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Suzuki K, Yagi T, Kawakami J. Long-term efficacies of selective vasodilators in pulmonary arterial hypertension: a comprehensive comparison using a spontaneous reporting database. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4981-4992. [PMID: 38180559 DOI: 10.1007/s00210-023-02929-0] [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: 11/25/2023] [Accepted: 12/23/2023] [Indexed: 01/06/2024]
Abstract
There is no clinical evidence of differences in drugs associated with long-term survival in patients with pulmonary arterial hypertension (PAH) due to the small population and lack of information on death in Japanese medical database systems. This study evaluated whether patient data from a spontaneous reporting database could be used for comparing the effects of pulmonary vasodilators on long-term survival in PAH patients. PAH patient data reported in the Japanese Adverse Drug Event Report (JADER) database from April 2004 to July 2022 were extracted. Kaplan-Meier curves were used to compare survival times. Adjusted hazard ratios (aHRs) for all-cause mortality were determined using Cox proportional hazards models. Of 1969 PAH patients reported in the JADER database, 1208 were included in the survival analyses. The patient demographics were similar to those of the PAH population reported in the Japan Pulmonary Hypertension Registry. Among drugs targeting the prostacyclin pathway, epoprostenol was most associated with long-term survival (aHR, 0.38; 95% confidence interval (CI), 0.23-0.64). The PAH patients treated with endothelin receptor antagonists had improved survival, especially among the macitentan users (aHR, 0.30; 95% CI, 0.22-0.42). Sildenafil was associated with a poor prognosis in the PAH patients (aHR, 1.56; 95% CI, 1.19-2.04). Although our results must be interpreted with caution due to several limitations inherent to spontaneous reporting databases, our approach using the JADER database for survival analysis may provide useful information in limited situations such as the treatment of rare diseases including PAH.
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Affiliation(s)
- Koji Suzuki
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Chuo-Ku, Hamamatsu, 431-3192, Japan.
| | - Tatsuya Yagi
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Chuo-Ku, Hamamatsu, 431-3192, Japan
| | - Junichi Kawakami
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Chuo-Ku, Hamamatsu, 431-3192, Japan
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Kochanski JJ, Feinstein JA, Ogawa M, Ritter V, Hopper RK, Adamson GT. Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension. Pulm Circ 2024; 14:e12328. [PMID: 38348195 PMCID: PMC10860541 DOI: 10.1002/pul2.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/15/2024] Open
Abstract
Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.
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Affiliation(s)
- Justin J. Kochanski
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Michelle Ogawa
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Victor Ritter
- Stanford University School of MedicineQuantitative Sciences UnitPalo AltoCaliforniaUSA
| | - Rachel K. Hopper
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Gregory T. Adamson
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
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3
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Farmakis IT, Baroutidou A, Patsiou V, Arvanitaki A, Doundoulakis I, Hobohm L, Zafeiropoulos S, Konstantinides SV, D'Alto M, Badagliacca R, Giannakoulas G. Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients. ERJ Open Res 2024; 10:00706-2023. [PMID: 38259812 PMCID: PMC10801731 DOI: 10.1183/23120541.00706-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.
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Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michele D'Alto
- Department of Cardiology, University “L. Vanvitelli”-Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Nabeh OA, Saud AI, Amin B, Khedr AS, Amr A, Faoosa AM, Esmat E, Mahmoud YM, Hatem A, Mohamed M, Osama A, Soliman YMA, Elkorashy RI, Elmorsy SA. A Systematic Review of Novel Therapies of Pulmonary Arterial Hypertension. Am J Cardiovasc Drugs 2024; 24:39-54. [PMID: 37945977 PMCID: PMC10805839 DOI: 10.1007/s40256-023-00613-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive, cureless disease, characterized by increased pulmonary vascular resistance and remodeling, with subsequent ventricular dilatation and failure. New therapeutic targets are being investigated for their potential roles in improving PAH patients' symptoms and reversing pulmonary vascular pathology. METHOD We aimed to address the available knowledge from the published randomized controlled trials (RCTs) regarding the role of Rho-kinase (ROCK) inhibitors, bone morphogenetic protein 2 (BMP2) inhibitors, estrogen inhibitors, and AMP-activated protein kinase (AMPK) activators on the PAH evaluation parameters. This systematic review (SR) was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CDR42022340658) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Overall, 5092 records were screened from different database and registries; 8 RCTs that met our inclusion criteria were included. The marked difference in the study designs and the variability of the selected outcome measurement tools among the studies made performing a meta-analysis impossible. However, the main findings of this SR relate to the powerful potential of the AMPK activator and the imminent antidiabetic drug metformin, and the BMP2 inhibitor sotatercept as promising PAH-modifying therapies. There is a need for long-term studies to evaluate the effect of the ROCK inhibitor fasudil and the estrogen aromatase inhibitor anastrozole in PAH patients. The role of tacrolimus in PAH is questionable. The discrepancy in the hemodynamic and clinical parameters necessitates defining cut values to predict improvement. The differences in the PAH etiologies render the judgment of the therapeutic potential of the tested drugs challenging. CONCLUSION Metformin and sotatercept appear as promising therapeutic drugs for PAH. CLINICAL TRIALS REGISTRATION This work was registered in PROSPERO (CDR42022340658).
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Affiliation(s)
- Omnia Azmy Nabeh
- Medical Pharmacology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Alaa I Saud
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Basma Amin
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Alaa Amr
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Eshraka Esmat
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Aya Hatem
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mariam Mohamed
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Osama
- Kasralainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Reem Ibrahim Elkorashy
- Pulmonology, Pulmonary Medicine Department, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Soha Aly Elmorsy
- Medical Pharmacology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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5
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Ghio S, Badagliacca R, Acquaro M, Filomena D, Recchioni T, Papa S, Colombo D, Ditali V, Carrozzi C, Greco A, Turco A, Breviario F, Benza R, Vizza D, Scelsi L. Prognostic value of deep echocardiographic phenotyping in pulmonary arterial hypertension. ERJ Open Res 2024; 10:00587-2023. [PMID: 38196894 PMCID: PMC10772897 DOI: 10.1183/23120541.00587-2023] [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: 08/12/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background A novel approach to derive prognostic information from echocardiography in pulmonary arterial hypertension (PAH) is to define a phenotype of right heart function combining standard echocardiographic parameters which describe right ventricular pump function and systemic venous congestion. We tested the hypothesis that the combination of advanced strain imaging parameters could yield high prognostic accuracy. Methods This was a prospective observational study with a single centre derivation cohort and a second centre validation cohort. The derivation cohort included 49 naive PAH patients who underwent right heart catheterisation and echocardiographic evaluation at baseline and 4-12 months after diagnosis. The validation cohort included 83 prevalent PAH patients who underwent the same examinations at 12 months after diagnosis. We stratified the risk of the derivation cohort according to three models: Model 1, based on haemodynamic parameters; Model 2, based on standard echocardiographic parameters; and Model 3, based on advanced echocardiographic parameters. The median follow-up period was 21 months; the end point of the analysis was clinical worsening. Results In the derivation cohort, haemodynamic and echocardiographic parameters obtained at diagnosis were not associated with outcome, whereas a significant association was observed at first reassessment. Model 3 yielded a better predictive accuracy (Harrell's C index 0.832) as compared to Model 2 (Harrell's C index 0.667), and to Model 1 (Harrell's C index 0.713). The validation cohort confirmed the accuracy of Model 3. Conclusions A comprehensive assessment of right heart function using right ventricular strain, right atrial reservoir strain and degree of tricuspid regurgitation provides accurate prognostic information in prevalent PAH patients.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- These authors contributed equally
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
- These authors contributed equally
| | - Mauro Acquaro
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- These authors contributed equally
| | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Davide Colombo
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Ditali
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Carrozzi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Annalisa Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Breviario
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raymond Benza
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, I School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Fauvel C, Liu Y, Correa-Jaque P, Kanwar MK, Vizza CD, Lin S, Benza RL. Do Patients With Low-Risk Pulmonary Arterial Hypertension Really Benefit From Upfront Combination Therapy?: Insight From the AMBITION Trial. Chest 2023; 164:1518-1530. [PMID: 37356711 PMCID: PMC10716797 DOI: 10.1016/j.chest.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Based on results of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial, upfront combination therapy is recommended for treatment-naive patients with low-risk pulmonary arterial hypertension (PAH). However, conflicting data exist whether adopting this treatment strategy in this risk group is beneficial or well tolerated. RESEARCH QUESTION Do patients with low-risk PAH really benefit from upfront combination therapy? STUDY DESIGN AND METHODS Using the data from the original AMBITION trial, patients with PAH were classified as low, intermediate, or high risk using the Registry to Evaluate Early and Long-term PAH Disease Management 2.0 (REVEAL 2.0) score and the Pulmonary Hypertension Outcomes and Risk Assessment (PHORA) tool. The primary end point was time to clinical worsening (including death, hospitalization for PAH worsening, and disease progression) censored at 1- and 3-year post-enrollment. Side effects that led to withdrawal of treatment were also considered. RESULTS Patients with low-risk PAH categorized by REVEAL 2.0 and PHORA did not see a statistically significant benefit of upfront combination therapy vs monotherapy for time to clinical worsening at 1 and 3 years' post-enrollment using Cox proportional analysis (3-year hazard ratio of 0.40 [95% CI, 0.15-1.06; P = .07] and 0.55 [95% CI, 0.26-1.18; P = .12] for REVEAL 2.0 and PHORA, respectively) or considering time to clinical worsening or side effects (3-year hazard ratio of 0.75 [95% CI, 0.39-1.47; P = .4] and 0.87 [95% CI, 0.49-1.54; P = .63] for REVEAL 2.0 and PHORA). Patients with low-risk PAH on upfront combination therapy experienced a higher but not significant incidence of side effects using REVEAL 2.0 and PHORA. In contrast, patients at intermediate or high risk saw a statistically significant benefit of upfront combination therapy considering each of the end points regardless of side effects. INTERPRETATION This analysis suggests that perhaps some patients with low-risk PAH should be further stratified using other modalities prior to committing to upfront combination therapy, especially when the occurrence of side effects is considered. Further prospective data are needed to validate this hypothesis prior to changes in current guideline directed therapy are contemplated.
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Affiliation(s)
- Charles Fauvel
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH; Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Yongqi Liu
- Department of Statistics, The Ohio State University, Columbus, OH
| | - Priscilla Correa-Jaque
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
| | | | - Shili Lin
- Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Raymond L Benza
- ICAHN School of Medicine at Mount Sinai, Mount Sinai Heart, New York, New York.
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de Barros JA, Sant'Ana G, Martins G, Madlum L, Scremim C, Petterle R, Escuissato D, Lima E. Severity of precapillary pulmonary hypertension: Predictive factor. Pulmonology 2023; 29 Suppl 4:S25-S35. [PMID: 34969648 DOI: 10.1016/j.pulmoe.2021.11.007] [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: 04/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pulmonary arterial hypertension (PAH) require risk assessments for prognosis and appropriate therapy. These assessments need to be improved by incorporating clinical and laboratory data such as the analysis of the right ventricle. We aim to establish echocardiographic morphometric data of the right ventricle and its relationship with the left ventricle, to estimate the hemodynamic severity of precapillary pulmonary hypertension (PHprecapillary). METHODS This cohort, prospective, observational, and cross-sectional study included 41 consecutive patients with PHprecapillary using echocardiographic study and cardiac catheterization. RESULTS Patients' mean age was 44.0±16.4 years, and 37 were women (90.2%). Idiopathic PAH was diagnosed in 18 patients (43.9%). The World Health Organization/New York Association functional class was III or IV in 31 patients (75.6%). The ratio of the right to left ventricles (RV/LV) echocardiographic diastolic diameters was associated with pulmonary arterial pressures in cardiac catheterization, with the best cutoff per receiver operating characteristic curve being 0.8 for systolic pressure (sensitivity 90.0%, specificity 78.3%, area under the curve [AUC] 0.882) and mean pressure (sensitivity 60.0%, specificity 95.7%, AUC 0.823). Spearman's correlation (R) of RV/LV echocardiographic ratio and the hemodynamic variables was significant for systolic pressure (R = 0.7015, p < 0.0001), mean pressure (R = 0.6332, p < 0.0001), transpulmonary pressure gradient (R = 0.6524, p < 0.0001), pulmonary vascular resistance (R = 0.6076, p = 0.0021), and pulmonary vascular resistance index (R = 0.6229, p = 0.0014). CONCLUSION The ratio of RV/LV echocardiographic diastolic diameters contribute to the estimates the hemodynamic severity of precapillary pulmonary hypertension. The best cutoff for this assessment was RV/LV of 0.8.
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Affiliation(s)
- J A de Barros
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil.
| | - G Sant'Ana
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - G Martins
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - L Madlum
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - C Scremim
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - R Petterle
- Federal University of Paraná, Department of Integrative Medicine, Curitiba, Brazil
| | - D Escuissato
- Federal University of Paraná, Department of Internal Medicine, Radiology Unit, Curitiba, Brazil
| | - E Lima
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
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8
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Harutyunova S, Benjamin N, Eichstaedt C, Marra AM, Xanthouli P, Nagel C, Grünig E, Egenlauf B. Long-Term Safety, Outcome, and Clinical Effects of Subcutaneous and Intravenous Treprostinil Treatment in Patients with Severe Chronic Pulmonary Arterial Hypertension. Respiration 2023; 102:579-590. [PMID: 37544296 DOI: 10.1159/000531169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Current guidelines recommend treatment with parenteral prostacyclin analogs in patients with severe pulmonary arterial hypertension (PAH), who have insufficient response to treatment. Real-life data are sought to help physicians in treatment decisions and clinical care of patients. OBJECTIVE This study analyzed safety, clinical effects, and long-term outcomes of subcutaneous (sc) and/or intravenous (iv) treprostinil via different pump systems in consecutive patients with PAH. METHODS Thirty-seven patients with severe progressive PAH despite dual combination therapy (20 female, mean age: 52.3 ± 15 years, mean pulmonary vascular resistance: 12.1 ± 5.1 WU) were initiated with add-on treprostinil sc and were routinely clinically assessed. Changes in clinical parameters, adverse events, and outcome were analyzed retrospectively. RESULTS In 24 of 37 patients, treprostinil administration was continued iv via implantation of LENUS Pro® pump after 3 ± 1.3 months, 6 patients continued with sc therapy, and 7 discontinued treatment. After 3, 6, 9, and 12 months of treprostinil treatment, patients showed a significant improvement in mean 6-min walk distance and tricuspid annular plane systolic excursion compared to baseline. In 8 of the 24 patients, iv pumps required surgical revision. During a mean follow-up of 2.82 ± 1.95 years, 12 patients died, four received lung transplantation. Transplant-free survival after 1, 2, and 3 years was 85.7%, 69.2%, and 65.3%, respectively. CONCLUSION sc treprostinil as add-on to double combination treatment significantly improved exercise capacity and right heart function. In most patients, treprostinil could be continued via more tolerable iv administration approach (LENUS Pro® pump), showing reasonable overall survival with respect to the severity of PAH.
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Affiliation(s)
- Satenik Harutyunova
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany,
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany,
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina Eichstaedt
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Institute of Human Genetics, Laboratory for Molecular Genetic Diagnostics, Heidelberg University, Heidelberg, Germany
| | - Alberto M Marra
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Internal Medicine Section, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Panagiota Xanthouli
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology, Clinic Baden-Baden, Baden-Baden, Germany
- Practice of Pneumology, Max Grundig Clinic Bühlerhöhe, Bühl, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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Ostad S, Sugarman J, Alkhodair A, Liang J, Mielniczuk LM, Hambly N, Helmersen D, Hirani N, Thakrar M, Varughese R, Norena M, Kularatne M, Swiston JR, Kapasi A, Weatherald J, Brunner NW. Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study. CJC Open 2023; 5:545-553. [PMID: 37496788 PMCID: PMC10366663 DOI: 10.1016/j.cjco.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.
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Affiliation(s)
- Sam Ostad
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Sugarman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Alkhodair
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jiaming Liang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Mielniczuk
- Department of Medicine, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathan Hambly
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naushad Hirani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mitesh Thakrar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John R. Swiston
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan W. Brunner
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Miles KG, Critser PJ, Evers PD, Cash M, Magness M, Geers E, O'Neil M, Gao Z, Ollberding NJ, Hirsch R. Factors leading to supranormal cardiac index in pediatric pulmonary hypertension patients treated with parenteral prostanoid therapy. Pulm Circ 2023; 13:e12264. [PMID: 37427091 PMCID: PMC10323166 DOI: 10.1002/pul2.12264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
Parenteral prostanoid therapy (PPT) can result in supranormal cardiac index (SCI; >4 L/min/m2) in pediatric pulmonary hypertension (PPH) patients. We evaluated the incidence, hemodynamic factors, and outcomes associated with SCI in PPH. This retrospective cohort study included 22 PPH patients on PPT from 2005 to 2020. Hemodynamic profiles were compared between the baseline and 3-6 month follow-up catheterization in the SCI and non-SCI cohorts. Cox regression analysis examined time to composite adverse outcome (CAO; Potts shunt, lung transplant, or death) controlling for initial disease severity. SCI developed in 17 (77%) patients, of whom 11 (65%) developed SCI within 6 months. The SCI cohort was characterized by significant augmentation of cardiac index (CI) and stroke volume (SV) as well as reductions in systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). Conversely, the non-SCI cohort had unchanged SV despite a modest rise in CI as well as persistent vasoconstriction. After median follow-up of 4.3 years (range 0.2-13 years), non-SCI patients were at significantly increased risk for the CAO (5/5: three deaths, two Potts shunts) compared with SCI patients (5/17: two deaths, three lung transplants; adjusted hazard ratio 14.0 [95% confidence interval: 2.1-91.3], p < 0.001). A majority of PPH patients developed SCI within 6-12 months of starting PPT and demonstrated lower risk of adverse outcomes compared with non-SCI patients. These data suggest that change in SVR and SV after 3-6 months of PPT may be early markers of therapeutic response and prognosis.
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Affiliation(s)
- Kimberley G. Miles
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Paul J. Critser
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Patrick D. Evers
- Division of Pediatric CardiologyOregon Health and Sciences UniversityPortlandOregonUSA
| | - Michelle Cash
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Melissa Magness
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Elizabeth Geers
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Meredith O'Neil
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nicholas J. Ollberding
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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11
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Jin Q, Chen D, Zhang X, Zhang F, Zhong D, Lin D, Guan L, Pan W, Zhou D, Ge J. Medical Management of Pulmonary Arterial Hypertension: Current Approaches and Investigational Drugs. Pharmaceutics 2023; 15:1579. [PMID: 37376028 DOI: 10.3390/pharmaceutics15061579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a malignant pulmonary vascular syndrome characterized by a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, which eventually leads to right heart failure and even death. Although the exact mechanism of PAH is not fully understood, pulmonary vasoconstriction, vascular remodeling, immune and inflammatory responses, and thrombosis are thought to be involved in the development and progression of PAH. In the era of non-targeted agents, PAH had a very dismal prognosis with a median survival time of only 2.8 years. With the deep understanding of the pathophysiological mechanism of PAH as well as advances in drug research, PAH-specific therapeutic drugs have developed rapidly in the past 30 years, but they primarily focus on the three classical signaling pathways, namely the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. These drugs dramatically improved pulmonary hemodynamics, cardiac function, exercise tolerance, quality of life, and prognosis in PAH patients, but could only reduce pulmonary arterial pressure and right ventricular afterload to a limited extent. Current targeted agents delay the progression of PAH but cannot fundamentally reverse pulmonary vascular remodeling. Through unremitting efforts, new therapeutic drugs such as sotatercept have emerged, injecting new vitality into this field. This review comprehensively summarizes the general treatments for PAH, including inotropes and vasopressors, diuretics, anticoagulants, general vasodilators, and anemia management. Additionally, this review elaborates the pharmacological properties and recent research progress of twelve specific drugs targeting three classical signaling pathways, as well as dual-, sequential triple-, and initial triple-therapy strategies based on the aforementioned targeted agents. More crucially, the search for novel therapeutic targets for PAH has never stopped, with great progress in recent years, and this review outlines the potential PAH therapeutic agents currently in the exploratory stage to provide new directions for the treatment of PAH and improve the long-term prognosis of PAH patients.
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Affiliation(s)
- Qi Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Dandan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai 201508, China
| | - Dongxiang Zhong
- Department of Cardiology, Shanghai East Hospital, Shanghai Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China
| | - Dawei Lin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Lihua Guan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
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12
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Camara RP, Coelho FDN, Cruz-Martins N, Marques-Alves P, Castro G, Baptista R, Ferreira F. Incidence of Bloodstream Infection in Patients with Pulmonary Hypertension under Intravenous Epoprostenol or Iloprost—A Multicentre, Retrospective Study. Int J Mol Sci 2023; 24:ijms24076434. [PMID: 37047407 PMCID: PMC10094981 DOI: 10.3390/ijms24076434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Intravenous synthetic prostacyclin analogs (iPCAs), such as epoprostenol, treprostinil and iloprost have been widely used for the treatment of pulmonary arterial hypertension (PAH). Despite having good outcomes, continuous infusion of iPCAs has been associated with some adverse effects. Bloodstream infection (BSI) is one of the most severe complications, although poorly recognized, especially under iloprost administration, which few studies have addressed. This study aimed to compare the BSI incidence rates between intravenous iloprost and epoprostenol administration. Patients with pulmonary hypertension (PH) functional class III or IV receiving intravenous iloprost or epoprostenol through Hickman catheter, between 2004 and 2019, were retrospectively selected from two PH treatment centers. From a total of 36 patients (13 for iloprost and 23 for epoprostenol), 75% (n = 27) fulfilled the PAH criteria, mainly belonging to the idiopathic group. Overall BSI rate was 1.5/1000 days of treatment (3.38 and 0.09/1000 days for iloprost and epoprostenol, respectively). Patients receiving iloprost were at a higher risk of developing BSI than those receiving epoprostenol (HR: 12.5; 95% CI: 1.569–99.092). A higher mortality rate from BSI was also identified in the iloprost group (p = 0.04). Twenty-seven patients developed BSI, with 92% of them requiring hospitalization. A total of 29 agents were found, 10 Gram-positive (mainly Staphylococcus aureus; n = 5) and 19 Gram-negative (mainly Pseudomonas aeruginosa; n = 6) bacteria. Iloprost administration was linked to a significantly higher incidence of BSI, worse prognosis, and more BSI-related deaths than epoprostenol. BSI due to Gram-negative, commensal, low-virulence bacteria was also higher in the iloprost group. In short, physicians should be aware when prescribing iPCA to guarantee their patients’ safety and best medical care.
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Affiliation(s)
- Raquel Paulinetti Camara
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Pulmonology Department, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro-Montijo, 2830-003 Barreiro, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Francisco das Neves Coelho
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Polyvalent Intensive Care Unit, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, 1349-019 Lisbon, Portugal
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, 4099-002 Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, 4099-002 Porto, Portugal
- Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Rua Central de Gandra, 4585-116 Gandra, Portugal
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Patrícia Marques-Alves
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Graça Castro
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Rui Baptista
- Cardiology Department, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- ICBR—Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3004-561 Coimbra, Portugal
| | - Filipa Ferreira
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
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13
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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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14
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Acute Vasoreactivity Testing and Outcomes in Pulmonary Arterial Hypertension: A Call for Increased Testing. Heart Lung Circ 2023; 32:156-165. [PMID: 36503731 DOI: 10.1016/j.hlc.2022.09.005] [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: 01/27/2022] [Revised: 08/14/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) has a progressive, unremitting clinical course. Vasoreactivity testing (VdT) during right heart catheterisation (RHC) identifies a subgroup with excellent long-term response to calcium channel blockade (CCB). Reporting on these patients is limited. Established in 2011, the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry offers the opportunity to assess the frequency of VdT during RHC, treatment and follow up of PAH patients. METHODS Registry data from 3,972 PAH patients with index RHC revealed 1,194 VdT appropriate patients. Data was analysed in three groups: 1) VdT+CCB+: VdT positive, CCB treated; 2) VdT+CCB-: VdT positive, no CCB prescribed, 3) VdT-/noVdT: VdT negative, or VdT not tested. Data was reviewed for adherence to guidelines, clinical response (World Health Organization functional class [WHO FC], 6-minute-walk-distance [6MWD], RHC), and outcomes (survival or lung transplantation). RESULTS Patients included had idiopathic (IPAH=1,087), heritable (HPAH=67) and drug or toxin-induced PAH (DPAH=40). A VdT was performed in 22% (268/1,194), with incomplete data in 26% (70/268); 28% (55/198) were VdT+. Analysis group allocation was: VdT+CCB+ (33/55), VdT+CCB- (22/55), VdT- (143)/noVdT (996). From patients with 1-year data VdT+CCB+ and VdT-/noVdT patients improved WHO FC, 6MWD and cardiac index (CI); VdT+CCB- data remained similar. Within the VdT+CCB+ group, 30% (10/33) were long-term CCB responders with a 100% 5-year survival; non-responders had a 61% survival at 5.4 years. Long-term responders were younger at diagnosis (40 yrs vs 54 yrs). CONCLUSION Use of VdT testing and documentation is poor in this contemporary patient cohort. Nonetheless, survival in VdT+CCB+ patients from the PHSANZ registry is excellent, supporting guidelines promoting VdT testing. Strategies to promote the use of VdT are warranted.
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15
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Zhou D, Li X, Yin G, Li S, Zhao S, Liu Z, Lu M. Risk Stratification and Outcomes in Patients With Pulmonary Hypertension: Insights into Right Ventricular Strain by MRI Feature tracking. J Magn Reson Imaging 2023; 57:545-556. [PMID: 35713378 DOI: 10.1002/jmri.28291] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Despite a recommended multidimensional approach for pulmonary hypertension (PH) risk stratification and guidance of treatment decisions, this may not always be achievable in patients with advanced disease. One issue is the lack of an imaging modality to assess right ventricular (RV) structure and function abnormalities. PURPOSE To explore the risk stratification and prognostic value of cardiac MR feature tracking (MR-FT)-derived RV strain. STUDY TYPE Retrospective. POPULATION A total of 80 patients with idiopathic pulmonary artery hypertension (N = 52) or chronic thromboembolic PH (N = 28). FIELD STRENGTH A 1.5 T or 3.0 T, balanced steady-state free precession sequence. ASSESSMENT All patients underwent laboratory testing, right heart catheterization, and MR imaging (and in 37 cases, a cardiopulmonary exercise test was also performed) within a 1-month period. Cardiac functional parameters and both global longitudinal strain (GLS) and global circumferential strain (GCS) were analyzed. Patients were stratified into low, intermediate, and high-risk groups by guideline suggested stratified values of risk factors. The combined endpoint was death or hospitalization for congestive heart failure assessed during follow-up since the date of MR examination. STATISTICAL TESTS Kolmogorov-Smirnov's test, independent-sample t-tests, Wilcoxon's rank-sum tests, one-way analysis of variance, χ2 tests or Fisher's exact test, receiver operating characteristic analysis, Kaplan-Meier survival analysis, and Cox regression analysis. A P value < 0.05 was considered statistically significant. RESULTS The median follow-up duration was 3.4 years. Thirty-five patients presented with combined endpoint including 10 cardiac deaths. RV structural and deformation impairments were significantly associated with combined endpoint (ejection fraction: 31.3% ± 13.2% vs. 38.0% ± 14.8%, hazard ratio [HR: 0.974; GLS: -14.5 [-18.6, -10.9] % vs. -20.4 [-26.0, -13.2] %, HR: 1.071; GCS: -9.8 [-14.5, -7.3] % vs. -12.3 [-19.9, -8.4] %, HR: 1.059). There were significant differences in RVGLS among low, intermediate, and high-risk groups (-19.3% ± 7.2% vs. -17.3% ± 9.4% vs. -11.5% ± 4.4% by cardiac functional class, -21.8% ± 7.3% vs. -19.4% ± 8.2% vs. -12.7 ± 5.3% by NT-proBNP, -19.7% ± 7.7 vs. -15.8% ± 6.5% vs. -12.6% ± 8.2% by cardiac index). DATA CONCLUSION RV deformation may aid risk stratification in patients with PH, providing crucial information for RV remodeling, pulmonary hemodynamic condition and exercise capacity. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Di Zhou
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gang Yin
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Li
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China
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16
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Kane CJ, Salama AA, Pislaru C, Kane GC, Pislaru SV, Lin G. Low Pulmonary Artery Pulsatility Index by Echocardiography Is Associated With Increased Mortality in Pulmonary Hypertension. J Am Soc Echocardiogr 2023; 36:189-195. [PMID: 36126823 DOI: 10.1016/j.echo.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a progressive pulmonary vascular disorder with elevated mortality risk. The pulmonary artery (PA) pulsatility index (PAPi) based on invasively acquired parameters has emerged as a hemodynamic risk predictor. Whether noninvasively derived PAPi (PA pulse pressure divided by right atrial pressure) is valuable is unclear. METHODS Consecutive patients undergoing transthoracic echocardiography for known or suspected PH were included with conventional echocardiographic measures of PA systolic, PA diastolic, and estimated right atrial pressures. In those patients with PH (mean PA pressure > 20 mm Hg), PAPi was divided into 3 groups: <1.5, 1.5 to 3, and >3. Mortality was assessed over 5 years. RESULTS Of 1,045 patients enrolled, 64% had PH. Patients with the lowest PAPi had higher N-terminal-pro hormone B-type natriuretic peptide levels, larger right ventricles (RVs), worse RV systolic function, and greater degrees of tricuspid regurgitation. In patients with PH, PAPi was inversely proportional to the risk of death, with PAPi <3 associated with a 1.96-fold increased risk of death (95% CI, 1.45-2.64, P < .0001). At multivariate analysis, RV longitudinal systolic strain (hazard ratio [HR] = 1.45, 1.24-1.71; P < .0001), PAPi <3 (HR = 1.76, 1.31-2.37; P = .0002), and the presence of a pericardial effusion (HR = 1.64, 1.20-2.26 P = .003) were independently associated with increased mortality. In age- and sex-adjusted models, PAPi was incremental to PA compliance. CONCLUSIONS In patients with PH, low PAPi derived noninvasively by transthoracic echocardiography is associated with markers of right heart failure, RV dysfunction, and worse survival. PAPi could be incorporated into the conventional echo parameters reported in patients with PH and may be a useful predictor of outcome.
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Affiliation(s)
- Conor J Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Abdalla A Salama
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Cristina Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Sorin V Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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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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18
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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: 397] [Impact Index Per Article: 397.0] [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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Pastore MC, Ilardi F, Stefanini A, Mandoli GE, Palermi S, Bandera F, Benfari G, Esposito R, Lisi M, Pasquini A, Santoro C, Valente S, D’Andrea A, Cameli M. Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit. J Clin Med 2022; 11:jcm11247538. [PMID: 36556154 PMCID: PMC9785677 DOI: 10.3390/jcm11247538] [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: 11/13/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Andrea Stefanini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, 20122 Milan, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Roberta Esposito
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease—AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Annalisa Pasquini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Antonello D’Andrea
- Department of Cardiology, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
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20
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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21
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Xu Z, Zahradka N, Ip S, Koneshloo A, Roemmich RT, Sehgal S, Highland KB, Searson PC. Evaluation of physical health status beyond daily step count using a wearable activity sensor. NPJ Digit Med 2022; 5:164. [PMID: 36352062 PMCID: PMC9646807 DOI: 10.1038/s41746-022-00696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
Physical health status defines an individual's ability to perform normal activities of daily living and is usually assessed in clinical settings by questionnaires and/or by validated tests, e.g. timed walk tests. These measurements have relatively low information content and are usually limited in frequency. Wearable sensors, such as activity monitors, enable remote measurement of parameters associated with physical activity but have not been widely explored beyond measurement of daily step count. Here we report on results from a cohort of 22 individuals with Pulmonary Arterial Hypertension (PAH) who were provided with a Fitbit activity monitor (Fitbit Charge HR®) between two clinic visits (18.4 ± 12.2 weeks). At each clinical visit, a maximum of 26 measurements were recorded (19 categorical and 7 continuous). From analysis of the minute-to-minute step rate and heart rate we derive several metrics associated with physical activity and cardiovascular function. These metrics are used to identify subgroups within the cohort and to compare to clinical parameters. Several Fitbit metrics are strongly correlated to continuous clinical parameters. Using a thresholding approach, we show that many Fitbit metrics result in statistically significant differences in clinical parameters between subgroups, including those associated with physical status, cardiovascular function, pulmonary function, as well as biomarkers from blood tests. These results highlight the fact that daily step count is only one of many metrics that can be derived from activity monitors.
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Affiliation(s)
- Zheng Xu
- Measurement Corps, In Health, Johns Hopkins University School of Medicine, Baltimore, MA, USA.,Institute of Nanobiotechnology, Johns Hopkins University, Baltimore, MA, USA
| | - Nicole Zahradka
- Measurement Corps, In Health, Johns Hopkins University School of Medicine, Baltimore, MA, USA.,Institute of Nanobiotechnology, Johns Hopkins University, Baltimore, MA, USA
| | - Seyvonne Ip
- Measurement Corps, In Health, Johns Hopkins University School of Medicine, Baltimore, MA, USA.,Institute of Nanobiotechnology, Johns Hopkins University, Baltimore, MA, USA
| | - Amir Koneshloo
- Measurement Corps, In Health, Johns Hopkins University School of Medicine, Baltimore, MA, USA.,Institute of Nanobiotechnology, Johns Hopkins University, Baltimore, MA, USA
| | - Ryan T Roemmich
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MA, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Sameep Sehgal
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Peter C Searson
- Measurement Corps, In Health, Johns Hopkins University School of Medicine, Baltimore, MA, USA. .,Institute of Nanobiotechnology, Johns Hopkins University, Baltimore, MA, USA. .,Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MA, USA. .,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MA, USA. .,Department of Materials Science & Engineering, Johns Hopkins University, Baltimore, MA, USA.
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22
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Zhao J, Wang Q, Deng X, Qian J, Tian Z, Liu Y, Li M, Zeng X. The treatment strategy of connective tissue disease associated pulmonary arterial hypertension: Evolving into the future. Pharmacol Ther 2022; 239:108192. [DOI: 10.1016/j.pharmthera.2022.108192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
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Otani N, Tomoe T, Kawabe A, Sugiyama T, Horie Y, Sugimura H, Yasu T, Nakamoto T. Recent Advances in the Treatment of Pulmonary Arterial Hypertension. Pharmaceuticals (Basel) 2022; 15:1277. [PMID: 36297387 PMCID: PMC9609229 DOI: 10.3390/ph15101277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 09/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease in which stenosis or obstruction of the pulmonary arteries (PAs) causes an increase in PA pressure, leading to right-sided heart failure and death. Basic research has revealed a decrease in the levels of endogenous vasodilators, such as prostacyclin, and an increase in the levels of endogenous vasoconstrictors, such as endothelin, in patients with PAH, leading to the development of therapeutic agents. Currently, therapeutic agents for PAH target three pathways that are selective for PAs: the prostacyclin, endothelin, and nitric oxide pathways. These treatments improve the prognosis of PAH patients. In this review, we introduce new drug therapies and provide an overview of the current therapeutic agents.
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Affiliation(s)
| | | | | | | | | | | | | | - Takaaki Nakamoto
- Department of Cardiology, Dokkyo Medical University Nikkyo Medical Center, 632 Takatoku, Nikko 321-2593, Japan
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24
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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: 945] [Impact Index Per Article: 472.5] [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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25
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Kumbhare U, Yelne P, Tekale S. Therapeutic Use of an Inhaled Drug Delivery in Pulmonary Hypertension: A Review. Cureus 2022; 14:e30134. [PMID: 36381737 PMCID: PMC9645391 DOI: 10.7759/cureus.30134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a serious condition in which there is increased blood pressure in arteries of the lungs (pulmonary arteries). The therapies or drugs for PAH have expanded with the revelation of three key pathological processes - encompassing prostacyclin, nitric oxide (NO), and endothelin pathways. An outlook for patients suffering from PAH is still mediocre amidst recent advancements. The evolution of pre-clinical and clinical research on PAH has facilitated the identification of several new targeted therapies for the disease. In this article, we examine recent data on new pulmonary hypertension physiological pathways, primarily concentrating on administering drugs through the inhalation route and their effects. Although they have been given clinical use approval, medications based on these routes are presently being studied in clinical or pre-clinical settings. To confirm these innovative medicines' therapeutic efficacy and safety, extensive clinical trials are needed.
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26
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Chennakesavulu PV, Uppaluri S, Koyi J, Jhaveri S, Avanthika C, Sakhamuri LT, Ashokbhai PK, Singh P. Pulmonary Hypertension in Scleroderma- Evaluation and Management. Dis Mon 2022:101468. [PMID: 36163292 DOI: 10.1016/j.disamonth.2022.101468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/hemodynamic criteria that are a consequence of several etiologies. Systemic Sclerosis (SSc), one of the most common causes of PAH, is an autoimmune disorder of the connective tissue leading to fibrosis that involves the skin, gastrointestinal tract, lungs, heart, kidney etc. SSc has an annual prevalence of one to five cases for every 1000 individuals and nearly 15 percent of all cases develop PAH. At its core, Pulmonary hypertension (PH) in SSc is an obliterative vasculopathy in small to medium-sized pulmonary arterioles. A host of other local and systemic mechanisms operate in concert to gradually alter the hemodynamics resulting in elevated pulmonary vascular resistance and thus right ventricular afterload. A diagnosis of PAH in SSc is virtually a death sentence, with studies reporting a mortality rate of 50 per cent in the 3 years of diagnosis. Therefore, developing and implementing a robust screening and diagnosis protocol is crucial in the fight against this pervasive disease. This review aims to summarize the current literature of PAH in SSc, with a special focus on the screening and diagnosis protocols, newer treatment options and prognostic indicators for the same.
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Affiliation(s)
| | - Srikar Uppaluri
- Kamineni Academy of medical sciences and research centre, Hyderabad, India.
| | | | | | | | | | | | - Priyanka Singh
- United health services hospital, Wilson medical center, New York
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27
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Tan Z, Wu PY, Zhu TT, Su W, Fang ZF. Efficacy and safety of sequential combination therapy for pulmonary arterial hypertension: A meta-analysis of Randomized-Controlled Trials. Pulm Pharmacol Ther 2022; 76:102144. [PMID: 35918025 DOI: 10.1016/j.pupt.2022.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/18/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous meta-analyses of pulmonary arterial hypertension (PAH) combination therapy pooled sequential and initial combination together, which might threaten their authenticity and clinical significance for the difference between two strategies. METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) that compared sequential combination therapy (SCT) with background therapy (BT) in PAH patients. Raw data were extracted to calculate risk ratio (RR) or weighted mean difference (WMD) for predefined efficacy and safety outcomes. Mantel-Haenszel fixed or random effects model was used based on heterogeneity. RESULTS 17 RCTs involving 4343 patients (97.2% of patients with WHO-FC II-III) were included. SCT decreased clinical worsening (RR 0.66, 95% CI 0.58 to 0.76), nonfatal clinical worsening (RR 0.61, 95% CI 0.52 to 0.71), functional class (decrease of 28% in the portion of patients with WHO-FC worsening and increase of 33% in the portion of patients with WHO-FC improvement), and increased 6-min walk distance (WMD 17.68 m, 95% CI 10.16 to 25.20), but didn't reduce mortality, lung transplantation, admission to hospital, and treatment escalation compared with BT. Although any adverse event and serious adverse event were similar between SCT and BT, SCT increased all-cause treatment discontinuation (RR 1.49, 95% CI 1.30 to 1.71) and drug-related treatment discontinuation (RR 2.30, 95% CI 1.86 to 2.84) with higher incidence of headache, flushing, nausea, diarrhoea and jaw pain. CONCLUSIONS For WHO-FC II-III PAH patients who have established BT, our study reinforced the recommendation of SCT to improve clinical worsening, functional status, and exercise capacity, although with higher incidence of side-effects and withdrawal.
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Affiliation(s)
- Zhen Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Pan-Yun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Teng-Teng Zhu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Wen Su
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
| | - Zhen-Fei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China.
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Shmalts AA. Dynamics of 6-Minute Walk Distance as a Predictor of Efficiency Specific Pulmonary Vasodilators. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-06-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension is a severe and often rapidly progressive disease with a fatal outcome. Approved specific therapy with five classes of drugs – prostanoids, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, soluble guanylate cyclase stimulators and prostacyclin receptor agonists has significantly improved the prognosis of patients. An accessible and reproducible criterion of exercise tolerance – a distance walked in six-minute walk test (6MXD) – occupies one of the central places among the performance indicators (clinical, echocardiographic and hemodynamic) of specific pulmonary vasodilators. Reflecting the clinical severity of pulmonary hypertension and, according to some data, its long-term prognosis, the dynamics of 6MXD is an integral component of the combined primary endpoints of randomized controlled trials. In the CHEST-2019 recommendations, the dynamics of the 6MXD was used to standardize the randomized controlled trials. The 6MXD is indispensable for dynamic observation and decisionmaking on further treatment tactics
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Affiliation(s)
- A. A. Shmalts
- A.N. Bakoulev National Medical Research Center for Cardiovascular Surgery; Russian State Medical Postgraduate Academy
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Chuang JH, Lu PH, Anh NV, Diep TK, Liu HY, Chiang XH, Ho CM, Huang SC, Hsu HH. Mortality risk factors in patients on waiting list for lung transplantation between 2005 and 2018: A single institutional experience. J Formos Med Assoc 2022; 121:2566-2573. [PMID: 35764487 DOI: 10.1016/j.jfma.2022.06.005] [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: 10/18/2021] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lung transplantation is a therapeutic option for patients with end-stage lung disease. However, the increase in organ demand has surpassed the number of donors, with many patients unable to outlive the long waiting period. This study aimed to assess mortality and its risk factors in patients on the waiting list for lung transplantation in a single medical centre. METHODS All evaluated clinical and laboratory data of the patients with end-stage lung disease assessed for lung transplantation between February 2005 and November 2018 in National Taiwan University Hospital were recorded in the waiting list database. The patients in this study were divided into two groups: survival and death groups. RESULTS Between February 2005 and November 2018, 169 patients were enrolled in the waiting list. Thirty-one patients were alive and waiting for the chance of lung transplantation, 56 underwent lung transplantation, and 82 died while waiting. The mean age of all patients was 43.7 years, and 91 were women. The mean body mass index (BMI) was 20.3. The most common blood type was type O. All patients were in New York Heart Association (NYHA) class III or IV. After analysis of the two groups, lower BMI presented as a mortality factor. CONCLUSION This is the first Taiwanese study to describe the mortality factors in patients waiting for lung transplantation. The main factors influencing the survival of these patients were lower BMI, NYHA class IV, and diseases which cause end-stage lung diseases (infection and pulmonary fibrosis).
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Affiliation(s)
- Jen-Hao Chuang
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pham Huu Lu
- Cardiovascular and Thoracic Center, Viet Duc University Hospital, Hanoi Medical University, Hanoi, Viet Nam
| | - Nguyen Viet Anh
- Cardiovascular and Thoracic Center, Viet Duc University Hospital, Hanoi Medical University, Hanoi, Viet Nam
| | - Trinh Ke Diep
- Department of Anesthesiology, Viet Duc University Hospital, Hanoi Medical University, Hanoi, Viet Nam
| | - Hao-Yun Liu
- Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Xu-Heng Chiang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Maw Ho
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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30
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Wang M, Hu Y, Guo B, Tang H. Simulation of Acute Pulmonary Hypertension in Beagle Dogs. Int Heart J 2022; 63:612-622. [PMID: 35650161 DOI: 10.1536/ihj.21-676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acoustic cardiography (AC) combined with heart sound (HS) recording and electrocardiogram (ECG) provides a noninvasive and inexpensive way to understand the electrical mechanical activity of the heart. Pulmonary artery stenosis can cause hemodynamic abnormalities that might lead to pulmonary hypertension (PH). In this paper, we examined the relationships between the acoustic characteristics of the AC and hemodynamic changes in a beagle dog model of PH.Four healthy beagle dogs were injected with the prostaglandin endoperoxide receptor agonist U-44069 to induce acute PH states. AC was employed to analyze the process of pre-PH, intra-PH, and post-PH. Right ventricular blood pressure (RVBP) was measured via right cardiac catheterization, an invasive method performed in parallel for comparative hemodynamic evaluation. As RVBP increased or decreased, the HS features changed accordingly during acute PH occurrence and development. Right ventricular systolic blood pressure (RVSBP) significantly correlated with the minimum of the first HS (S1) amplitude (correlation coefficient (CC) = -0.82), energy of the S1 (CC = 0.86), energy of the second HS (S2) (CC = 0.67), entropy of the S1 (CC = -0.94), and ratio of electromechanical systolic time (EMST) to the cardiac cycle time (CC = 0.81). The two techniques (AC [HSs and ECG] versus right cardiac catheterization [RVBP]) were significantly correlated. Especially, the diastolic filling time (DFT) had a significant relationship with the right ventricular diastolic time (RVDT) (CC = 0.97), perfusion time (PT) (CC = 0.96), and cardiac cycle time (RR) (CC = 0.96). The CCs between the RVDT and the max dp/dt to min dp/dt, the EMST and the Q to min dp/dt, and the electromechanical activation time and the Q to max dp/dt were 0.95, 0.99, and 0.86, respectively. Furthermore, the logistic regression model with different combinations was used to identify the effective features for monitoring hemodynamic and pathophysiologic conditions.AC provided significant insight into mechanical dysfunction in a rapid and noninvasive way that could be used for early screening of PH.
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Affiliation(s)
- Miao Wang
- School of Biomedical Engineering, Dalian University of Technology
| | - YaTing Hu
- School of Biomedical Engineering, Dalian University of Technology
| | - BinBin Guo
- School of Biomedical Engineering, Dalian University of Technology
| | - Hong Tang
- School of Biomedical Engineering, Dalian University of Technology
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31
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Sugiyama Y, Matsubara H, Shimokawahara H, Ogawa A. Outcome of mean pulmonary arterial pressure-based intensive treatment for patients with pulmonary arterial hypertension. J Cardiol 2022; 80:432-440. [DOI: 10.1016/j.jjcc.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022]
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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Wang P, Deng J, Zhang Q, Feng H, Zhang Y, Lu Y, Han L, Yang P, Deng Z. Additional Use of Prostacyclin Analogs in Patients With Pulmonary Arterial Hypertension: A Meta-Analysis. Front Pharmacol 2022; 13:817119. [PMID: 35222031 PMCID: PMC8864222 DOI: 10.3389/fphar.2022.817119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Combination therapy has become an attractive option in pulmonary arterial hypertension (PAH) treatment. The aim of this study was to investigate whether additional use of prostacyclin analogs could exert any additional benefits over background targeted therapies in PAH patients. Methods: Searches were performed on PubMed, Embase, and ClinicalTrials.gov from inception to 1 October 2021. Randomized controlled trials were included if patients had been treated with prostacyclin analog-containing combination therapy and compared with the use of other PAH-specific background therapies. The bias risk and statistical analysis of the enrolled studies were performed with RevMan 5.1. Sensitivity analysis and funnel plot were used to evaluate the stability and publication bias, respectively. PROSPERO registered number CRD42021284196. Results: Ten trials involving 1828 patients were included. Prostacyclin analog treatment was associated with greater improvement in clinical worsening (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.57–0.86), 6-min walk distance (mean difference [MD], 37.17 m; 95% CI, 3.01–71.33 m), NYHA/WHO functional class (RR, 1.58; 95% CI, 1.21–2.05), mean pulmonary artery pressure (MD, −9.23 mmHg; 95% CI, −17.44 to −1.03 mmHg), and cardiac index (MD, 0.41 L/min/m2; 95% CI, 0.26–0.55 L/min/m2) than the control group. No significant differences in pulmonary vascular resistance (MD, −137.22 dyn·s/cm5; 95% CI, −272.61 to −1.84 dyn·s/cm5) and all-cause mortality (RR, 0.96; 95% CI, 0.57–1.61) were found between the prostacyclin analog group and control group. Of note, more adverse events (RR, 1.07; 95% CI, 1.02–1.13) occurred in the prostacyclin analog group but no significant increase in serious adverse events (RR, 1.25; 95% CI, 0.75–2.11). Conclusion: Additional prostacyclin analog treatment exerted benefits on clinical worsening, exercise capacity, functional class, mean pulmonary artery pressure, and cardiac index in PAH patients, but it was associated with overall risk of adverse events. Clinical Trial Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284196, identifier CRD42021284196.
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Affiliation(s)
- Pengwei Wang
- Department of Pharmacy, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Jiaxin Deng
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Quanying Zhang
- Nursing Department, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Hongyan Feng
- Outpatient Department, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Yongheng Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Yizhong Lu
- Department of Pharmacy, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Lizhu Han
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Pengfei Yang
- Henan International Joint Laboratory of Cardiovascular Remodeling and Drug Intervention, Xinxiang Key Laboratory of Vascular Remodeling Intervention and Molecular Targeted Therapy Drug Development, College of Pharmacy, Xinxiang Medical University, Xinxiang, China
| | - Zhijian Deng
- Department of Pharmacy, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
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Adachi S, Nishiyama I, Yasuda K, Yoshida M, Nakano Y, Kondo T, Murohara T. Safe and successful transition from oral selexipag to subcutaneous treprostinil in a patient with idiopathic pulmonary arterial hypertension treated with triple combination therapy. J Cardiol Cases 2022; 26:42-45. [PMID: 35923524 PMCID: PMC9214813 DOI: 10.1016/j.jccase.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/21/2022] [Accepted: 02/19/2022] [Indexed: 11/25/2022] Open
Abstract
Learning objectives
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35
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Prognostic value of improvement endpoints in pulmonary arterial hypertension trials: A COMPERA analysis. J Heart Lung Transplant 2022; 41:971-981. [DOI: 10.1016/j.healun.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
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Takeuchi K, Goda A, Ito J, Kikuchi H, Inami T, Kohno T, Soejima K, Satoh T. Successful epoprostenol withdrawal and termination with an aid of the exercise stress test in pulmonary arterial hypertension. Int J Cardiol 2022; 346:80-85. [PMID: 34798203 DOI: 10.1016/j.ijcard.2021.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/16/2021] [Accepted: 11/15/2021] [Indexed: 11/05/2022]
Abstract
Continuous infusion of intravenous epoprostenol (EPO) improves exercise capacity and survival in pulmonary arterial hypertension (PAH); however, it is associated with side effects. This study aimed to describe our experience on safe EPO withdrawal with the aid of an exercise stress test. This retrospective review included patients with PAH who were successfully withdrawn from EPO. Haemodynamic data were obtained before EPO administration, at withdrawal, and after discontinuation. After the mean pulmonary arterial pressure (mPAP) decreased to <25 mmHg for at least 1 year, an exercise test under right heart catheterisation was performed. If exercise pulmonary hypertension was not record (mPAP - cardiac output slope < 3), EPO was withdrawn. Of the 99 patients who received EPO, ten were identified as having undergone withdrawal or termination. mPAP decreased from 61 (54-71) mmHg before treatment to 19 (17-21) mmHg before withdrawal and remained unchanged, at 19 (14-23) mmHg, 1 year after EPO discontinuation. After a median follow-up of 32 months, all the patients survived. Patients with PAH who recovered their normal haemodynamic function were safely withdrawn from EPO with the aid of an exercise stress test.
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Affiliation(s)
- Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan.
| | - Junnosuke Ito
- 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
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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Ewert R, Habedank D, Halank M, Stubbe B, Opitz CF. Strategies for optimizing intravenous prostacyclin-analog therapy in patients with pulmonary arterial hypertension. Expert Rev Respir Med 2021; 16:57-66. [PMID: 34846985 DOI: 10.1080/17476348.2022.2011220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Intravenous prostacyclin-analogs (PCA, e.g. epoprostenol, treprostinil, iloprost) have become an essential part in the therapy of patients with pulmonary hypertension (PH), mainly pulmonary arterial hypertension (PAH). They show considerable differences in pharmacology. A combination therapy including intravenous drugs is regarded as the 'gold standard' in most of PAH patients. AREAS COVERED This review discusses and summarizes the studies and concepts on which this therapy is based. To date, intravenous prostacyclin-analogs are mainly administered when standard therapy fails to improve patients to low-risk status. However, preliminary data from uncontrolled studies suggest that an 'upfront triple' therapy including intravenous or subcutaneous prostacyclin-analogs could be preferable in selected patients. EXPERT OPINION Various IV PCA have been evaluated in the treatment of patients with PAH. Today, combination therapy is the 'gold standard' for the majority of patients. Intravenous PCA is recommended from functional class III onwards. Timing of its initiation is still a point of discussion. An escalation of therapy to IV or SC PCA is always necessary if a low-risk status cannot be achieved with other targeted therapies. Preliminary data suggest that selected patients could benefit from an 'upfront triple' therapy. Controlled studies on which such recommendation could be based are lacking.
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Affiliation(s)
- Ralf Ewert
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
| | - Dirk Habedank
- Internal Medicine, Cardiology, DRK Kliniken Berlin, Berlin, Germany
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Beate Stubbe
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
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Lattanzio M, Scelsi L, Golino M, Lattuada M, Raineri C, Turco A, Giuntini C, Ceriani F, Curti M, Bonelli A, Piacentino F, Venturini M, Ghiringhelli S, Morandi F, De Ponti R, Ghio S. Assessment of right ventricle in pulmonary arterial hypertension with three-dimensional echocardiography and cardiovascular magnetic resonance. J Cardiovasc Med (Hagerstown) 2021; 22:929-936. [PMID: 34482325 PMCID: PMC10414158 DOI: 10.2459/jcm.0000000000001250] [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: 03/11/2021] [Revised: 06/03/2021] [Accepted: 08/08/2021] [Indexed: 11/05/2022]
Abstract
AIM To correlate 3-D Echo and CMR RV parameters and to verify whether they are similarly related to the clinical conditions of patients with pulmonary arterial hypertension (PAH), a disease in which the RV plays a crucial prognostic role. METHODS We enrolled 34 consecutive PAH patients followed by our PAH clinics. All patients underwent a 3-D Echo and CMR assessment of RV volumes and functions in the same day. The presence or absence of correlation between major findings was investigated; functional RV parameters were also analyzed in relation to 6-min walking test (6MWT) results and BNP/Nt-proBNP plasma levels. Twenty-four subjects served as controls. RESULTS Good agreement was found between 3-D Echo and CMR measures of RV volumes [RV-end-diastolic volume (r = 0.72, P < 0.0001), RV-end-systolic volume (ESV) (r = 0.80, P < 0.0001)] and function [RV-EF (r = 0.73, P < 0.0001), RV-ESV/SV (r = 0.83, P = 0.001)] for all the subjects of the study. These correlations were stronger in PAH patients than in control subjects. Importantly, 3-D Echo and CMR RV-EF and RV to pulmonary arterial coupling (RV-ESV/SV) similarly correlated with BNP/Nt-proBNP levels and with functional capacity measured at 6MWT in the PAH patients group. CONCLUSIONS 3-D Echo demonstrated a significant agreement with CMR in the assessment of RV volume and function in PAH patients. Both techniques showed a similar correlation with clinical and prognostic parameters. The use of 3-D Echo should be amply boosted in the real-world clinical evaluation of PAH patients.
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Affiliation(s)
- Mariangela Lattanzio
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Michele Golino
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Maddalena Lattuada
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Claudia Raineri
- Division of Cardiology, Città della Salute e della Scienza, Ospedale Molinette, Torino
| | - Annalisa Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Chiara Giuntini
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Francesca Ceriani
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Marco Curti
- Department of Diagnostic and Interventional Radiology, Ospedale di Circolo, University of Insubria, Varese
| | - Andrea Bonelli
- Division of Cardiology, Ospedali ‘Spedali Civili’, Brescia, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, Ospedale di Circolo, University of Insubria, Varese
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Ospedale di Circolo, University of Insubria, Varese
| | - Sergio Ghiringhelli
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | | | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo & Fondazione Macchi, University of Insubria, Varese
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia
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Ogo T, Shimokawahara H, Kinoshita H, Sakao S, Abe K, Matoba S, Motoki H, Takama N, Ako J, Ikeda Y, Joho S, Maki H, Saeki T, Sugano T, Tsujino I, Yoshioka K, Shiota N, Tanaka S, Yamamoto C, Tanabe N, Tatsumi K. Selexipag for the treatment of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 60:13993003.01694-2021. [PMID: 34824052 PMCID: PMC9260121 DOI: 10.1183/13993003.01694-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/04/2021] [Indexed: 11/05/2022]
Abstract
Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin-receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH.In this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary endpoint was the change in pulmonary vascular resistance (PVR) from baseline to week 20. The secondary endpoints were changes in other haemodynamic parameters, 6-min walk distance (6 WMD), Borg Dyspnoea Scale score, World Health Organisation (WHO) functional class, EuroQol 5 dimensions 5-level and N-terminal pro-brain natriuretic peptide.The change in PVR was -98.2±111.3 dyn·s·cm-5 and -4.6±163.6 dyn·s·cm-5 in the selexipag and placebo groups, respectively (mean difference, -93.5 dyn·s·cm-5; 95% confidence interval, -156.8, -30.3; p=0.006). The changes in cardiac index (p<0.001) and Borg Dyspnoea Scale score (p=0.036) were also significantly improved over placebo. 6WMD and WHO functional class were not significantly improved. The common adverse events in the selexipag group were corresponded to those generally observed following a prostacyclin analogue is administered.Selexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.
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Affiliation(s)
- Takeshi Ogo
- Division of Advanced Medical Research in Pulmonary Hypertension, Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Centre, Okayama, Okayama, Japan
| | - Hideyuki Kinoshita
- Department of Community Medicine Supporting System, Kyoto University Graduate School of Medicine, Kyoto, Kyoto, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kohtaro Abe
- Departments of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Fukuoka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Hirohiko Motoki
- Department of Cardiology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yasuhiro Ikeda
- Department of Cardiology, Yamaguchi Prefectural Grand Medical Centre, Hofu, Yamaguchi, Japan
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Hisataka Maki
- Department of Cardiology, The University of Tokyo Hospital, Tokyo, Tokyo, Japan
| | - Takahiro Saeki
- Cardiovascular Medicine, National Hospital Organization Kanazawa Medical Centre, Kanazawa, Ishikawa, Japan
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ichizo Tsujino
- Internal Medicine I, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Koichiro Yoshioka
- Department of Cardiology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Naoki Shiota
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Shinichi Tanaka
- Data Science Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Chieko Yamamoto
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan.,Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
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Abstract
Pulmonary arterial hypertension (PAH) is a progressive fatal disease. Although medical therapies have improved the outlook for these patients, there still exists a cohort of patients with PAH who are refractory to these therapies. Lung transplantation (LT), and in certain cases heart-lung transplantation (HLT), is a therapeutic option for patients with severe PAH who are receiving optimal therapy yet declining. ECMO may serve as a bridge to transplant or recovery in appropriate patients. Although, the mortality within the first 3 months after transplant is higher in PAH recipients than the other indications for LT, and the long-term survival after LT is excellent for this group of individuals. In this review, we discuss the indications for LT in PAH patients, when to refer and list patients for LT, the indications for double lung transplant (DLT) versus HLT for PAH patients, types of advanced circulatory support for severe PAH, and short and long-term outcomes in transplant recipients with PAH.
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Affiliation(s)
- Marie M Budev
- Lung and Heart Lung Transplant Program, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A -90, Cleveland, OH 44195, USA.
| | - James J Yun
- Lung Transplant Program, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Desk J4-1, Cleveland, OH 44195, USA
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Umemoto S, Abe K, Hosokawa K, Horimoto K, Saku K, Sakamoto T, Tsutsui H. Increased Pulmonary Arterial Compliance after Balloon Pulmonary Angioplasty Predicts Exercise Tolerance Improvement in Inoperable CTEPH Patients with Lower Pulmonary Arterial Pressure. Heart Lung 2021; 52:8-15. [PMID: 34801772 DOI: 10.1016/j.hrtlng.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) improved pulmonary arterial compliance (CPA) and exercise tolerance in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). OBJECTIVES To investigate whether CPA is a useful index to indicate exercise tolerance improvement by BPA in CTEPH patients. METHODS The correlation between changes in CPA and improvements in 6-minute walk distance (6MWD) by BPA was retrospectively analyzed in 70 patients (Analysis 1), and it was sequentially analyzed in 46 symptomatic patients who achieved mean pulmonary arterial pressure (mPAP)<30mmHg (Analysis 2). RESULTS We enrolled 70 patients (female/male:57/13, mean age:59 years) who underwent a total of 352 BPA sessions which significantly increased CPA (1.5±0.8 vs. 3.0±1.0 mL/mmHg) and decreased pulmonary vascular resistance (PVR) (8.0 ± 3.9 vs. 3.6 ± 1.7 wood units). The correlation coefficient between improvement in 6MWD and changes in PVR and CPA were r=0.21 (p=0.09) and r=0.14 (p=0.26) (Analysis 1). In Analysis 2, those were r=0.32 (p=0.06) and r=0.38 (p=0.02), respectively. CONCLUSIONS CPA can be a useful index to indicate the improvement in exercise tolerance by BPA in symptomatic patients with lower mPAP.
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Affiliation(s)
- Shintaro Umemoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koshin Horimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Cardiology, Matsuyama Red Cross Hospital, Ehime, Japan
| | - Keita Saku
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Sakamoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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Sung SH, Yeh WY, Chiang CE, Huang CJ, Huang WM, Chen CH, Cheng HM. The prognostic significance of the alterations of pulmonary hemodynamics in patients with pulmonary arterial hypertension: a meta-regression analysis of randomized controlled trials. Syst Rev 2021; 10:284. [PMID: 34717773 PMCID: PMC8556931 DOI: 10.1186/s13643-021-01816-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodynamic assessment in patients with pulmonary arterial hypertension (PAH) is essential for risk stratification and pharmacological management. However, the prognostic value of the hemodynamic changes after treatment is less well established. OBJECTIVES We investigated the prognostic impacts of the changes in hemodynamic indices, including mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), right atrial pressure (RAP), and cardiac output index (CI). We conducted this systematic review with meta-regression analysis on existing clinical trials. METHODS We searched and identified all relevant randomized controlled trials from multiple databases. An analogous R2 index was used to quantify the proportion of variance explained by each predictor in the association with PAH patients' prognosis. A total of 21 trials and 3306 individuals were enrolled. RESULTS The changes in mPAP, PVR, RAP, and CI were all significantly associated with the change in 6MWD (∆6MWD). The change in mPAP was with the highest explanatory power for ∆6MWD (R2 analog = 0.740). Additionally, the changes in mPAP, PVR, and CI were independently predictive of adverse clinical events. The change in mPAP had the highest explanatory power for the clinical events (R2 analog = 0.911). Furthermore, the change in PVR was with the highest explanatory power for total mortality of PAH patients (R2 analog = 0.612). CONCLUSION Hemodynamic changes after treatment, including mPAP, PVR, CI, and RAP, were significantly associated with adverse clinical events or mortality in treated PAH patients. It is recommended that further studies be conducted to evaluate the changes in hemodynamic indices to guide drug titration. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019125157.
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Affiliation(s)
- Shih-Hsien Sung
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan
| | - Wan-Yu Yeh
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan
| | - Chern-En Chiang
- Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan.,General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Jung Huang
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan
| | - Wei-Ming Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan
| | - Chen-Huan Chen
- Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan.,Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hao-Min Cheng
- Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan. .,Center for Evidence-based Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan. .,Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan. .,Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.
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Cerne JW, Pathrose A, Gordon DZ, Sarnari R, Veer M, Blaisdell J, Allen BD, Avery R, Markl M, Ragin A, Carr JC. Evaluation of Pulmonary Hypertension Using 4D Flow MRI. J Magn Reson Imaging 2021; 56:234-245. [PMID: 34694050 DOI: 10.1002/jmri.27967] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cardiac magnetic resonance imaging (MRI) is becoming an alternative to right heart catheterization (RHC) for evaluating pulmonary hypertension (PH). A need exists to further evaluate cardiac MRI's ability to characterize PH. PURPOSE To evaluate the potential for four-dimensional (4D) flow MRI-derived pulmonary artery velocities to characterize PH. STUDY TYPE Prospective case-control. POPULATION Fifty-four PH patients (56% female); 25 controls (36% female). FIELD STRENGTH/SEQUENCE 1.5 T; gradient recalled echo 4D flow and balanced steady-state free precession cardiac cine. ASSESSMENT RHC was used to derive patients' pulmonary vascular resistance (PVR). 4D flow measured blood velocities at the main, left, and right pulmonary arteries (MPA, LPA, and RPA); cine measured ejection fraction, end diastolic, and end systolic volumes (EF, EDV, and ESV). EDV and ESV were normalized (indexed) to body surface area (ESVI and EDVI). Parameters were evaluated between, and within, PH subgroups: pulmonary arterial hypertension (PAH); PH due to left heart disease (PH-LHD)/chronic lung disease (PH-CLD)/or chronic thrombo-emboli (CTE-PH). STATISTICAL TESTS Analysis of variance and Kruskal-Wallis tests compared parameters between subgroups. Pearson's r assessed velocity, PVR, and volume correlations. Significance definition: P < 0.05. RESULTS PAH peak and mean velocities were significantly lower than in controls at the LPA (36 ± 12 cm/second and 20 ± 4 cm/second vs. 59 ± 15 cm/second and 32 ± 9 cm/second). At the RPA, mean velocities were significantly lower in PAH vs. controls (27 ± 6 cm/second vs. 40 ± 9 cm/second). Peak velocities significantly correlated with right ventricular EF at the MPA (r = 0.286), RPA (r = 0.400), and LPA (r = 0.401). Peak velocity significantly correlated with right ventricular ESVI at the RPA (r = -0.355) and LPA (r = -0.316). Significant correlations between peak velocities and PVR were moderate at the LPA in PAH (r = -0.641) and in PH-LHD (r = -0.606) patients, and at the MPA in PH-CLD (r = -0.728). CTE-PH showed non-significant correlations between peak velocity and PVR at all locations. DATA CONCLUSION Preliminary findings suggest 4D flow can identify PAH and track PVR changes. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- John W Cerne
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Ashitha Pathrose
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Daniel Z Gordon
- Department of Infectious Diseases, Northwestern University, Chicago, Illinois, USA
| | - Roberto Sarnari
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Manik Veer
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Julie Blaisdell
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Bradley D Allen
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Ryan Avery
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Michael Markl
- Department of Radiology, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Ann Ragin
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - James C Carr
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
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The role of intraoperative pulmonary arterial catheterization data in determining the need for extracorporeal membrane oxygenation in lung transplantation. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:480-486. [PMID: 35096445 PMCID: PMC8762920 DOI: 10.5606/tgkdc.dergisi.2021.20485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/20/2020] [Indexed: 11/21/2022]
Abstract
Background
This study aims to investigate predictive factors of identification of the need of patients for extracorporeal membrane oxygenation support during lung transplantation.
Methods
A total of 63 patients (49 males, 14 females, mean age: 44.9±14.4 years; range, 14 to 64 years) who underwent lung transplantation in our institution between December 2016 and December 2019 were retrospectively analyzed. Demographic characteristics and perioperative clinical data of patients were recorded. After induction and pulmonary artery catheterization, cardiac output, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, pulmonary vascular resistance, systemic vascular resistance, and right atrial pressure were measured using the thermodilution technique.
Results
Thirty-three of the patients received extracorporeal membrane oxygenation support during surgery. The right atrial pressure (p<0.001), pulmonary capillary wedge pressure (p<0.002), mean pulmonary artery pressure (p<0.001), and pulmonary vascular resistance (p<0.001) were statistically significantly higher in the patients who required extracorporeal membrane oxygenation support intraoperatively. The systemic vascular resistance (p<0.032) was statistically significantly lower in the patients who required extracorporeal membrane oxygenation support intraoperatively. A mean pulmonary artery pressure of >39 mmHg (p<0.02) and a right atrial pressure of >12 mmHg (p<0.047) were independent risk factors for ECMO support intraoperatively during lung transplantation.
Conclusion
Predicting the need of intraoperative extracorporeal membrane oxygenation support is of utmost importance in timing the need for mechanical support, protecting the new graft from high mechanical ventilator pressures, and adequately maintaining hemodynamic stability.
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Maximal Exercise Testing Using the Incremental Shuttle Walking Test Can Be Used to Risk-Stratify Patients with Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2021; 18:34-43. [PMID: 32926635 PMCID: PMC7780966 DOI: 10.1513/annalsats.202005-423oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rationale: Exercise capacity predicts mortality in pulmonary arterial hypertension (PAH), but limited data exist on the routine use of maximal exercise testing. Objectives: This study evaluates a simple-to-perform maximal test (the incremental shuttle walking test) and its use in risk stratification in PAH. Methods: Consecutive patients with pulmonary hypertension were identified from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) registry (2001–2018). Thresholds for levels of risk were identified at baseline and tested at follow-up, and their incorporation into current risk stratification approaches was assessed. Results: Of 4,524 treatment-naive patients with pulmonary hypertension who underwent maximal exercise testing, 1,847 patients had PAH. A stepwise reduction in 1-year mortality was seen between levels 1 (≤30 m; 32% mortality) and 7 (340–420 m; 1% mortality) with no mortality for levels 8–12 (≥430 m) in idiopathic and connective tissue disease–related PAH. Thresholds derived at baseline of ≤180 m (>10%; high risk), 190–330 m (5–10%; intermediate risk), and ≥340 m (<5%; low risk of 1-yr mortality) were applied at follow-up and also accurately identified levels of risk. Thresholds were incorporated into the REVEAL (Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management) 2.0 risk score calculator and French low-risk approach to risk stratification, and distinct categories of risk remained. Conclusions: We have demonstrated that maximal exercise testing in PAH stratifies mortality risk at baseline and follow-up. This study highlights the potential value of the incremental shuttle walking test as an alternative to the 6-minute walking test, combining some of the advantages of maximal exercise testing and maintaining the simplicity of a simple-to-perform field test.
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Abstract
Exercise intolerance is the dominant symptom of pulmonary hypertension (PH). The gold standard for the estimation of exercise capacity is a cycle ergometer incremental cardiopulmonary exercise test (CPET). The main clinical variables generated by a CPET are peak oxygen uptake (Vo2peak), ventilatory equivalents for carbon dioxide (VE/Vco2), systolic blood pressure, oxygen (O2) pulse, and chronotropic responses. PH is associated with hyperventilation at rest and at exercise, and an increase in physiologic dead space. Maximal cardiac output depends on right ventricular function and critically determines a PH patient's exercise capacity. Dynamic arterial O2 desaturation can also depress the Vo2peak.
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47
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Boucly A, Savale L, Jaïs X, Bauer F, Bergot E, Bertoletti L, Beurnier A, Bourdin A, Bouvaist H, Bulifon S, Chabanne C, Chaouat A, Cottin V, Dauphin C, Degano B, De Groote P, Favrolt N, Feng Y, Horeau-Langlard D, Jevnikar M, Jutant EM, Liang Z, Magro P, Mauran P, Moceri P, Mornex JF, Palat S, Parent F, Picard F, Pichon J, Poubeau P, Prévot G, Renard S, Reynaud-Gaubert M, Riou M, Roblot P, Sanchez O, Seferian A, Tromeur C, Weatherald J, Simonneau G, Montani D, Humbert M, Sitbon O. Association Between Initial Treatment Strategy and Long-term Survival in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 204:842-854. [PMID: 34185620 DOI: 10.1164/rccm.202009-3698oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The relationship between initial treatment strategy and survival in pulmonary arterial hypertension (PAH) remains uncertain. Objectives: To evaluate long-term survival in PAH according to initial treatment strategy. Methods: Retrospective analysis of incident patients with idiopathic, heritable or anorexigen-induced PAH enrolled in the French Registry (01/2006 to 12/2018). Survival was assessed according to initial strategy: monotherapy, dual or triple combination (two oral medications and a parenteral prostacyclin). Results: Among 1611 enrolled patients, 984 were initiated with monotherapy, 551 with dual and 76 with triple therapy. The triple combination group was younger with fewer comorbidities but higher mortality risk. Survival was better with triple therapy (91% at 5 years) as compared to dual or monotherapy (both 61% at 5 years), p<0.001. A propensity score matching on age, sex and pulmonary vascular resistance also showed significant differences between triple and dual therapy (10-year survival 85% vs 65%). In high-risk patients (n=243), survival was better with triple therapy vs monotherapy or dual therapy, while there was no difference between monotherapy and double therapy. In intermediate-risk patients (n=1134), survival improved with increasing number of therapies. In multivariable Cox regression, triple therapy was independently associated with a lower risk of death (hazard ratio 0.29, 95% confidence interval 0.11-0.80, p=0.017). Among the 148 patients initiated with a parenteral prostacyclin, those on triple therapy had better survival than those on monotherapy or dual therapy. Conclusions: Initial triple combination therapy including parenteral prostacyclin seems to be associated with better survival in PAH, particularly in the youngest high-risk patients.
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Affiliation(s)
- Athénaïs Boucly
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Laurent Savale
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Xavier Jaïs
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Fabrice Bauer
- INSERM U1096, Heart Failure Clinic and Pulmonary Hypertension Center, Service de chirurgie cardiaque, Hôpital Charles Nicole, Rouen, France
| | | | - Laurent Bertoletti
- Université de Saint-Etienne, Jean Monnet; INSERM, Thrombosis Research Group, EA3065; CIC-CIE3, Saint-Etienne, France.,Centre Hospitalier Universitaire, Service de Médecine Interne et Thérapeutique, Saint-Etienne, France
| | - Antoine Beurnier
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Physiologie, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Arnaud Bourdin
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, Pneumonology, Montpellier, France
| | - Hélène Bouvaist
- CHU Grenoble Alpes Service de Cardiologie, 568151, Grenoble, France
| | - Sophie Bulifon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Céline Chabanne
- CHU de Rennes, Hôpital Pontchaillou, Cardiology, Rennes, France
| | - Ari Chaouat
- Centre hospitalier régional universitaire de Nancy, 26920, Département de Pneumologie Hôpital de Brabois, Nancy, France.,Université de Lorraine, 137665, Inserm UMR_S 1116, Défaillance Cardiovasculaire Aigüe et Chronique, Faculté de Médecine de Nancy, Nancy, France
| | - Vincent Cottin
- Louis Pradel University Hospital, Respiratory Medicine, Lyon, France
| | - Claire Dauphin
- Hôpital Gabriel Montpied, 55448, Service de Cardiologie et Maladies Vasculaires, Clermont-Ferrand, France
| | - Bruno Degano
- Centre Hospitalier Universitaire Grenoble Alpes, 36724, Pneumologie-Physiologie, Grenoble, France
| | - Pascal De Groote
- CHR Lille - Hôpital cardiologique, Clinique de cardiologie, Lille, France
| | - Nicolas Favrolt
- CHU François Mitterrand, Service de Pneumologie et Soins Intensifs Respiratoires, Dijon, France
| | - Yuanchao Feng
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | | | - Mitja Jevnikar
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Etienne-Marie Jutant
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Zhiying Liang
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | - Pascal Magro
- CHU de Tours, service de pneumologie, Tours, France
| | - Pierre Mauran
- Paediatric and Congenital Cardiology Unit, American Memorial Hospital, CHU Reims, Reims, France
| | | | | | | | - Florence Parent
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | | | - Jérémie Pichon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Patrice Poubeau
- CHU de La Réunion Sites Sud Saint-Pierre, 56577, Saint-Pierre, Réunion
| | | | - Sébastien Renard
- Hopital de la Timone - Deparment de Cardiologie, 375330, Marseille, France
| | | | | | - Pascal Roblot
- Department of Internal Medicine, Infectious and Tropical Diseases, Poitiers University Hospital, Poitiers, France
| | - Olivier Sanchez
- Hopital Europeen Georges Pompidou, 55647, Respiratory Unit, Paris, France
| | - Andrei Seferian
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Cécile Tromeur
- CHRU de Brest, 26990, Internal Medicine and Chest Disease, Brest, France
| | | | - Gérald Simonneau
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - David Montani
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Marc Humbert
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Olivier Sitbon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France;
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Cristo Ropero MJ, Cruz-Utrilla A, Escribano-Subias MP. Epoprostenol for the treatment of pulmonary arterial hypertension. Expert Rev Clin Pharmacol 2021; 14:1005-1013. [PMID: 34030557 DOI: 10.1080/17512433.2021.1929925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Pulmonary arterial hypertension (PAH) is a rare, progressive, and severe disease. Since the first demonstration of survival benefit of intravenous epoprostenol in monotherapy in 1996, prostanoids remain the cornerstone for PAH patients at high risk. This review is essential to understand the current situation of this drug among all the therapeutic possibilities concerning this entity.Areas covered: The aim of this article is to review the pharmacological properties of epoprostenol and to update its clinical evidence in different specific clinical scenarios. A deep literature search was carried out on the MEDLINE database for published literature before March 2021.Expert opinion: Epoprostenol is still the best treatment option for high-risk PAH patients. Nevertheless, there are many unsolved questions: drug dosing, its use in combination therapy with other pulmonary vasodilators, and the utility in PAH associated with connective tissue disease, congenital heart disease, or pulmonary veno-occlusive disease are only a few examples. Its safety and efficacy are supported by clinical trials, observational work, and experience, both as monotherapy and in combination therapy. Epoprostenol should be considered a destination treatment in high-risk patients and not only as a bridge to pulmonary transplantation. However, it remains underused in clinical practice.
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Affiliation(s)
- María José Cristo Ropero
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 De Octubre, Madrid, Spain
| | - Alejandro Cruz-Utrilla
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 De Octubre, Madrid, Spain
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Sun Y, Wang L, Meng X, Gong S, Zhao Q, Shi L, Jiang R, He J, Wu W, Li Y, Luo C, Qiu H, Li J, Yuan P, Liu J. Soluble ST2 and mixed venous oxygen saturation for prediction of mortality in patients with pulmonary hypertension. J Thorac Dis 2021; 13:3478-3488. [PMID: 34277043 PMCID: PMC8264676 DOI: 10.21037/jtd-20-2732] [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] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 04/29/2021] [Indexed: 11/09/2022]
Abstract
Background Although soluble suppression of tumorigenicity-2 (sST2) has been identified as a clinical biomarker for pulmonary hypertension (PH) by previous studies, the implication of sST2 combined with hemodynamic parameters in PH has not been well studied. This study aimed to evaluate the relationship between sST2 and hemodynamic parameters and to evaluate the predictive value of sST2 for mortality in patients with PH. Methods One hundred eighty-four incident patients with PH and 14 healthy controls were retrospectively enrolled by Shanghai Pulmonary Hospital for this retrospective study. After all patients underwent right heart catheterization, blood samples were collected and serum sST2 concentration was assessed by the Presage™ ST2 assay. Kaplan-Meier curve and Cox regression analyses were used to predict survival and the association between survival and different factors such as sST2, SvO2. Results During a follow-up of 44.9 (IQR 28.5–64.4) months, 65 patients died. The median concentration of sST2 in PH patients was 33.1 ng/mL, which is higher than that in control group (23.1 ng/mL, P=0.005). Furthermore, for PH group, the level of sST2 was higher in non-survivors than that in survivors. Cox regression analyses demonstrated that sST2 and SvO2 were independent risk factors for survival. In Kaplan-Meier curve analyses, elevated sST2 level and reduced SvO2 predicted a poor outcome for patients with PH. Conclusions Higher sST2 was independently associated with increased mortality, as well as lower SvO2 in patients with PH. Especially, the combination of higher sST2 and lower SvO2 had the strongest predictive value of mortality in patients with PH.
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Affiliation(s)
- Yuanyuan Sun
- 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
| | - Xiangrui Meng
- Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai, China
| | - Sugang Gong
- 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
| | - Lingzi Shi
- School of Clinical Medicine, Hebei Medical University, Shijiazhuang, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Wenhui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yuan Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Cijun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Hongling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jinling Li
- 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
| | - Jinming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
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50
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Kahraman BO, Yuksel E, Nalbant A, Kocak UZ, Unver B. Arm span as a predictor of the six-minute walk test in healthy children. Braz J Phys Ther 2021; 25:281-285. [PMID: 32773287 PMCID: PMC8134777 DOI: 10.1016/j.bjpt.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Six-minute walk test (6MWT) is the most used test to assess functional capacity. Including arm span in the prediction equations for 6MWT performance might be an alternative for use in traditional reference equations. OBJECTIVE The aim was to investigate the usability of arm span to predict the 6MWT distance in healthy children. METHODS 262 healthy children aged between 6 and 12 years old participated in this study. 6MWT was conducted according to the standardized protocol. Height, weight, and arm span were measured before performing the 6MWT. A multiple stepwise linear regression analysis was used to generate the regression model. RESULTS The 6MWT distance had strong positive correlations with age, arm span, height, and weight (p<0.001). There was also a very strong correlation between arm span and height (p<0.001). Age and arm span were found as significant predictors in the first regression model. These two variables explained 60.2% of the variance in the 6MWT distance. Age and height were also found as significant predictors, explaining 60.5% of the variance in the 6MWT distance. The two following formula were obtained to predict the 6MWT distance: (-23.09+(31.12×Age)+(2.39×Arm span)) or (-80.0+(28.98×Age)+(2.92×Height)). CONCLUSIONS The results suggest that the combination of arm span (or height) and age are strong predictors of the 6MWT distance in healthy children.
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Affiliation(s)
- Buse Ozcan Kahraman
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey.
| | - Ertugrul Yuksel
- Institute of Health Sciences, Dokuz Eylül University, Izmir, Turkey
| | | | - Umut Ziya Kocak
- Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
| | - Bayram Unver
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
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