 ) increased (Δ1.1 ± 2.0 ml/kg/min, p < 0.05) and VO2 /workload slope was steeper (Δ0.67 ± 1.7 L/min/W, p < 0.01). CONCLUSIONS Intravenous ferric carboxymaltose improves the hypercapnic ventilatory response and sleep-related breathing disorders in patients with heart failure, anaemia and iron deficiency. These newly described findings, along with improved oxygen delivery to exercising muscles, likely contribute to the favourable effects of ferric carboxymaltose in anaemic patients with heart failure.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Management, Information and Production EngineeringUniversity of BergamoDalmineItaly
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | | | - Sara Pelucchi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | | | | | - Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Camilla Torlasco
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | | | - Alessandra Villani
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Gabriella Malfatto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Elisa Perger
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
| | - Carolina Lombardi
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Alberto Piperno
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCSMilanItaly,Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
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17
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Ovchinnikov A, Potekhina A, Belyavskiy E, Ageev F. Heart Failure with Preserved Ejection Fraction and Pulmonary Hypertension: Focus on Phosphodiesterase Inhibitors. Pharmaceuticals (Basel) 2022; 15:ph15081024. [PMID: 36015172 PMCID: PMC9414416 DOI: 10.3390/ph15081024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) is common in patients with heart failure with preserved ejection fraction (HFpEF). A chronic increase in mean left atrial pressure leads to passive remodeling in pulmonary veins and capillaries and modest PH (isolated postcapillary PH, Ipc-PH) and is not associated with significant right ventricular dysfunction. In approximately 20% of patients with HFpEF, "precapillary" alterations of pulmonary vasculature occur with the development of the combined pre- and post-capillary PH (Cpc-PH), pertaining to a poor prognosis. Current data indicate that pulmonary vasculopathy may be at least partially reversible and thus serves as a therapeutic target in HFpEF. Pulmonary vascular targeted therapies, including phosphodiesterase (PDE) inhibitors, may have a valuable role in the management of patients with PH-HFpEF. In studies of Cpc-PH and HFpEF, PDE type 5 inhibitors were effective in long-term follow-up, decreasing pulmonary artery pressure and improving RV contractility, whereas studies of Ipc-PH did not show any benefit. Randomized trials are essential to elucidate the actual value of PDE inhibition in selected patients with PH-HFpEF, especially in those with invasively confirmed Cpc-PH who are most likely to benefit from such treatment.
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Affiliation(s)
- Artem Ovchinnikov
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, 3-d Cherepkovskaya St., 15a, 121552 Moscow, Russia
- Department of Clinical Functional Diagnostics, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Delegatskaya St., 20, p. 1, 127473 Moscow, Russia
- Correspondence: ; Tel.: +7-(495)-414-66-12 or +7-(916)-505-79-58; Fax: +7-(495)-414-66-12
| | - Alexandra Potekhina
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, 3-d Cherepkovskaya St., 15a, 121552 Moscow, Russia
| | - Evgeny Belyavskiy
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz, 13353 Berlin, Germany
| | - Fail Ageev
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, 3-d Cherepkovskaya St., 15a, 121552 Moscow, Russia
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18
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Raza F, Dharmavaram N, Hess T, Dhingra R, Runo J, Chybowski A, Kozitza C, Batra S, Horn EM, Chesler N, Eldridge M. Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E /VCO 2 and ETCO 2 identify pulmonary vascular disease. Clin Cardiol 2022; 45:742-751. [PMID: 35419844 PMCID: PMC9286332 DOI: 10.1002/clc.23831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management. HYPOTHESIS Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH. METHODS We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant. RESULTS The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2 = 0.70* and ETCO2 = 0.73*. Based on this, optimal thresholds of rest VE /VCO2 > 40 mm Hg and rest ETCO2 < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group. CONCLUSIONS In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2 > 40 mm Hg and ETCO2 < 30 mm Hg) identify PVD.
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Affiliation(s)
- Farhan Raza
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Naga Dharmavaram
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Timothy Hess
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Ravi Dhingra
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - James Runo
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Amy Chybowski
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Callyn Kozitza
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Supria Batra
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Evelyn M. Horn
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Naomi Chesler
- University of California‐Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringIrvineCaliforniaUSA
| | - Marlowe Eldridge
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of PediatricsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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19
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Vicenzi M, Caravita S, Rota I, Casella R, Deboeck G, Beretta L, Lombi A, Vachiery JL. The added value of right ventricular function normalized for afterload to improve risk stratification of patients with pulmonary arterial hypertension. PLoS One 2022; 17:e0265059. [PMID: 35587927 PMCID: PMC9119555 DOI: 10.1371/journal.pone.0265059] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Risk stratification is central to the management of pulmonary arterial hypertension (PAH). For this purpose, multiparametric tools have been developed, including the ESC/ERS risk score and its simplified versions derived from large database analysis such as the COMPERA and the French Pulmonary Hypertension Network (FPHN) registries. However, the distinction between high and intermediate-risk profiles may be difficult as the latter lacks granularity. In addition, neither COMPERA or FPHN strategies included imaging-derived markers. We thus aimed at investigating whether surrogate echocardiographic markers of right ventricular (RV) to pulmonary artery (PA) coupling could improve risk stratification in patients at intermediate-risk. Material and methods A single-center retrospective analysis including 102 patients with a diagnosis of PAH was performed. COMPERA and FPHN strategies were applied to stratify clinical risk. The univariate linear regression was used to test the influence of the echo-derived parameters qualifying the right heart (right ventricle basal diameter, right atrial area, and pressure, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion -TAPSE-). Among these, the TAPSE and tricuspid regurgitation velocity ratio (TAPSE/TRV) as well as the TAPSE and systolic pulmonary artery pressure ratio (TAPSE/sPAP) were considered as surrogate of RV-PA coupling. Results TAPSE/TRV and TAPSE/sPAP resulted the more powerful markers of prognosis. Once added to COMPERA, TAPSE/TRV or TAPSE/sPAP significantly dichotomized intermediate-risk group in intermediate-to-low-risk (TAPSE/TRV≥3.74 mm∙nm/s)-1 or TAPSE/sPAP≥0.24 mm/mmHg) and in intermediate-to-high-risk subgroups (TAPSE/TRV<3.74 mm∙(m/s)-1 or TAPSE/sPAP<0.24 mm/mmHg). In the same way, TAPSE/TRV or TAPSE/sPAP was able to select patients at lower risk among those with 2, 1, and 0 low-risk criteria of both invasive and non-invasive FPHN registries. Conclusions Our results suggest that adopting functional-hemodynamic echo-derived parameters may provide a more accurate risk stratification in patients with PAH. In particular, TAPSE/TRV or TAPSE/sPAP improved risk stratification in patients at intermediate-risk, that otherwise would have remained less characterized.
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Affiliation(s)
- Marco Vicenzi
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
| | - Irene Rota
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Rosa Casella
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gael Deboeck
- Faculty of Motricity Sciences, Department of Physiotherapy, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Lombi
- Department of Health Science, Pulmonology Unit, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
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20
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Inampudi C, Silverman D, Simon MA, Leary PJ, Sharma K, Houston BA, Vachiéry JL, Haddad F, Tedford RJ. Pulmonary Hypertension in the Context of Heart Failure With Preserved Ejection Fraction. Chest 2021; 160:2232-2246. [PMID: 34391755 PMCID: PMC8727853 DOI: 10.1016/j.chest.2021.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/23/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure and frequently is associated with pulmonary hypertension (PH). HFpEF associated with PH may be difficult to distinguish from precapillary forms of PH, although this distinction is crucial because therapeutic pathways are divergent for the two conditions. A comprehensive and systematic approach using history, clinical examination, and noninvasive and invasive evaluation with and without provocative testing may be necessary for accurate diagnosis and phenotyping. After diagnosis, HFpEF associated with PH can be subdivided into isolated postcapillary pulmonary hypertension (IpcPH) and combined postcapillary and precapillary pulmonary hypertension (CpcPH) based on the presence or absence of elevated pulmonary vascular resistance. CpcPH portends a worse prognosis than IpcPH. Despite its association with reduced functional capacity and quality of life, heart failure hospitalizations, and higher mortality, therapeutic options focused on PH for HFpEF associated with PH remain limited. In this review, we aim to provide an updated overview on clinical definitions and hemodynamically characterized phenotypes of PH, pathophysiologic features, therapeutic strategies, and ongoing challenges in this patient population.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Daniel Silverman
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Marc A Simon
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco
| | - Peter J Leary
- Department of Medicine, University of Washington, Seattle, WA
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Jean-Luc Vachiéry
- Département de Cardiologie Cliniques, Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Francois Haddad
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC.
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21
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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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22
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Blasi FBM, Rota I, Graziadei G, Vicenzi M. The tailor-made treatment in a particular case of pulmonary hypertension in thalassaemia intermedia: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab193. [PMID: 34142009 PMCID: PMC8207166 DOI: 10.1093/ehjcr/ytab193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/13/2021] [Accepted: 04/22/2021] [Indexed: 11/13/2022]
Abstract
Background Pulmonary hypertension (PH) is a haemodynamic condition, secondary to different causes. Thalassaemia may lead to PH of different origin and needs a comprehensive analysis to be correctly characterized and possibly treated. Case summary We present a case study of a patient with a non-transfusion-dependent thalassaemia and a previous diagnosis of group 5 PH. A complete diagnostic assessment led to a specific diagnosis of chronic thromboembolic PH. Thus, we were able to start a specific therapy with riociguat that provided an improvement in terms of haemodynamic, imaging, and functional status. Discussion A correct characterization and treatment of PH are essential in order to change the patient's prognosis. Chronic thromboembolic PH is a treatable cause of PH in thalassemic patients and should be investigated.
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Affiliation(s)
- Federico B M Blasi
- Department of Medicine and Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy.,Dyspnea Lab, Department Clinical Sciences and Community Health, University of Milan, Italy
| | - Irene Rota
- Cardiovascular Disease Unit, Internal Medicine Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Giovanna Graziadei
- General Medicine Unit, Department of Medicine and Medical Specialities, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy
| | - Marco Vicenzi
- Dyspnea Lab, Department Clinical Sciences and Community Health, University of Milan, Italy.,Cardiovascular Disease Unit, Internal Medicine Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
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23
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Moghaddam N, Swiston JR, Tsang MYC, Levy R, Lee L, Brunner NW. Impact of targeted pulmonary arterial hypertension therapy in patients with combined post- and precapillary pulmonary hypertension. Am Heart J 2021; 235:74-81. [PMID: 33422519 DOI: 10.1016/j.ahj.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/05/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Combined post- and precapillary pulmonary hypertension (CpcPH) portends poor outcomes in pulmonary hypertension related to left heart disease (PH-LHD). While recent evidence does not support the use of targeted pulmonary arterial hypertension (PAH) therapy in PH-LHD, there is a lack of clinical data on their use in CpcPH. We evaluated the outcomes in patients with CpcPH treated with PAH therapies. METHODS Retrospectively, 50 patients meeting hemodynamic criteria of CpcPH and started on PAH-targeted drugs were identified. Fifty age- and gender-matched PAH patients were chosen as controls. We evaluated the change in 6-minute walk distance, World Health Organization functional class (FC), tricuspid annular plane systolic excursion, BNP or NT-proBNP, and pulmonary artery systolic pressure at 3, 6, 12, and 24 months of follow-up. RESULTS After adjusting for age and gender, there was no improvement in World Health Organization FC in CpcPH over 2 years (odds ratio of change to FC I/II 1.01, 95% CI: 0.98-1.04). There was no significant improvement in 6-minute walk distance (β coefficient 0.21, 95% CI: -0.98 to 1.4), reduction in BNP/NT-proBNP (β coefficient -12.16, 95% CI: -30.68 to 6.37), increase in tricuspid annular plane systolic excursion (β coefficient 0.074, 95% CI: 0.010-0.139), or decrease in pulmonary artery systolic pressure (0.996, 95% CI: 0.991-1.011) in CpcPH with therapy. There was higher mortality in CpcPH compared to PAH on treatment (24% vs 4%, P = .003). CONCLUSIONS There were no improvements in symptoms, exercise capacity, or echocardiographic parameters with PAH-targeted therapy in CpcPH. Further studies into potential treatments benefiting this population are needed.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John R Swiston
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Michael Y C Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Levy
- Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Lisa Lee
- Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada
| | - Nathan W Brunner
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital Pulmonary Hypertension Program, Vancouver, British Columbia, Canada.
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24
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Baratto C, Caravita S, Faini A, Perego GB, Senni M, Badano LP, Parati G. Impact of COVID-19 on exercise pathophysiology: a combined cardiopulmonary and echocardiographic exercise study. J Appl Physiol (1985) 2021; 130:1470-1478. [PMID: 33764166 PMCID: PMC8143785 DOI: 10.1152/japplphysiol.00710.2020] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Survivors from COVID-19 pneumonia can present with persisting multisystem involvement (lung, pulmonary vessels, heart, muscle, red blood cells) that may negatively affect exercise capacity. We sought to determine the extent and the determinants of exercise limitation in patients with COVID-19 at the time of hospital discharge. Eighteen consecutive patients with COVID-19 and 1:1 age-, sex-, and body mass index-matched controls underwent: spirometry, echocardiography, cardiopulmonary exercise test and exercise echocardiography for the study of pulmonary circulation. Arterial blood was sampled at rest and during exercise in patients with COVID-19. Patients with COVID-19 lie roughly on the same oxygen consumption isophlets than controls both at rest and during submaximal exercise, thanks to supernormal cardiac output (P < 0.05). Oxygen consumption at peak exercise was reduced by 30% in COVID-19 (P < 0.001), due to a peripheral extraction limit. In addition, within COVID-19 patients, hemoglobin content was associated with peak oxygen consumption (R2 = 0.46, P = 0.002). Respiratory reserve was not exhausted (median [IRQ], 0.59 [0.15]) in spite of moderate reduction of forced vital capacity (79 ± 40%). Pulmonary artery pressure increase during exercise was not different between patients and controls. Ventilatory equivalents for carbon dioxide were higher in patients with COVID-19 than in controls (39.5 [8.5] vs. 29.5 [8.8], P < 0.001), and such an increase was mainly explained by increased chemosensitivity. When recovering from COVID-19, patients present with reduced exercise capacity and augmented exercise hyperventilation. Peripheral factors, including anemia and reduced oxygen extraction by peripheral muscles were the major determinants of deranged exercise physiology. Pulmonary vascular function seemed unaffected, despite restrictive lung changes.NEW & NOTEWORTHY At the time of hospital discharge, patients with COVID-19 present with reduced functional capacity and exercise hyperventilation. Peripheral factors, namely reduced oxygen extraction (myopathy) and anemia, which are not fully compensated by a supernormal cardiac output response, account for exercise limitation before exhaustion of the respiratory reserve. Enhanced chemoreflex sensitivity, rather increased dead space, mainly accounts for exercise hyperventilation. The pulmonary vascular response to exercise circulation of survived patients with COVID-19 does not present major pathological changes.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Giovanni Battista Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
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Zhong X, Tang J, Jiang R, Yuan P, Zhao Q, Gong S, Liu J, Wang L. The predictive value of minute ventilation versus carbon dioxide production in pulmonary hypertension associated with left heart disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:351. [PMID: 33708978 PMCID: PMC7944330 DOI: 10.21037/atm-21-366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The aim of the present study was to investigate the role of key cardiopulmonary exercise testing (CPET) parameters in the identification of pre-capillary components in patients with pulmonary hypertension associated with left heart disease (PH-LHD), and to evaluate their correlations with hemodynamic parameters. Methods Ninety patients with PH-LHD underwent right-heart catheterization, echocardiography, and CPET. The differences in related indexes between a combined post- and pre-capillary PH (Cpc-PH) group (n=47) and an isolated post-capillary PH (Ipc-PH) group (n=43) were compared. Correlation analysis was performed. Logistic regression and receiver operator characteristic (ROC) analyses were performed to assess the ability of CPET variables to distinguish patients with Cpc-PH from those with Ipc-PH. Results The hemodynamics, hyperventilation and right ventricular function of Cpc-pH group were worse than those of Ipc-pH group. The parameters related to minute ventilation versus carbon dioxide production (VE/VCO2) played a significant role in the differentiation of Cpc-PH and Ipc-PH, and had a moderate positive correlation with pulmonary vascular resistance (PVR). Univariate and multivariate logistic analyses showed that lowest percentage of VE/VCO2 in predicted value (VE/VCO2%pred) was the single best predictor of Cpc-PH, and the area under ROC curve also confirmed that lowest VE/VCO2%pred (≥137%) could serve as a novel diagnostic marker for Cpc-PH. On the basis of this lowest VE/VCO2%pred threshold, patients were divided into two groups. Most hemodynamic parameters were worse in patients with a lowest VE/VCO2%pred ≥137%. Conclusions VE/VCO2-related parameters are powerful prognosticators for the presence of pre-capillary components in patients with PH-LHD, especially lowest VE/VCO2%pred.
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Affiliation(s)
- Xiujun Zhong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Tang
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qinhua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Sugang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Abstract
In cardiopulmonary medicine, residual exertional dyspnea (RED) can be defined by the persistence of limiting breathlessness in a patient who is already under the best available therapy for the underlying heart and/or lung disease. RED is a challenge to the pulmonologist because the patient (and the referring physician) assumes that the "lung doctor" should invariably provide a successful plan to fight the symptom. After presenting a simplified framework to understand the neurobiological underpinnings of dyspnea in cardiorespiratory disease, I discuss the seeds of RED associated with 1) increased metabolic cost of work, 2) increased inspiratory constraints, 3) diaphragm dysfunction, 4) impaired right ventricle preload, 5) increased central and/or peripheral chemosensitivity, 6) increased physiological dead space, 7) increased pulmonary venous and/or high left ventricle filling pressures, 8) impaired chronotropic response to exertion, and 9) increased activation of the cortical-limbic circuits. I finalize by outlining the following two common coexistence of diseases in which these multiple mechanisms interact to produce severe RED: chronic obstructive pulmonary disease-heart failure with reduced ejection fraction and chronic pulmonary fibrosis-emphysema. RED exposes the important limitations of the current reductionist approach focused only on the (over)treatment of the poorly reversible cardiopulmonary disease(s). Conversely, recognizing the existence of RED sets the stage for a more holistic approach toward one of the most devastating symptoms known to man.
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27
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Oakland HT, Joseph P, Elassal A, Cullinan M, Heerdt PM, Singh I. Diagnostic utility of sub-maximum cardiopulmonary exercise testing in the ambulatory setting for heart failure with preserved ejection fraction. Pulm Circ 2020; 10:2045894020972273. [PMID: 33282205 PMCID: PMC7691918 DOI: 10.1177/2045894020972273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/17/2020] [Indexed: 12/04/2022] Open
Abstract
Pulmonary hypertension is commonly associated with heart failure with preserved
ejection fraction. In heart failure with preserved ejection fraction, the
elevated left-sided filling pressures result in isolated post-capillary
pulmonary hypertension or combined pre- and post-capillary pulmonary
hypertension. Although right heart catheterization is the gold standard for
diagnosis, it is an invasive test with associated risks. The ability of
sub-maximum cardiopulmonary exercise test as an adjunct diagnostic tool in
pulmonary hypertension-associated heart failure with preserved ejection fraction
is not known. Forty-six patients with heart failure with preserved ejection
fraction and pulmonary hypertension (27 patients with combined pre- and
post-capillary pulmonary hypertension and 19 patients with isolated
post-capillary pulmonary hypertension) underwent sub-maximum cardiopulmonary
exercise test followed by right heart catheterization. The study also included
18 age- and gender-matched control subjects. Several sub-maximum gas exchange
parameters were examined to determine the ability of sub-maximum cardiopulmonary
exercise test to distinguish between isolated post-capillary pulmonary
hypertension and combined pre- and post-capillary pulmonary hypertension.
Conventional echocardiogram measures did not distinguish between isolated
post-capillary pulmonary hypertension and combined pre- and post-capillary
pulmonary hypertension. Compared to isolated post-capillary pulmonary
hypertension, combined pre- and post-capillary pulmonary hypertension had
greater ventilatory equivalent for carbon dioxide (VE/VCO2) slope,
reduced delta end-tidal CO2 change during exercise, reduced oxygen
uptake efficiency slope, and reduced gas exchange determined pulmonary vascular
capacitance. The latter was significantly associated with right heart
catheterization determined pulmonary artery compliance
(r = 0.5; p = 0.0004). On univariate analysis,
sub-maximum VE/VCO2, delta end-tidal carbon dioxide, and gas exchange
determined pulmonary vascular capacitance emerged as independent predictors of
the extrapolated maximum oxygen uptake (%predicted) (β-coefficient values of
–7.32, 95% CI: –13.3 – (–1.32), p = 0.01; 8.01, 95% CI:
1.96–14.05, p = 0.01; 8.78, 95% CI: 2.26–15.29,
p = 0.01, respectively). Sub-maximum gas exchange
parameters obtained during cardiopulmonary exercise test in an ambulatory
setting allows for discrimination between isolated post-capillary pulmonary
hypertension and combined pre- and post-capillary pulmonary hypertension.
Additionally, sub-maximum cardiopulmonary exercise test derived
VE/VCO2, delta end-tidal carbon dioxide, and gas exchange
determined pulmonary vascular capacitance influences aerobic capacity in heart
failure with preserved ejection fraction.
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Affiliation(s)
- Hannah T Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Ahmed Elassal
- Department of Anesthesiology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Marjorie Cullinan
- Department of Respiratory Care, Yale New Haven Hospital, New Haven, CT, USA
| | - Paul M Heerdt
- Department of Anesthesiology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
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28
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Lalande S, Cross TJ, Keller-Ross ML, Morris NR, Johnson BD, Taylor BJ. Exercise Intolerance in Heart Failure: Central Role for the Pulmonary System. Exerc Sport Sci Rev 2020; 48:11-19. [PMID: 31453845 DOI: 10.1249/jes.0000000000000208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We propose that abnormalities of the pulmonary system contribute significantly to the exertional dyspnea and exercise intolerance observed in patients with chronic heart failure. Interventions designed to address the deleterious pulmonary manifestations of heart failure may, therefore, yield promising improvements in exercise tolerance in this population.
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Affiliation(s)
- Sophie Lalande
- Department of Kinesiology and Heath Education, The University of Texas at Austin, Austin, TX
| | | | - Manda L Keller-Ross
- Divisions of Physical Therapy and Rehabilitation Sciences, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN
| | - Norman R Morris
- School of Physiotherapy and Exercise Science, Griffith University, Queensland, Australia
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bryan J Taylor
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
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29
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Santaniello A, Casella R, Vicenzi M, Rota I, Montanelli G, De Santis M, Bellocchi C, Lombardi F, Beretta L. Cardiopulmonary exercise testing in a combined screening approach to individuate pulmonary arterial hypertension in systemic sclerosis. Rheumatology (Oxford) 2020; 59:1581-1586. [PMID: 31637433 PMCID: PMC7310101 DOI: 10.1093/rheumatology/kez473] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/11/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives The DETECT algorithm has been developed to identify SSc patients at risk for pulmonary arterial hypertension (PAH) yielding high sensitivity but low specificity, and positive predictive value. We tested whether cardiopulmonary exercise testing (CPET) could improve the performance of the DETECT screening strategy. Methods Consecutive SSc patients over a 30-month period were screened with the DETECT algorithm and positive subjects were referred for CPET before the execution of right-heart catheterization. The predictive performance of CPET on top of DETECT was evaluated and internally validated via bootstrap replicates. Results Out of 314 patients, 96 satisfied the DETECT application criteria and 54 were positive. PAH was ascertained in 17 (31.5%) and pre-capillary pulmonary hypertension in 23 (42.6%) patients. Within CPET variables, the slope of the minute ventilation to carbon dioxide production relationship (VE/VCO2 slope) had the best performance to predict PAH at right-heart catheterization [median (interquartile range) of specificity 0.778 (0.714–0.846), positive predictive value 0.636 (0.556–0.750)]; exploratory analysis on pre-capillary yielded a specificity of 0.714 (0.636–0.8) and positive predictive value of 0.714 (0.636–0.8). Conclusion In association with the DETECT algorithm, CPET may be considered as a useful tool in the workup of SSc-related pulmonary hypertension. The sequential determination of the VE/VCO2 slope in DETECT-positive subjects may reduce the number of unnecessary invasive procedures without any loss in the capability to capture PAH. This strategy had also a remarkable performance in highlighting the presence of pre-capillary pulmonary hypertension.
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Affiliation(s)
| | - Rosa Casella
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan
| | - Marco Vicenzi
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Irene Rota
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan
| | - Gaia Montanelli
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases
| | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy
| | - Chiara Bellocchi
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases
| | - Federico Lombardi
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases
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30
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Taylor BJ, Shapiro BP, Johnson BD. Exercise intolerance in heart failure: The important role of pulmonary hypertension. Exp Physiol 2020; 105:1997-2003. [PMID: 32092200 DOI: 10.1113/ep088105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/20/2020] [Indexed: 12/21/2022]
Abstract
NEW FINDINGS What is the topic of this review? This review concerns the negative impact of pulmonary hypertension (PH) on the pulmonary haemodynamic and gas exchange responses to exercise, considering the mechanisms by which PH plays a role in exercise intolerance in heart failure (HF) patients. What advances does it highlight? The hallmark limited pulmonary vascular 'reserve' and impaired pulmonary gas exchange responses to exercise in HF are worsened by the development of PH; these are key determinants of exercise intolerance. Even HF patients who present with 'normal' pulmonary vascular function experience exercise-induced PH, which plays a role in exercise intolerance. ABSTRACT Patients with heart failure universally complain of exertional intolerance, but the underlying cause(s) of this intolerance may differ between patients with different disease phenotypes. Exercise introduces an impressive stress to the lungs, where elevations in venous return and cardiac output engender substantial increases in pulmonary blood volume and flow. Relative to healthy individuals, the pulmonary vascular reserve to accept this increase in pulmonary perfusion is compromised in heart failure, with a growing body of evidence suggesting that the development of pulmonary hypertension (PH), and in particular a precapillary component of PH, worsens the pulmonary haemodynamic response to exercise in these patients. Characterized by an exaggerated increase in pulmonary arterial pressure and an elevation in pulmonary vascular resistance, this dysfunctional pulmonary haemodynamic response plays a role in exercise intolerance, probably through an impairment of right ventricular function, underperfusion of the pulmonary circulation and a subsequent reduction in systemic blood flow and oxygen delivery. The hallmark abnormalities in ventilatory and pulmonary gas exchange that accompany heart failure, including a greater ventilatory equivalent for carbon dioxide, are also worsened by the development of PH. This raises the possibility that measures of exercise pulmonary gas exchange might help to 'describe' underlying PH in heart failure; however, several fundamental issues and questions need to be addressed before such gas exchange measures could truly be considered efficacious measures used to differentiate the type of PH and track the severity of PH in heart failure. exercise intolerance, heart failure, pulmonary gas exchange, pulmonary haemodynamics, pulmonary hypertension.
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Affiliation(s)
- Bryan J Taylor
- School of Biomedical Sciences, University of Leeds, Leeds, UK.,Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Brian P Shapiro
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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31
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Levine AR, Simon MA, Gladwin MT. Pulmonary vascular disease in the setting of heart failure with preserved ejection fraction. Trends Cardiovasc Med 2019; 29:207-217. [PMID: 30177249 PMCID: PMC6378124 DOI: 10.1016/j.tcm.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/12/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is defined as clinical features of heart failure, ideally with biomarker evidence such as elevated plasma natriuretic peptide levels, in the setting of an ejection fraction (EF) greater than 50% and imaging evidence of diastolic left ventricular dysfunction [1,2]. In the absence of cardiac imaging or invasive hemodynamics, this is a clinical syndrome that is often indistinguishable from heart failure with reduced ejection fraction (HFrEF). HFpEF and HFrEF present with a cadre of comparable signs and symptoms including jugular venous distention, pulmonary rales on auscultation, breathlessness, orthopnea, exercise intolerance, exertional dyspnea, fatigue and peripheral edema. HFpEF accounts for at least half of all diagnoses of heart failure [1,2]. Pulmonary hypertension (PH) is a common complication of HFpEF that is linked to worse disease morbidity and mortality. In fact, mortality has been linked to increases in the intrinsic pulmonary vascular resistance in the setting of increased left ventricular end diastolic pressure, characterized hemodynamically by rises in the transpulmonary pressure gradient, pulmonary vascular resistance or diastolic pressure gradient. Despite being the most common form of PH, there are no approved therapies for the treatment of PH secondary to HFpEF. This review will summarize the hemodynamic classifications of PH in the setting of HFpEF, mechanisms of disease, the potential contribution of pulmonary vascular disease to poor outcomes in patients with HFpEF, and new approaches to therapy.
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Affiliation(s)
- Andrea R Levine
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Marc A Simon
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Medical Center Heart and Vascular Institute Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Department of Bioengineering Pittsburgh, Pittsburgh, PA 15213, United States
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States.
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32
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Affiliation(s)
- Brian A Houston
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Ryan J Tedford
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston.
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33
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Vachiéry JL, Tedford RJ, Rosenkranz S, Palazzini M, Lang I, Guazzi M, Coghlan G, Chazova I, De Marco T. Pulmonary hypertension due to left heart disease. Eur Respir J 2019; 53:13993003.01897-2018. [PMID: 30545974 PMCID: PMC6351334 DOI: 10.1183/13993003.01897-2018] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/22/2022]
Abstract
Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific “left heart” phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies. State of the art and research perspectives in pulmonary hypertension due to left heart disease including diagnostic and treatment insightshttp://ow.ly/vr0I30md6KC
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Affiliation(s)
- Jean-Luc Vachiéry
- Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Ryan J Tedford
- Division of Cardiology, Dept of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Dept of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | | | - Irene Lang
- Dept of Cardiology, AKH-Vienna, Medical University of Vienna, Vienna, Austria
| | - Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan and Dept of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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34
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van Empel V, Brunner-La Rocca HP. Helping to understand heart failure with preserved ejection fraction. Eur Heart J 2018; 39:2836-2838. [PMID: 29992303 DOI: 10.1093/eurheartj/ehy368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
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35
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van Duin RWB, Stam K, Cai Z, Uitterdijk A, Garcia-Alvarez A, Ibanez B, Danser AHJ, Reiss IKM, Duncker DJ, Merkus D. Transition from post-capillary pulmonary hypertension to combined pre- and post-capillary pulmonary hypertension in swine: a key role for endothelin. J Physiol 2018; 597:1157-1173. [PMID: 29799120 PMCID: PMC6375874 DOI: 10.1113/jp275987] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
Key points Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
Abstract Passive, isolated post‐capillary pulmonary hypertension (IpcPH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH (CpcPH) characterized by chronic pulmonary vascular constriction and remodelling. The mechanisms underlying this ‘activation’ of passive pulmonary hypertension (PH) remain incompletely understood. Here we investigated the role of the vasoconstrictor endothelin‐1 (ET) in the progression from IpcPH to CpcPH in a swine model for post‐capillary PH. Swine underwent pulmonary vein banding (PVB; n = 7) or sham‐surgery (Sham; n = 6) and were chronically instrumented 4 weeks later. Haemodynamics were assessed for 8 weeks, at rest and during exercise, before and after administration of the ET receptor antagonist tezosentan. After sacrifice, the pulmonary vasculature was investigated by histology, RT‐qPCR and myograph experiments. Pulmonary arterial pressure and resistance increased significantly over time. mRNA expression of prepro‐endothelin‐1 and endothelin converting enzyme‐1 in the lung was increased, while ETA expression was unchanged and ETB expression was downregulated. This was associated with increased plasma ET levels from week 10 onward and a more pronounced vasodilatation to in vivo administration of tezosentan at rest and during exercise. Myograph experiments showed decreased endothelium‐dependent vasodilatation to Substance P and increased vasoconstriction to KCl in PVB swine consistent with increased muscularization observed with histology. Moreover, maximal vasoconstriction to ET was increased whereas ET sensitivity was decreased. In conclusion, PVB swine gradually developed PH with structural and functional vascular remodelling. From week 10 onward, the pulmonary ET pathway was upregulated, likely contributing to pre‐capillary activation of the initially isolated post‐capillary PH. Inhibition of the ET pathway could thus potentially provide a pharmacotherapeutic target for early stage post‐capillary PH. Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
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Affiliation(s)
- Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Zongye Cai
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - A H Jan Danser
- Department of Pharmacology, Erasmus MC, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Pediatrics / Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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Caravita S, Faini A, Carolino D’Araujo S, Dewachter C, Chomette L, Bondue A, Naeije R, Parati G, Vachiéry JL. Clinical phenotypes and outcomes of pulmonary hypertension due to left heart disease: Role of the pre-capillary component. PLoS One 2018; 13:e0199164. [PMID: 29920539 PMCID: PMC6007912 DOI: 10.1371/journal.pone.0199164] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/01/2018] [Indexed: 12/22/2022] Open
Abstract
Background In pulmonary hypertension (PH), both wedge pressure elevation (PAWP) and a precapillary component may affect right ventricular (RV) afterload. These changes may contribute to RV failure and prognosis. We aimed at describing the different haemodynamic phenotypes of patients with PH due to left heart disease (LHD) and at characterizing the impact of pulmonary haemodynamics on RV function and outcome PH-LHD. Methods Patients with PH-LHD were compared with treatment-naïve idiopathic/heritable pulmonary arterial hypertension (PAH, n = 35). PH-LHD patients were subdivided in Isolated post-capillary PH (IpcPH: diastolic pressure gradient, DPG<7 mmHg and pulmonary vascular resistance, PVR≤3 WU, n = 37), Combined post- and pre-capillary PH (CpcPH: DPG≥7 mmHg and PVR>3 WU, n = 27), and “intermediate” PH-LHD (either DPG <7 mmHg or PVR ≤3 WU, n = 29). Results Despite similar PAWP and cardiac index, haemodynamic severity and prevalence of RV dysfunction increased from IpcPH, to “intermediate” and CpcPH. PVR and DPG (but not compliance, Ca) were linearly correlated with RV dysfunction. CpcPH had worse prognosis (p<0.05) than IpcPH and PAH, but similar to “intermediate” patients. Only NTproBNP and Ca independently predicted survival in PH-LHD. Conclusions In PH-LHD, haemodynamic characterization according to DPG and PVR provides important information on disease severity, predisposition to RV failure and prognosis. Patients presenting the CpcPH phenotype appear to have haemodynamic profile closer to PAH but with worse prognosis. In PH-LHD, Ca and NTproBNP were independent predictors of survival.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Sandy Carolino D’Araujo
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Laura Chomette
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Robert Naeije
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
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Weatherald J, Sattler C, Garcia G, Laveneziana P. Ventilatory response to exercise in cardiopulmonary disease: the role of chemosensitivity and dead space. Eur Respir J 2018; 51:51/2/1700860. [PMID: 29437936 DOI: 10.1183/13993003.00860-2017] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 11/11/2017] [Indexed: 12/30/2022]
Abstract
The lungs and heart are irrevocably linked in their oxygen (O2) and carbon dioxide (CO2) transport functions. Functional impairment of the lungs often affects heart function and vice versa The steepness with which ventilation (V'E) rises with respect to CO2 production (V'CO2 ) (i.e. the V'E/V'CO2 slope) is a measure of ventilatory efficiency and can be used to identify an abnormal ventilatory response to exercise. The V'E/V'CO2 slope is a prognostic marker in several chronic cardiopulmonary diseases independent of other exercise-related variables such as peak O2 uptake (V'O2 ). The V'E/V'CO2 slope is determined by two factors: 1) the arterial CO2 partial pressure (PaCO2 ) during exercise and 2) the fraction of the tidal volume (VT) that goes to dead space (VD) (i.e. the physiological dead space ratio (VD/VT)). An altered PaCO2 set-point and chemosensitivity are present in many cardiopulmonary diseases, which influence V'E/V'CO2 by affecting PaCO2 Increased ventilation-perfusion heterogeneity, causing inefficient gas exchange, also contributes to the abnormal V'E/V'CO2 observed in cardiopulmonary diseases by increasing VD/VT During cardiopulmonary exercise testing, the PaCO2 during exercise is often not measured and VD/VT is only estimated by taking into account the end-tidal CO2 partial pressure (PETCO2 ); however, PaCO2 is not accurately estimated from PETCO2 in patients with cardiopulmonary disease. Measuring arterial gases (PaO2 and PaCO2 ) before and during exercise provides information on the real (and not "estimated") VD/VT coupled with a true measure of gas exchange efficiency such as the difference between alveolar and arterial O2 partial pressure and the difference between arterial and end-tidal CO2 partial pressure during exercise.
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Affiliation(s)
- Jason Weatherald
- Dept of Medicine, Division of Respiratory Medicine, University of Calgary, Calgary, AB, Canada.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Caroline Sattler
- Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Gilles Garcia
- Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,These authors contributed equally to this work and are both last authors
| | - Pierantonio Laveneziana
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France .,Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Dépt "R3S", Pôle PRAGUES, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,These authors contributed equally to this work and are both last authors
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Rocha A, Arbex FF, Sperandio PA, Souza A, Biazzim L, Mancuso F, Berton DC, Hochhegger B, Alencar MCN, Nery LE, O'Donnell DE, Neder JA. Excess Ventilation in Chronic Obstructive Pulmonary Disease-Heart Failure Overlap. Implications for Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med 2017; 196:1264-1274. [PMID: 28665692 DOI: 10.1164/rccm.201704-0675oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE An increased ventilatory response to exertional metabolic demand (high [Formula: see text]e/[Formula: see text]co2 relationship) is a common finding in patients with coexistent chronic obstructive pulmonary disease and heart failure. OBJECTIVES We aimed to determine the mechanisms underlying high [Formula: see text]e/[Formula: see text]co2 and its impact on operating lung volumes, dyspnea, and exercise tolerance in these patients. METHODS Twenty-two ex-smokers with combined chronic obstructive pulmonary disease and heart failure with reduced left ventricular ejection fraction undertook, after careful treatment optimization, a progressive cycle exercise test with capillary (c) blood gas collection. MEASUREMENTS AND MAIN RESULTS Regardless of the chosen metric (increased [Formula: see text]e-[Formula: see text]co2 slope, [Formula: see text]e/[Formula: see text]co2 nadir, or end-exercise [Formula: see text]e/[Formula: see text]co2), ventilatory inefficiency was closely related to PcCO2 (r values from -0.80 to -0.84; P < 0.001) but not dead space/tidal volume ratio. Ten patients consistently maintained exercise PcCO2 less than or equal to 35 mm Hg (hypocapnia). These patients had particularly poor ventilatory efficiency compared with patients without hypocapnia (P < 0.05). Despite the lack of between-group differences in spirometry, lung volumes, and left ventricular ejection fraction, patients with hypocapnia had lower resting PaCO2 and lung diffusing capacity (P < 0.01). Excessive ventilatory response in this group was associated with higher exertional PcO2. The group with hypocapnia, however, had worse mechanical inspiratory constraints and higher dyspnea scores for a given work rate leading to poorer exercise tolerance compared with their counterparts (P < 0.05). CONCLUSIONS Heightened neural drive promoting a ventilatory response beyond that required to overcome an increased "wasted" ventilation led to hypocapnia and poor exercise ventilatory efficiency in chronic obstructive pulmonary disease-heart failure overlap. Excessive ventilation led to better arterial oxygenation but at the expense of earlier critical mechanical constraints and intolerable dyspnea.
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Affiliation(s)
- Alcides Rocha
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Flavio F Arbex
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Priscilla A Sperandio
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Aline Souza
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Ligia Biazzim
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Frederico Mancuso
- 2 Division of Cardiology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Danilo C Berton
- 3 Division of Respirology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Bruno Hochhegger
- 4 Medical Imaging Research Laboratory, Federal University of Health Sciences, Porto Alegre, Brazil; and
| | - Maria Clara N Alencar
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Luiz E Nery
- 1 Pulmonary Function and Clinical Exercise Physiology Unit, Division of Respirology, and
| | - Denis E O'Donnell
- 5 Respiratory Investigation Unit, Queen's University, Kingston, Ontario, Canada
| | - J Alberto Neder
- 5 Respiratory Investigation Unit, Queen's University, Kingston, Ontario, Canada
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Adusumalli S, Mazurek JA. Pulmonary Hypertension Due to Left Ventricular Cardiomyopathy: Is it the Result or Cause of Disease Progression? Curr Heart Fail Rep 2017; 14:507-513. [PMID: 29063280 PMCID: PMC5846484 DOI: 10.1007/s11897-017-0368-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to define pulmonary hypertension in the setting of left heart disease (PH-LHD), discuss its epidemiology and pathophysiology, and highlight the cause and effect relationship it has with disease progression in the setting of cardiomyopathy. RECENT FINDINGS Both pulmonary hypertension (PH) and heart failure are becoming increasingly common. As such, PH-LHD is now the most common form of PH. The pathophysiology of the condition relates to backward transmission of elevated left ventricular filling pressures into the pulmonary circulation and, ultimately, right ventricular (RV) strain/dysfunction. It is evident that these pathophysiologic processes are both the effect and cause of left heart disease progression. In this review, we describe the complex relationship between disease progression in left ventricular cardiomyopathy and PH-LHD. Clinicians and researchers should take note of the importance of PH-LHD and RV dysfunction to appropriately risk stratify patients and develop therapies for the condition.
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Affiliation(s)
- Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Advanced Heart Failure/Transplantation and Pulmonary Hypertension Programs, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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41
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Correale M, Tricarico L, Ferraretti A, Monaco I, Concilio M, Padovano G, Acanfora G, Di Biase M, Brunetti ND. Cardiopulmonary exercise test predicts right heart catheterization. Eur J Clin Invest 2017; 47. [PMID: 29082512 DOI: 10.1111/eci.12851] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/25/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Right heart catheterization (RHC) is usually required to confirm the diagnosis of pulmonary artery hypertension (PAH). As an invasive test, RHC may be associated with possible complications, so noninvasive parameters able to predict PAH at RHC would be extremely useful. AIM To ascertain possible correlations between cardiopulmonary exercise testing (CPET) and hemodynamic parameters at RHC indicative of pulmonary hypertension (PH). METHODS Thirty-six consecutive outpatients with suspect of PAH underwent CPET and RHC; the intercept of ventilation (VEint) on the VE vs carbon dioxide production (VE/VCO2 ) and VE/VCO2 slope at CPET and diastolic pressure gradient (DPG), trans-pulmonary pressure gradient (TPG), mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) at RHC were assessed and compared. RESULTS Ventilation VCO2 slope was directly related to DPG (r: .41, P: .019), TPG (r: .45, P: .01), mean pulmonary arterial pressure (mPAP, r: .36, P: .031), PVR (r: .41, P: .029), VEint and VE/VCO2 slope inversely related to DPG (r: -.63, P < .001), TPG (r: -.67, P < .001), mPAP (r: -.68, P < .001) and PVR (r: -.5, P < .001). CONCLUSION In patients with suspected PAH, VEint during exercise and the VE/VCO2 slope might provide useful information to predict results of RHC. Their correlations with PVR and with DPG may be helpful in discriminating patients with isolated postcapillary PH from those with combined postcapillary and precapillary.
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Affiliation(s)
- Michele Correale
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Armando Ferraretti
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ilenia Monaco
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Morena Concilio
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giuseppina Padovano
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gianfranco Acanfora
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Matteo Di Biase
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
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Lombardi C, Caravita S, Parati G. Central sleep apnea during continuous positive airway pressure therapy in obstructive sleep apnea patients: from the compliance to adaptation, maladaptation and reflexes. J Thorac Dis 2017; 9:4152-4156. [PMID: 29268457 DOI: 10.21037/jtd.2017.09.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carolina Lombardi
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gianfranco Parati
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
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43
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Naeije R, Gerges M, Vachiery JL, Caravita S, Gerges C, Lang IM. Hemodynamic Phenotyping of Pulmonary Hypertension in Left Heart Failure. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004082. [PMID: 28912263 DOI: 10.1161/circheartfailure.117.004082] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Increased pulmonary venous pressure secondary to left heart disease is the most common cause of pulmonary hypertension (PH). The diagnosis of PH due to left heart disease relies on a clinical probability assessment followed by the invasive measurements of a mean pulmonary artery pressure (PAP) ≥25 mm Hg and mean wedged PAP (PAWP) >15 mm Hg. A combination of mean PAP and mean PAWP defines postcapillary PH. Postcapillary PH is generally associated with a diastolic pulmonary pressure gradient (diastolic PAP minus mean PAWP) <7 mm Hg, a transpulmonary pressure gradient (mean PAP minus mean PAWP) <12 mm Hg, and pulmonary vascular resistance ≤3 Wood units (WU). This combination of criteria defines isolated postcapillary PH. Postcapillary PH with elevated vascular gradients and pulmonary vascular resistance defines combined post- and precapillary PH (Cpc-PH). Postcapillary PH is associated with a decreased survival in proportion to increased pulmonary vascular gradients, decreased pulmonary arterial compliance, and reduced right ventricular function. The Cpc-PH subcategory occurs in 12% to 13% of patients with PH due to left heart disease. Patients with Cpc-PH have severe PH, with higher diastolic pulmonary pressure gradient, transpulmonary pressure gradient, and pulmonary vascular resistance and more pronounced ventilatory responses to exercise, lower pulmonary arterial compliance, depressed right ventricular ejection fraction, and shorter life expectancy than isolated postcapillary PH. Cpc-PH bears similarities to pulmonary arterial hypertension. Whether Cpc-PH is amenable to therapies targeting the pulmonary circulation remains to be tested by properly designed randomized controlled trials.
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Affiliation(s)
- Robert Naeije
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Mario Gerges
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Jean-Luc Vachiery
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Sergio Caravita
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Christian Gerges
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Irene M Lang
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.).
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