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Seitler S, Dimopoulos K, Ernst S, Price LC. Medical Emergencies in Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:777-796. [PMID: 37595615 DOI: 10.1055/s-0043-1770120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
The management of acute medical emergencies in patients with pulmonary hypertension (PH) can be challenging. Patients with preexisting PH can rapidly deteriorate due to right ventricular decompensation when faced with acute physiological challenges that would usually be considered low-risk scenarios. This review considers the assessment and management of acute medical emergencies in patients with PH, encompassing both pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), acknowledging these comprise the more severe groups of PH. Management protocols are described in a systems-based approach. Respiratory emergencies include pulmonary embolism, airways disease, and pneumonia; cardiac emergencies including arrhythmia and chest pain with acute myocardial infarction are discussed, alongside PH-specific emergencies such as pulmonary artery dissection and extrinsic coronary artery compression by a dilated proximal pulmonary artery. Other emergencies including sepsis, severe gastroenteritis with dehydration, syncope, and liver failure are also considered. We propose management recommendations for medical emergencies based on available evidence, international guidelines, and expert consensus. We aim to provide advice to the specialist alongside the generalist, and emergency doctors, nurses, and acute physicians in nonspecialist centers. A multidisciplinary team approach is essential in the management of patients with PH, and communication with local and specialist PH centers is paramount. Close hemodynamic monitoring during medical emergencies in patients with preexisting PH is vital, with early referral to critical care recommended given the frequent deterioration and high mortality in this setting.
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Affiliation(s)
- Samuel Seitler
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Sabine Ernst
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Huang J, An Q, Zhang CL, He L, Wang L. Decreased low‑density lipoprotein and the presence of pulmonary arterial hypertension among newly diagnosed drug‑naïve patients with systemic lupus erythematosus: D‑dimer as a mediator. Exp Ther Med 2022; 24:595. [PMID: 35949327 PMCID: PMC9353521 DOI: 10.3892/etm.2022.11531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is commonly associated with systemic lupus erythematosus (SLE). The present study investigated the relationship between coagulation and changes in lipid parameters in newly-diagnosed patients with SLE in the presence of PAH and whether the coagulation parameters were mediators between lipids and PAH presence. A total of 301 subjects scheduled for new-onset drug-naïve SLE were consecutively enrolled. Baseline data for patients without PAH and with PAH were gathered and compared. Coagulation and lipid parameters were compared across patients without lipid regulating and anticoagulation medications. Multivariable logistic regression model was applied to examine potential predictors of PAH in SLE. The relationships between them were examined using Spearman's correlation analysis. The relationship between coagulation index and lipids with SLE-PAH was evaluated using mediation analysis. Female patients accounted for 88.0% of the 301 subjects, and the average age was 32 years (range, 25-45 years). A total of 40 patients (13.3%) had PAH, and the average pulmonary artery systolic pressure (sPAP) was 55.825±26.67 mmHg. Patients with PAH were older and had higher levels of fibrin/fibrinogen degradation products (FDP), D-dimer, C-reactive protein, lower levels of complement 3, complement 4 and 25-hydroxy vitamin D3 compared with the non-PAH group. Multivariable logistic regression analysis showed that age and D-dimer were independent predictor factors for PAH. Among patients without lipid regulating and anticoagulation medications, patients in the PAH group had higher levels of D-dimer and FDP, and lower low-density lipoprotein (LDL) levels compared with patients without PAH. There was also a positive relationship between sPAP and D-dimer and FDP, and a negative relationship between sPAP and total cholesterol and LDL. Mediation analysis indicated that 25.61% of the effect of low LDL on PAH presence in systemic lupus erythematosus was mediated by D-dimer. Overall, the effect of low LDL on SLE-PAH appeared to be mediated by D-dimer, which mediated 25.61% of this effect.
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Affiliation(s)
- Jing Huang
- Department of Rheumatism and Immunology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qi An
- Department of Rheumatism and Immunology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Cai-Lian Zhang
- Department of Pulmonary and Critical Care Medicine, Yan'an University Affiliated Hospital, Yan'an, Shaanxi 716000, P.R. China
| | - Lan He
- Department of Rheumatism and Immunology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Lei Wang
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
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Santos-Gomes J, Gandra I, Adão R, Perros F, Brás-Silva C. An Overview of Circulating Pulmonary Arterial Hypertension Biomarkers. Front Cardiovasc Med 2022; 9:924873. [PMID: 35911521 PMCID: PMC9333554 DOI: 10.3389/fcvm.2022.924873] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH), also known as Group 1 Pulmonary Hypertension (PH), is a PH subset characterized by pulmonary vascular remodeling and pulmonary arterial obstruction. PAH has an estimated incidence of 15-50 people per million in the United States and Europe, and is associated with high mortality and morbidity, with patients' survival time after diagnosis being only 2.8 years. According to current guidelines, right heart catheterization is the gold standard for diagnostic and prognostic evaluation of PAH patients. However, this technique is highly invasive, so it is not used in routine clinical practice or patient follow-up. Thereby, it is essential to find new non-invasive strategies for evaluating disease progression. Biomarkers can be an effective solution for determining PAH patient prognosis and response to therapy, and aiding in diagnostic efforts, so long as their detection is non-invasive, easy, and objective. This review aims to clarify and describe some of the potential new candidates as circulating biomarkers of PAH.
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Affiliation(s)
- Joana Santos-Gomes
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Gandra
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Adão
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Frédéric Perros
- Paris-Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERM, Université Paris-Saclay, Paris, France
- Université Paris–Saclay, AP-HP, INSERM UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Carmen Brás-Silva
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
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Circulating biomarkers in pulmonary arterial hypertension: Update and future direction. J Heart Lung Transplant 2015; 34:282-305. [DOI: 10.1016/j.healun.2014.12.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 12/29/2022] Open
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Andersen CU, Mellemkjær S, Nielsen-Kudsk JE, Bendstrup E, Hilberg O, Simonsen U. Pulmonary hypertension in chronic obstructive and interstitial lung diseases. Int J Cardiol 2013; 168:1795-804. [PMID: 23849967 DOI: 10.1016/j.ijcard.2013.06.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/25/2013] [Accepted: 06/20/2013] [Indexed: 12/27/2022]
Abstract
The purpose of the present review is to summarize the current knowledge on PH in relation to COPD and ILD from a clinical perspective with emphasis on diagnosis, biomarkers, prevalence, impact, treatment, and practical implications. PH in COPD and ILD is associated with a poor prognosis, and is considered one of the most frequent types of PH. However, the prevalence of PH among patients with COPD and ILD is not clear. The diagnosis of PH in chronic lung disease is often established by echocardiographic screening, but definitive diagnosis requires right heart catheterization, which is not systematically performed in clinical practice. Given the large number of patients with chronic lung disease, biomarkers to preclude or increase suspicion of PH are needed. NT-proBNP may be used as a rule-out test, but biomarkers with a high specificity for PH are still required. It is not known whether specific treatment with existent drugs effective in pulmonary arterial hypertension (PAH) is beneficial in lung disease related PH. Studies investigating existing PAH drugs in animal models of lung disease related PH have indicated a positive effect, and so have case reports and open label studies. However, treatment with systemically administered pulmonary vasodilators implies the risk of worsening the ventilation-perfusion mismatch in patients with lung disease. Inhaled vasodilators may be better suited for PH in lung disease, but new treatment modalities are also required.
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Abstract
Vascular birthmarks can be difficult to diagnose in the perinatal period due to varied growth characteristics and similar initial appearances. Location and type of birthmark can provide signals that extracutaneous involvement may be a concern. This article provides a baseline framework that can help diagnose, define associations and guide workup and treatment in these neonates.
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Affiliation(s)
- Kristen P Hook
- University of Minnesota, Departments of Dermatology & Pediatrics, Minneapolis, MN 55455, USA.
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Andersen CU, Mellemkjær S, Nielsen-Kudsk JE, Bendstrup E, Simonsen U, Hilberg O. Diagnostic and prognostic role of biomarkers for pulmonary hypertension in interstitial lung disease. Respir Med 2012; 106:1749-55. [DOI: 10.1016/j.rmed.2012.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 08/17/2012] [Accepted: 09/11/2012] [Indexed: 11/30/2022]
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Barrier M, Meloche J, Jacob MH, Courboulin A, Provencher S, Bonnet S. Today's and tomorrow's imaging and circulating biomarkers for pulmonary arterial hypertension. Cell Mol Life Sci 2012; 69:2805-31. [PMID: 22446747 PMCID: PMC11115077 DOI: 10.1007/s00018-012-0950-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 02/18/2012] [Accepted: 02/20/2012] [Indexed: 01/04/2023]
Abstract
The pathobiology of pulmonary arterial hypertension (PAH) involves a remodeling process in distal pulmonary arteries, as well as vasoconstriction and in situ thrombosis, leading to an increase in pulmonary vascular resistance, right heart failure and death. Its etiology may be idiopathic, but PAH is also frequently associated with underlying conditions such as connective tissue diseases. During the past decade, more than welcome novel therapies have been developed and are in development, including those increasingly targeting the remodeling process. These therapeutic options modestly increase the patients' long-term survival, now approaching 60% at 5 years. However, non-invasive tools for confirming PAH diagnosis, and assessing disease severity and response to therapy, are tragically lacking and would help to select the best treatment. After exclusion of other causes of pulmonary hypertension, a final diagnosis still relies on right heart catheterization, an invasive technique which cannot be repeated as often as an optimal follow-up might require. Similarly, other techniques and biomarkers used for assessing disease severity and response to treatment generally lack specificity and have significant limitations. In this review, imaging as well as current and future circulating biomarkers for diagnosis, prognosis, and follow-up are discussed.
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Affiliation(s)
- Marjorie Barrier
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Jolyane Meloche
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Maria Helena Jacob
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Audrey Courboulin
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
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Arunthari V, Burger CD. Utility of d-dimer in the diagnosis of patients with chronic thromboembolic pulmonary hypertension. Open Respir Med J 2009; 3:85-9. [PMID: 19572023 PMCID: PMC2703202 DOI: 10.2174/1874306400903010085] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 04/21/2009] [Accepted: 04/29/2009] [Indexed: 11/29/2022] Open
Abstract
Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of severe pulmonary hypertension (PH). D-dimer, a degradation product of fibrin, has been used as a marker for various diseases. In patients with idiopathic pulmonary arterial hypertension there is evidence to suggest that D-dimer levels are associated with disease severity; however, data regarding D-dimer in patients with CTEPH are lacking. Objective: To assess the significance of D-dimer in patients with CTEPH. Patients and Methods: Retrospective chart review of 618 patients seen at our PH clinic from 1991 to June 2008. Data collection focused on patients diagnosed with CTEPH, D-dimer levels, demographics, clinical, and hemodynamics. We compared D-dimer levels in CTEPH patients or World Health Organization (WHO) diagnostic group 4 with PH patients in WHO group 1. Results: Thirty-four patients with confirmed CTEPH were identified, of these 19 had D-dimer levels and 7 were positive. Of the 234 patients in WHO group 1 excluding patients with portopulmonary hypertension (n = 54) and pulmonary venoocclusive disease (n = 2) 97 had D-dimer levels and 52 were positive. We found an estimated sensitivity of the D-dimer test in diagnosing CTEPH was 37% while the estimated specificity was 46%. The positive predictive value and negative predictive value were 12% and 79% respectively. Conclusion: D-dimer is an insensitive and nonspecific test for the diagnosis of CTEPH. Despite a high negative predictive value D-dimer alone cannot be used to rule out CTEPH in patients with PH.
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Affiliation(s)
- Vichaya Arunthari
- Division of Pulmonary Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Shitrit D, Bendayan D, Bar-Gil-Shitrit A, Huerta M, Rudensky B, Fink G, Kramer MR. Significance of a plasma D-dimer test in patients with primary pulmonary hypertension. Chest 2002; 122:1674-8. [PMID: 12426270 DOI: 10.1378/chest.122.5.1674] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND D-dimer, a degradation product of fibrin, has been increasingly used as a marker or prognostic factor in various thrombotic diseases. OBJECTIVE To assess the significance of a d-dimer test in patients with primary pulmonary hypertension (PPH). PATIENTS AND METHODS Fourteen patients with PPH (12 women and 2 men) aged 25 to 68 years (mean +/- SD age, 50 +/- 14 years) entered the study. Plasma d-dimer was determined by Miniquant assay (Biopool International; Venture, CA) 3 +/- 5 months after the disease onset, and patients were followed up for 1 year. We compared the d-dimer levels to the demographic, clinical, and hemodynamic data of the patients. RESULTS D-dimer levels were positively correlated with New York Heart Association classification (r = 0.59, p = 0.01) and pulmonary artery pressure (r = 0.43, p = 0.03) and were negatively correlated with oxygen saturation (r = - 0.45, p = 0.03) and 6-min walk distance (r = - 0.49, p = 0.04). One-year survival was also negatively correlated with d-dimer (point-biserial r = - 0.71, p = 0.004), with a higher d-dimer value associated with poorer survival. No significant correlations were found between d-dimer values and sex, age, diffusing capacity of the lung for carbon monoxide, or cardiac index. CONCLUSION D-dimer levels may have a role in the evaluation of patients with PPH. This simple, noninvasive test may be helpful for identifying patients who are at a higher risk for severe disease.
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Affiliation(s)
- David Shitrit
- Pulmonary Institute, Rabin Medical Center, Petach-Tiqwa, Israel
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