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Kramer T, Nattmann P, Gerhardt F, Stafiej P, Dumitrescu D, ten Freyhaus H, Wißmüller M, Hohmann C, Baldus S, Rosenkranz S. Impact of rapid sequential combination therapy on distinct haemodynamic measures in newly diagnosed pulmonary arterial hypertension. ESC Heart Fail 2024; 11:1540-1552. [PMID: 38224960 PMCID: PMC11098663 DOI: 10.1002/ehf2.14611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/16/2023] [Accepted: 11/16/2023] [Indexed: 01/17/2024] Open
Abstract
AIMS In pulmonary arterial hypertension (PAH), upfront combination therapy with ERA and PDE5i is associated with a reduction in morbidity and mortality events and improves standard haemodynamics, but data remain limited. Aims of this study were (i) to capture detailed haemodynamic effects of rapid sequential dual combination therapy in patients with newly diagnosed PAH; (ii) to monitor the impact of treatment initiation on clinical variables and patients' risk status, and (iii) to compare the treatment effect in patients with 'classical PAH' and 'PAH with co-morbidities'. METHODS Fifty patients (median age 57 [42-71] years, 66% female) with newly diagnosed PAH (76% idiopathic) were treated with a PD5i/sGC-S or ERA, followed by addition of the respective other drug class within 4 weeks. All patients underwent repeat right heart catheterization (RHC) during early follow-up. RESULTS At early repeat RHC (7 ± 2 months), there were substantial reductions in mean pulmonary artery pressure (mPAP: 52.2 ± 13.5 to 39.0 ± 10.6 mmHg; -25.3%), and pulmonary vascular resistance (PVR: 12.1 ± 5.7 to 5.8 ± 3.1 WU; -52.1%), and an increase in cardiac index (2.1 ± 0.4 to 2.7 ± 0.7 mL/min/m2; +32.2%) (all P < 0.05). Haemodynamic improvements correlated with improved clinical parameters including 6-min walking distance (336 ± 315 to 389 ± 120 m), NTproBNP levels (1.712 ± 2.024 to 506 ± 550 ng/L, both P < 0.05) and WHO-FC at 12 months, resulting in improved risk status, and were found in patients with few (n = 37) or multiple cardiovascular co-morbidities (BMI > 30 kg/m2, hypertension, diabetes, coronary artery disease [≥3]; n = 13), albeit baseline PVR in PAH patients with multiple co-morbidities was lower (9.3 ± 4.4 vs. 13.1 ± 5.9 WU) and PVR reduction less pronounced compared with those with few co-morbidities (-42.7% vs. -54.7%). However, comprehensive haemodynamic assessment considering further variables of prognostic relevance such as stroke volume index and pulmonary artery compliance showed similar improvements among the two groups (SVI: +50.0% vs. +49.2%; PAC: 91.7% vs. 100.0%). Finally, the 4-strata risk assessment approach was better able to capture treatment response as compared with other approaches, particularly in patients with co-morbidities. CONCLUSIONS Rapid sequential combination therapy with PDE5i/sGC-S and ERA substantially ameliorates cardiopulmonary haemodynamics at early follow-up in patients without, and to a lesser extent, with cardiovascular co-morbidities. This occurs in line with improvements of clinical parameters and risk status.
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Affiliation(s)
- Tilmann Kramer
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Phillip Nattmann
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Felix Gerhardt
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Patrycja Stafiej
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Daniel Dumitrescu
- Klinik für Allgemeine und Interventionelle KardiologieHerz‐ und Diabeteszentrum NRWBad OeynhausenGermany
| | - Henrik ten Freyhaus
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
| | - Max Wißmüller
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Christopher Hohmann
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
| | - Stephan Baldus
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
| | - Stephan Rosenkranz
- Klinik III für Innere MedizinHerzzentrum der Universität zu KölnCologneGermany
- Cologne Cardiovascular Research Center (CCRC)Klinikum der Universität zu KölnCologneGermany
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2
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Yang L, Luo D, Huang T, Li X, Zhang C, Fei H. New risk model by right ventricle - pulmonary arterial coupling and inferior vena cava from echocardiography in patients with conventional low-intermediate risk pulmonary artery hypertension under targeted treatment. Echocardiography 2024; 41:e15850. [PMID: 38818775 DOI: 10.1111/echo.15850] [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: 03/24/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Accurately stratifying patients with pulmonary arterial hypertension (PAH) is very important, and traditional risk scores still have internal heterogeneity. This study aimed to construct a risk stratification model that can accurately identify clinical worsening (CW) events in conventional low-intermediate risk patients with pulmonary hypertension under targeted drug treatment by using echocardiographic parameters. METHODS This study is a single-center, prospective study, including 105 PAH patients who underwent regular follow-up at Guangdong Provincial People's Hospital from October 2021 to April 2023. The primary endpoint was the occurrence of CW, including death, hospitalization due to pulmonary hypertension, escalation of targeted drug therapy, and worsening of PAH. The predictive value of the echocardiography-based three-strata risk model was assessed using Kaplan-Meier curves and COX regression analysis. RESULTS A total of 98 PAH patients were ultimately included in this study. The median follow-up duration was 26 months (range 7-28 months). The echocardiography-based three-strata model included the ratio of tricuspid annular plane systolic excursion and pulmonary artery systolic pressure (TAPSE/PASP) and inferior vena cava (IVC). The echocardiography-based three-strata model had higher diagnostic value (C-index = .76) compared to the 2022 ESC/ERS three-strata model and four-strata model (C-index = .66 and C-index = .61, respectively). PAH patients with lower TAPSE/PASP and wider IVC showed a higher CW rate compared to patients with higher TAPSE/PASP and normal IVC (HR = 15.1, 95%CI:4.4-51.9, p < .001). CONCLUSION The echocardiography-based three-strata model based on TAPSE/PASP and IVC can effectively improve the stratification of low-intermediate risk PAH patients under targeted treatment.
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Affiliation(s)
- Lifang Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Dongling Luo
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Taoran Huang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
- Shantou University Medical College, Shantou, Guangdong Province, China
| | - Xiaoshan Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
- Guangdong Medical University, Zhanjiang, Guangdong Province, China
| | - Caojin Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
| | - Hongwen Fei
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong Province, China
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Cruz-Utrilla A, Pérez-Olivares C, Luna-López R, Jiménez López-Guarch C, Bedate P, Martínez Meñaca A, López Meseguer M, Escribano-Subias P. Risk Stratification in Pulmonary Veno-Occlusive Disease. Arch Bronconeumol 2024; 60:321-323. [PMID: 38461109 DOI: 10.1016/j.arbres.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Alejandro Cruz-Utrilla
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain; ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain
| | | | - Raquel Luna-López
- Department of Cardiology, Hospital Sant Joan de Déu, Espluges de Llobregat, Spain
| | - Carmen Jiménez López-Guarch
- Pulmonary Hypertension Unit & Cardiovascular Imaging Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Pedro Bedate
- Department of Pulmonary Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Amaya Martínez Meñaca
- Department of Pneumology, Hospital Universitario Marqués de Valdecilla, Santander, Spain; ERN-LUNG (European Reference Network on rare respiratory diseases), Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | - Manuel López Meseguer
- Department of Pulmonary Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain; ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
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4
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D'Alto M, Badagliacca R, Airò E, Ameri P, Argiento P, Garascia A, Lombardi CM, Mulè M, Raineri C, Scelsi L, Vizza CD, Ghio S. Gaps in evidence in the management of patients with intermediate-risk pulmonary arterial hypertension: Considerations following the ESC/ERS 2022 guidelines. Vascul Pharmacol 2024; 155:107374. [PMID: 38642596 DOI: 10.1016/j.vph.2024.107374] [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: 12/19/2023] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
A comprehensive evaluation of risk, using multiple indices, is necessary to provide reliable prognostic information and guide therapy in pulmonary arterial hypertension (PAH). The current ESC/ERS guidelines suggest using a three-strata model for incident (newly diagnosed) patients and a four-strata model for prevalent patients with PAH. The four-strata model serves as a fundamental risk-stratification tool and relies on a minimal dataset of indicators that must be considered during follow-up. Nevertheless, there are still areas of vagueness and ambiguity when classifying and managing patients in the intermediate-risk category. For these patients, considerations should include right heart imaging, hemodynamics, as well as individual factors such as age, sex, genetic profile, disease type, comorbidities, and kidney function. The aim of this report is to present case studies, with a specific focus on patients ultimately classified as intermediate risk. We aim to emphasize the challenges and complexities encountered in the realms of diagnosis, classification, and treatment for these particular patients.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Scienze Cliniche Internistiche, Anestesiologiche e Cardiologiche, Università "La Sapienza", Roma, Italy
| | - Edoardo Airò
- UO Pneumologia - Fondazione Toscana "G.Monasterio" - CNR/Regione Toscana, Pisa, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy; Cardiac, Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Paola Argiento
- U.O.C. Cardiologia pediatrica e UTIC, A.O.R.N. dei colli - Ospedale Monaldi, Napoli, Italy
| | - Andrea Garascia
- Cardiologia 2 Insufficienza Cardiaca e Trapianti, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Massimiliano Mulè
- Clinical Cardiology and Heart Failure Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Claudia Raineri
- Department of Cardiology, Città della salute- Molinette Hospital, Turin, Italy
| | - Laura Scelsi
- Fondazione I.R.C.C.S. Policlinico San Matteo Pavia, Pavia, Italy
| | - Carmine Dario Vizza
- Department of Scienze Cliniche Internistiche, Anestesiologiche e Cardiologiche, Università "La Sapienza", Roma, Italy
| | - Stefano Ghio
- UOC Cardiologia 1, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.
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5
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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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6
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Pienn M, Gertz RJ, Gerhardt F, Kröger JR, Zaytoun H, Reimer RP, Kaplan A, Wissmüller M, Kovacs G, Rosenkranz S, Olschewski H, Bunck AC. CT-derived lung vessel morphology correlates with prognostic markers in precapillary pulmonary hypertension. J Heart Lung Transplant 2024; 43:54-65. [PMID: 37619642 DOI: 10.1016/j.healun.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/30/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND While computed tomography pulmonary angiography (CTPA) is an integral part of the work-up in patients with suspected pulmonary hypertension (PH), there is no established CTPA-derived prognostic marker. We aimed to assess whether quantitative readouts of lung vessel morphology correlate with established prognostic indicators in PH. METHODS We applied a fully-automatic in-house developed algorithm for segmentation of arteries and veins to determine lung vessel morphology in patients with precapillary PH who underwent right heart catheterization and CTPA between May 2016 and May 2019. Primary endpoint of this retrospective study was the calculation of receiver operating characteristics for identifying low and high mortality risk according to the 3-strata risk assessment model presented in the current guidelines. RESULTS We analyzed 73 patients, median age 65 years (interquartile range (IQR): 54-76), female/male ratio 35/38, median mean pulmonary arterial pressure 37 mm Hg (IQR: 30-46), and found significant correlations with important prognostic factors in pulmonary arterial hypertension. N-terminal pro-brain natriuretic peptide, cardiac index, mixed venous oxygen saturation, and 6-minute walking distance were correlated with the ratio of the number of arteries over veins with vessel diameters of 6-10 mm (Spearman correlation coefficients ρ = 0.64, p < 0.001; ρ = -0.60, p < 0.001; ρ = -0.47, p = 0.005; ρ = -0.45, p = 0.001, respectively). This ratio predicted a low- and high-risk score with an area under the curve of 0.73 (95% confidence interval (CI): 0.56-0.90) and 0.86 (95% CI: 0.74-0.97), respectively. CONCLUSIONS The ratio of the number of arteries over veins with diameters between 6 and 10 mm is significantly correlated with prognostic markers in pulmonary hypertension and predicts low and high mortality risk.
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Affiliation(s)
- Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Roman J Gertz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Felix Gerhardt
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan R Kröger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Hasan Zaytoun
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Robert P Reimer
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anil Kaplan
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Wissmüller
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander C Bunck
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
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7
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Topyła-Putowska W, Tomaszewski M, Wojtkowska A, Wysokiński A. Novel Echocardiographic Measurements of Right Ventricular-Pulmonary Artery Coupling in Predicting the Prognosis of Precapillary Pulmonary Hypertension. J Pers Med 2023; 13:1627. [PMID: 38138854 PMCID: PMC10744346 DOI: 10.3390/jpm13121627] [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: 10/22/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Currently, there are many parameters with proven prognostic significance in pulmonary hypertension (PH). Recently, the parameters defining right ventricular-pulmonary artery coupling (RVPAC) have gained clinical importance. In our study, we investigated the prognostic potential of previously known single echocardiographic parameters and new parameters reflecting RVPAC in patients with precapillary PH. OBJECTIVE Our study aimed to evaluate the prognostic value of selected echocardiographic parameters and the neutrophil-lymphocyte ratio (NLR) in adults with precapillary PH. METHODS This study included 39 patients (74% women; average age, 63 years) with precapillary PH: pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured several echocardiographic parameters, which reflect right ventricular function, pulmonary hemodynamics, and RVPAC. To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. The patient's physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of the N-terminal prohormone brain natriuretic peptide (NT-proBNP) and NLR. RESULTS TAPSE × AcT and TAPSE/sPAP were shown to statistically and significantly correlate with PH predictors, including WHO-FC, 6MWT, and NT-proBNP. Univariate Cox proportional hazards regression analysis revealed that AcT, TAPSE, mPAP, TAPSE/sPAP, RAP, TRPG/AcT, TAPSE × AcT, and NLRs are good predictors of mortality in patients with PH. In addition, the ROC curve analysis showed that TAPSE × AcT is a better predictor of PH-related deaths than TAPSE/sPAP and TAPSE alone. In our study, patients with TAPSE × AcT values < 126.36 had shorter survival times (sensitivity = 72.7%; specificity = 80.0%). CONCLUSIONS TAPSE × AcT is a novel, promising, and practicable echocardiographic parameter reflecting RVPAC, which is comparable to TAPSE/sPAP. Moreover, TAPSE × AcT can be a useful parameter in assessing the severity and prognosis of patients with precapillary PH.
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Affiliation(s)
- Weronika Topyła-Putowska
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.T.); (A.W.); (A.W.)
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Wissmüller M, Tichelbäcker T, Finke K, Dohr J, Adler J, Ochs L, Hohmann C, Baldus S, Rosenkranz S. [Pulmonary hypertension associated with left heart disease (group 2)]. Dtsch Med Wochenschr 2023; 148:1498-1506. [PMID: 37949078 DOI: 10.1055/a-2012-0803] [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: 11/12/2023]
Abstract
Patients with left heart disease (LHD) often display pulmonary hypertension (PH), which impacts morbidity and mortality. The pathophysiology of PH is complex and entails pulmonary congestion due to elevated left-sided filling pressures, pulmonary vasoconstriction as well as vascular remodeling. The recent ESC/ERS Guidelines on pulmonary hypertension updated the hemodynamic definitions of pulmonary hypertension in general, and the subclassification of post-capillary PH. This review summarizes recent advances in the diagnostic work-up and management strategies of PH associated with LHD. Specifically, we summarize revisited hemodynamic definitions and the characteristics of isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH). Furthermore, we review the current knowledge on the pathogenesis of PH-LHD, the prognostic relevance of hemodynamic parameters, and the management strategies, differentiating between treatment of the underlying left heart disease and therapies targeting the pulmonary circulation. The article emphasises the need for precise diagnostic work-up and individualized treatment strategies in patients with PH-LHD.
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Lauder L, Pérez Navarro P, Götzinger F, Ewen S, Al Ghorani H, Haring B, Lepper PM, Kulenthiran S, Böhm M, Link A, Scheller B, Mahfoud F. Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: hemodynamic outcomes at three months. Respir Res 2023; 24:257. [PMID: 37880651 PMCID: PMC10601326 DOI: 10.1186/s12931-023-02552-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload. METHODS In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up. RESULTS Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events. CONCLUSIONS Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany.
| | - Patricia Pérez Navarro
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Hussam Al Ghorani
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Bernhard Haring
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Andreas Link
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Bruno Scheller
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
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Lee JH. Enhancing Prognostication in Acute Heart Failure: Significance of RV-PA Coupling and the TAPSE/PASP Ratio. J Cardiovasc Imaging 2023; 31:207-208. [PMID: 37902000 PMCID: PMC10622633 DOI: 10.4250/jcvi.2023.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 10/31/2023] Open
Affiliation(s)
- Ju-Hee Lee
- Division of Healthcare and Artificial Intelligence, Department of Precision Medicine, National Institute of Health, Cheongju, Korea
- Division of Cardiology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
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11
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Topyła-Putowska W, Tomaszewski M, Wojtkowska A, Styczeń A, Wysokiński A. Tricuspid Regurgitation Velocity/Tricuspid Annular Plane Systolic Excursion (TRV/TAPSE) Ratio as a Novel Indicator of Disease Severity and Prognosis in Patients with Precapillary Pulmonary Hypertension. Diseases 2023; 11:117. [PMID: 37754313 PMCID: PMC10528921 DOI: 10.3390/diseases11030117] [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: 08/14/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Tricuspid annular plane systolic excursion (TAPSE) and tricuspid regurgitation velocity (TRV) are two echocardiographic parameters with prognostic value in patients with pulmonary hypertension (PH). When analyzed concurrently as the TRV/TAPSE ratio, they allow the ventricular-pulmonary artery coupling (RVPAC) to be assessed. This could better predict disease severity in patients with PH. OBJECTIVE Our study aimed to evaluate the prognostic value of the TRV/TAPSE ratio echocardiographic parameter in adults with precapillary PH. METHODS This study included 39 patients (74% women; average age, 63 years) with precapillary PH (pulmonary arterial hypertension and chronic thromboembolic PH) The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured TAPSE as a surrogate of RV contractility and TRV reflecting RV afterload, while ventricular-arterial coupling was evaluated by the ratio between these two parameters (TRV/TAPSE). To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. Patient physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of N-terminal prohormone brain natriuretic peptide (NT-proBNP), which were taken routinely during the follow-up visit. RESULTS The mean calculated TRV/TAPSE ratio was 0.26 ± 0.08 m/s/mm. Upon comparison of the TRV/TAPSE ratio to the disease prognostic indicators, we observed a statistically significant correlation between TRV/TAPSE and the results of the WHO FC, 6MWT, and NT-proBNP. The TRV/TAPSE ratio is thus a good predictor of mortality in PH patients (AUC, 0.781). Patients with a TRV/TAPSE ratio > 0.30 m/s/mm had a shorter survival time, with log-rank test p < 0.0001. Additionally, ROC analysis revealed higher AUC for TRV/TAPSE than for TAPSE and TRV alone. CONCLUSIONS TRV/TAPSE is a promising practicable echocardiographic parameter reflecting RVPAC. Moreover, TRV/TAPSE could be viable risk stratification parameter and could have prognostic value in patients with PH.
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Yogeswaran A, Rako ZA, Yildiz S, Ghofrani HA, Seeger W, Brito da Rocha B, Gall H, Kremer NC, Douschan P, Papa S, Vizza CD, Filomena D, Tedford RJ, Naeije R, Richter MJ, Badagliacca R, Tello K. Echocardiographic evaluation of right ventricular diastolic function in pulmonary hypertension. ERJ Open Res 2023; 9:00226-2023. [PMID: 37727674 PMCID: PMC10505953 DOI: 10.1183/23120541.00226-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/26/2023] [Indexed: 09/21/2023] Open
Abstract
Background Right ventricular (RV) diastolic dysfunction may be prognostic in pulmonary hypertension (PH). However, its assessment is complex and relies on conductance catheterisation. We aimed to evaluate echocardiography-based parameters as surrogates of RV diastolic function, provide validation against the gold standard, end-diastolic elastance (Eed), and define the prognostic impact of echocardiography-derived RV diastolic dysfunction. Methods Patients with suspected PH who underwent right heart catheterisation including conductance catheterisation were prospectively recruited. In this study population, an echocardiography-based RV diastolic function surrogate was derived. Survival analyses were performed in patients with precapillary PH in the Giessen PH Registry, with external validation in patients with pulmonary arterial hypertension at Sapienza University (Rome). Results In the derivation cohort (n=61), the early/late diastolic tricuspid inflow velocity ratio (E/A) and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (E/e') did not correlate with Eed (p>0.05). Receiver operating characteristic analysis revealed a large area under the curve (AUC) for the peak lateral tricuspid annulus systolic velocity/right atrial area index ratio (S'/RAAi) to detect elevated Eed (AUC 0.913, 95% confidence interval (CI) 0.839-0.986) and elevated end-diastolic pressure (AUC 0.848, 95% CI 0.699-0.998) with an optimal threshold of 0.81 m2·s-1·cm-1. Subgroup analyses demonstrated a large AUC in patients with preserved RV systolic function (AUC 0.963, 95% CI 0.882-1.000). Survival analyses confirmed the prognostic relevance of S'/RAAi in the Giessen PH Registry (n=225) and the external validation cohort (n=106). Conclusions Our study demonstrates the usefulness of echocardiography-derived S'/RAAi for noninvasive assessment of RV diastolic function and prognosis in PH.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- These authors contributed equally to this work
| | - Zvonimir A. Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- These authors contributed equally to this work
| | - Selin Yildiz
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Bruno Brito da Rocha
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Nils C. Kremer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Philipp Douschan
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Silvia Papa
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Domenico Filomena
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, South Carolina, USA
| | | | - Manuel J. Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Roberto Badagliacca
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- These authors contributed equally to this work
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- These authors contributed equally to this work
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Vraka A, Diamanti E, Kularatne M, Yerly P, Lador F, Aubert JD, Lechartier B. Risk Stratification in Pulmonary Arterial Hypertension, Update and Perspectives. J Clin Med 2023; 12:4349. [PMID: 37445381 DOI: 10.3390/jcm12134349] [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: 06/01/2023] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Risk stratification in pulmonary arterial hypertension (PAH) is crucial in assessing patient prognosis. It serves a prominent role in everyday patient care and can be determined using several validated risk assessment scores worldwide. The recently published 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines underline the importance of risk stratification not only at baseline but also during follow-up. Achieving a low-risk status has now become the therapeutic goal, emphasising the importance of personalised therapy. The application of these guidelines is also important in determining the timing for lung transplantation referral. In this review, we summarise the most relevant prognostic factors of PAH as well as the parameters used in PAH risk scores and their evolution in the guidelines over the last decade. Finally, we describe the central role that risk stratification plays in the current guidelines not only in European countries but also in Asian countries.
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Affiliation(s)
- Argyro Vraka
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Eleni Diamanti
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Patrick Yerly
- Division of Cardiology, Cardiovascular Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Division, Geneva University Hospital, 1211 Geneva, Switzerland
| | - John-David Aubert
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Benoit Lechartier
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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Trushenko NV, Suvorova OA, Nekludova GV, Levina IA, Chikina SY, Nikolenko AM, Tsareva NA, Volkov AV, Yaroshetskiy AI, Merzhoeva ZM, Nuralieva GS, Avdeev SN. Predictors of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients with Hypersensitivity Pneumonitis. Life (Basel) 2023; 13:1348. [PMID: 37374130 PMCID: PMC10302253 DOI: 10.3390/life13061348] [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: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) that occurs in susceptible individuals in response to various inhaled antigens. The fibrotic phenotype of HP is characterized by disease progression and can lead to pulmonary hypertension (PH). The aim of this study was to estimate the prevalence of PH and to identify predictors of PH in patients with chronic HP. METHODS We conducted an observational longitudinal study that included 85 patients with an established diagnosis of HP. Clinical examination, quality of life questionnaires, high-resolution computed tomography (HRCT) of the chest, arterial blood gases analyses, six-minute walking test (6-MWT), pulmonary function tests, and echocardiography were performed. RESULTS Patients were divided into groups with fibrotic (71.8%) and nonfibrotic phenotype (28.2%). PH was detected in 41 (48.2%) patients. Patients with PH had the predominant fibrotic phenotype of HP, were older, more symptomatic, and had a higher FVC/DLco ratio. The most significant predictors of PH were CT signs of fibrosis, finger clubbing, FVC/DLco, decreased distance, and SpO2 at the end of 6-MWT, as well as the presence of cardiovascular diseases. CONCLUSIONS PH is a common condition in patients with chronic HP, especially with the fibrotic phenotype. Early detection of the PH predictors is necessary for the timely diagnosis of this complication of HP.
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Affiliation(s)
- Natalia V. Trushenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Olga A. Suvorova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Galina V. Nekludova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Iuliia A. Levina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Svetlana Y. Chikina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Alexandra M. Nikolenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Natalia A. Tsareva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Alexandr V. Volkov
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Federal State Budgetary Scientific Institution, V. A. Nasonova Research Institute of Rheumatology, Kashirskoye Highway 34A, 115522 Moscow, Russia
| | - Andrey I. Yaroshetskiy
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Zamira M. Merzhoeva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Galiya S. Nuralieva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Sergey N. Avdeev
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
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15
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Wissmüller M, Dohr J, Adler J, Ochs L, Tichelbäcker T, Hohmann C, Baldus S, Rosenkranz S. Pulmonary hypertension associated with left heart disease. Herz 2023:10.1007/s00059-023-05189-z. [PMID: 37289211 DOI: 10.1007/s00059-023-05189-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/09/2023]
Abstract
Pulmonary hypertension (PH) is a common condition in patients with left heart disease (LHD) that is highly relevant for morbidity and mortality. While post-capillary in nature, the pathophysiology of PH in patients with LHD (heart failure/cardiomyopathy, valvular heart disease; other: congenital/acquired) is complex, and decisions about management strategies are challenging. Recently, the updated European Society of Cardiology/European Respiratory Society guidelines on the diagnosis and treatment of PH revisited hemodynamic definitions and the sub-classification of post-capillary PH, and provided numerous new recommendations on the diagnosis and management of PH associated with various types of LHD. Here, we review several novel aspects that focus on: (a) updated hemodynamic definitions, including the distinction between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH); (b) the pathogenesis of PH-LHD, considering various components contributing to PH, such as pulmonary congestion, vasoconstriction, and vascular remodeling; (c) the prognostic relevance of PH and hemodynamic markers; (d) the diagnostic approach to PH-LHD; (e) management strategies in PH-LHD, distinguishing between targeting the underlying left heart condition, the pulmonary circulation, and/or impaired right ventricular function. In conclusion, precise clinical and hemodynamic characterization and detailed phenotyping are essential for prognostication and the management of patients with PH-LHD.
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Affiliation(s)
- Max Wissmüller
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Johannes Dohr
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Joana Adler
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Laurin Ochs
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tobias Tichelbäcker
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christopher Hohmann
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Stephan Baldus
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Dept. of Cardiology, Pulmonology, and Intensive Care Medicine), Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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16
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Aslanger E, Akaslan D, Ataş H, Kocakaya D, Yıldızeli B, Mutlu B. Right Ventricular Energy Failure Predicts Mortality in Patients With Pulmonary Hypertension. Am J Cardiol 2023; 193:19-27. [PMID: 36857840 DOI: 10.1016/j.amjcard.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
Right ventricular (RV) failure has a significant adverse impact on pulmonary hypertension (PH) prognosis. None of the currently used parameters directly assess whether RV fails to provide enough energy output to propel the blood through diseased pulmonary vascular system. Furthermore, most of the current parameters are affected by the volume status of the patient. We aimed to explore whether RV energy failure has a predictive power for mortality on top of the established prognostic risk parameters in patients with PH. We screened 723 cases from our database. A total of 3 sets of binary regression analyses were executed to determine the hazard ratios (HRs) of RV energy failure for 5-year mortality in clinical, echocardiographic, and hemodynamic context, using adjustment variables chosen according to previous studies. The final study population encompassed 549 cases. A total of 77 patients died during the 5-year follow-up (14%). RV energy failure was observed in 146 of 549 patients (26.6%). In the univariate model, RV energy failure strongly associated with increased long-term mortality (HR 4.25, 95% confidence interval [CI] 2.58 to 7.00, p <0.001). It also emerged as a significant predictor of long-term mortality in clinical and hemodynamic multivariate models (HR 2.59, 95% CI 1.43 to 4.67, p = 0.002 and HR 2.05, 95% CI 1.15 to 3.63, p = 0.015, respectively). In conclusion, our study indicates that the presence of RV energy failure independently predicts long-term mortality in PH.
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Affiliation(s)
- Emre Aslanger
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey.
| | - Dursun Akaslan
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Halil Ataş
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | | | - Bedrettin Yıldızeli
- Thoracic Surgery, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
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17
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Richter MJ, Rako ZA, Tello K. Ratio between right ventricular strain and systolic pulmonary artery pressure as a surrogate for right ventricular to pulmonary arterial coupling: validation against the gold standard. Eur Heart J Cardiovasc Imaging 2023; 24:e50-e52. [PMID: 36546641 DOI: 10.1093/ehjci/jeac253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Manuel J Richter
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Klinikstrasse 33, 35392 Giessen, Germany
| | - Zvonimir A Rako
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Klinikstrasse 33, 35392 Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Klinikstrasse 33, 35392 Giessen, Germany
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18
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [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: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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