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Kanazawa Y, Goda A, Mohri T, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Soejima K, Kohno T. Exercise pulmonary hypertension in patients with systemic sclerosis based on updated guidelines. Sci Rep 2024; 14:13358. [PMID: 38858443 PMCID: PMC11164881 DOI: 10.1038/s41598-024-63823-0] [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: 01/29/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024] Open
Abstract
Recent European guidelines have introduced the concept of exercise pulmonary hypertension (ex-PH). However, the clinical characteristics of ex-PH in systemic sclerosis (SSc) remains unknown. We aimed to investigate the characteristics of exercise pulmonary hypertension (ex-PH) in patients with systemic sclerosis (SSc), which are unknown. We retrospectively examined 77 patients with SSc who underwent symptom-limited exercise testing using a cycle ergometer with right heart catheterization at our hospital. Nineteen patients with postcapillary PH were excluded. Fifty-eight patients (median age, 63 years; 55 women) were divided into the overt-PH (n = 18, mean pulmonary arterial pressure [PAP] > 20 mmHg and pulmonary vascular resistance > 2 Wood units at rest), ex-PH (n = 19, mean PAP/cardiac output slope > 3), and non-PH (n = 21) groups. Exercise tolerance and echocardiography results were compared among the groups. Peak oxygen consumption was high in the non-PH group, intermediate in the ex-PH group, and low in the overt-PH group (14.5 vs. 13.0 vs. 12.5 mL/kg/min, p = 0.043), and the minute ventilation/peak carbon dioxide production slope was also intermediate in the ex-PH group (32.2 vs. 32.4 vs. 43.0, p = 0.003). The tricuspid annular plane systolic excursion/systolic PAP ratio decreased from non-PH to ex-PH to overt-PH (0.73 vs. 0.69 vs. 0.55 mm/mmHg, p = 0.018). In patients with SSc, exercise PH may represent an intermediate condition between not having PH and overt PH, according to the new guidelines.
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Affiliation(s)
- Yu Kanazawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Madigan S, Proudman S, Schembri D, Davies H, Adams R. Use of exercise tests in screening for pulmonary arterial hypertension in systemic sclerosis: A systematic literature review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:50-58. [PMID: 38333530 PMCID: PMC10848927 DOI: 10.1177/23971983231199148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/17/2023] [Indexed: 02/10/2024]
Abstract
Background and objective Patients with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH) have a poor prognosis, accounting for 30% of all SSc-related deaths. Guidelines recommend annual screening for PAH regardless of symptoms, as early treatment improves outcomes. Current protocols include combinations of clinical features, biomarkers, pulmonary function tests, and echocardiography. None include exercise testing, although early-stage PAH may only be evident during exercise. This systematic review assessed the performance of exercise tests in predicting the presence of PAH in patients with SSc, where PAH was confirmed through right heart catheterisation (RHC). Methods Comprehensive literature searches were performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trails, CINAHL, Scopus and Web of Science from inception to May 2023. Articles were screened for eligibility by two independent reviewers. Eligibility criteria included the use of a non-invasive exercise test to screen adult patients to detect PAH in a population without a previous diagnosis of PAH, with diagnosis confirmed by RHC. Results Eight studies met the inclusion criteria, describing at least one of three different non-invasive exercise tests: cardiopulmonary exercise test, six-minute walk test and stress Doppler echocardiography. All studies found that exercise tests had some ability to predict the presence of PAH, with sensitivity between 50% and 100% and specificity from 73% to 91%. Conclusion Exercise tests are infrequently used for screening for PAH in SSc but can predict the presence of PAH. More data are required to establish which tests are most effective.
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Affiliation(s)
- Sarah Madigan
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- Respiratory, Sleep and Ventilation Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Susanna Proudman
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- Rheumatology Unit, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - David Schembri
- Respiratory, Sleep and Ventilation Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Huw Davies
- Respiratory, Sleep and Ventilation Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- FHMRI–Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Robert Adams
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- Respiratory, Sleep and Ventilation Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- FHMRI–Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [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: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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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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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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Douschan P, Kovacs G, Sassmann T, Stadlbauer V, Avian A, Foris V, Tatscher E, Durchschein F, Rainer F, Spindelboeck W, Wagner M, Kniepeiss D, Zollner G, Bachmaier G, Fickert P, Olschewski H, Stauber RE. Pulmonary vascular disease and exercise hemodynamics in chronic liver disease. Respir Med 2022; 202:106987. [PMID: 36115317 DOI: 10.1016/j.rmed.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are severe pulmonary vascular complications of chronic liver disease and strongly associated with morbidity and mortality. The prevalence of these complications is relatively high in patients evaluated for liver transplantation, however it is virtually unknown in patients with stable chronic liver disease. METHODS We assessed the pulmonary hypertension (PH) and HPS prevalence in a prospective registry study of our liver out-patient clinic in a tertiary center. Between 2011 and 2016, consecutive patients with cirrhosis or non-cirrhotic portal hypertension were prospectively enrolled after written informed consent. We excluded patients with acute decompensation of liver disease and other causes of PH like severe chronic heart or lung diseases and chronic thromboembolic PH. HPS was diagnosed using contrast enhanced echocardiography and blood gas analysis. Patients were screened for PH using an algorithm implementing severity of dyspnea, echocardiography, cardiopulmonary exercise testing and exercise echocardiography employing a threshold of systolic pulmonary arterial pressure (SPAP) = 50 mmHg at peak exercise. If the algorithm indicated an increased PH risk, patients were invited for invasive investigations by means of right heart and hepatic vein catheter. We defined POPH as resting mPAP≥21 mmHg and PVR>3WU and PAWP<15 mmHg, mild PH as resting mPAP = 21-24 mmHg, and exercise PH as mPAP>30 mmHg and TPR >3 WU at peak exercise. RESULTS Two-hundred-five patients were enrolled (male 75%; cirrhosis 96%; median age 57 yrs). Sixty-seven patients (33%) fulfilled HPS criteria but only two (1.0%) for severe (PaO2:50-60 mmHg) or very severe HPS (PaO2<50 mmHg). In 18/77 patients (23%) undergoing exercise echocardiography, SPAP at peak exercise exceeded 50 mmHg. Finally, n = 3 (1.5%) patients were invasively diagnosed with POPH, n = 4 (2.9%) with mild PH and n = 2 with exercise PH. CONCLUSION In chronic liver disease, excluding acute decompensation and other causes of PH, POPH and severe HPS are rare findings while mild to moderate HPS and mild PH or exercise PH are more frequent.
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Affiliation(s)
- Philipp Douschan
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elisabeth Tatscher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Franziska Durchschein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
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Hossain S, Choudhury MR, Haque MM, Yeasmin S, Hossain F, Zaman MM. Functional disability and health-related quality of life among systemic sclerosis patients in Bangladesh. BMC Rheumatol 2022; 6:60. [PMID: 36175976 PMCID: PMC9524111 DOI: 10.1186/s41927-022-00291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To assess the relationship between functional disability and health-related quality of life (HRQoL) among systemic sclerosis (SSc) patients. Methodology This cross-sectional study was carried out on 78 adults who met the classification criteria for SSc defined by the American College of Rheumatology/European League of Rheumatology (ACR/EULAR)-2013. The Bangla version of Short Form 36 (SF-36) and Health Assessment Questionnaire-Disability Index (HAQ-DI) were used to measure HRQoL and functional disability in SSc patients. Results The patients' median [IQR] HAQ-DI was 1.4 [0.6–2.1], with 37.2% having a mild functional disability, 33.3 percent having a moderate functional disability, and 29.5 percent having a severe functional disability. The hygiene and activity domains of the HAQ-DI obtained the highest scores, 2.0 [0.0–3.0] and 2.0 [1.0–3.0], respectively. The Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36 had median [IQR] values of 26.2 [15.0–58.1] and 42.0 [19.6–60.6]. The highest score was 50.0 [25.0–75.0] in social functioning. The PCS of the SF-36 was moderately correlated with the HAQ-DI (rs = − 0.629, P < 0.001) and the MCS of the SF-36 was weakly correlated with the HAQ-DI ((rs = − 0.344, P < 0.001). Age, female sex, and incomplete fist closure substantially influenced functional status. Calcinosis, Raynaud's Phenomenon, and flexion contracture significantly diminished the quality of life. Conclusions Functional disability negatively affects health-related quality of life. Age, Musculoskeletal, and skin involvement are significantly associated with poor quality of life and functional disability. Therefore, treatment strategies should be aimed at reducing functional disability, which will enhance the HRQoL of SSc patients.
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Affiliation(s)
- Sigma Hossain
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag Avenue, Dhaka, Bangladesh.
| | - Minhaj Rahim Choudhury
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag Avenue, Dhaka, Bangladesh
| | - Md Mahmudul Haque
- Department of Community Medicine, National Institute of Preventive and Social Medicine (NIPSOM), Dhaka, Bangladesh
| | - Surayea Yeasmin
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag Avenue, Dhaka, Bangladesh
| | - Farzana Hossain
- National Institute of Preventive and Social Medicine (NIPSOM), Dhaka, Bangladesh
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Madonna R, Fabiani S, Morganti R, Forniti A, Biondi F, Ridolfi L, Iapoce R, Menichetti F, De Caterina R. Exercise-Induced Pulmonary Hypertension Is Associated with High Cardiovascular Risk in Patients with HIV. J Clin Med 2022; 11:2447. [PMID: 35566573 PMCID: PMC9100247 DOI: 10.3390/jcm11092447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/10/2022] Open
Abstract
Background and Aim: Pulmonary hypertension (PH) at rest can be preceded by the onset of exercise-induced PH (ExPH). We investigated its association with the cardiovascular (CV) risk score in patients with human immunodeficiency virus (HIV). Methods: In 46 consecutive patients with HIV with low (n = 43) or intermediate (n = 3) probability of resting PH, we evaluated the CV risk score based on prognostic determinants of CV risk. Diagnosis of ExPH was made by cardiopulmonary exercise test (CPET) and exercise stress echocardiogram (ESE). Results: Twenty-eight % (n = 13) of the enrolled patients had ExPH at both CPET and ESE, with good agreement between the two methods (Cohen’s kappa = 0.678). ExPH correlated directly with a higher CV score (p < 0.001). Patients with a higher CV score also had lower CD4+ T-cell counts (p = 0.001), a faster progression to acquired immunodeficiency syndrome (p < 0.001), a poor immunological response to antiretroviral therapy (p = 0.035), higher pulmonary vascular resistance (p = 0.003) and a higher right atrial area (p = 0.006). Conclusions: Isolated ExPH is associated with a high CV risk score in patients with HIV. Assessment of ExPH may better stratify CV risk in patients with HIV.
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Affiliation(s)
- Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Silvia Fabiani
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Riccardo Morganti
- Section of Statistics, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Arianna Forniti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Filippo Biondi
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Lorenzo Ridolfi
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Riccardo Iapoce
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Francesco Menichetti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Raffaele De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
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Mohri T, Goda A, Takeuchi K, Kikuchi H, Inami T, Kohno T, Sakata K, Soejima K, Satoh T. High prevalence of occult left ventricular diastolic dysfunction detected by exercise stress test in systemic sclerosis. Sci Rep 2022; 12:2423. [PMID: 35165319 PMCID: PMC8844378 DOI: 10.1038/s41598-022-06400-7] [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: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the poor prognosis of systemic sclerosis (SSc) due to the co-occurrence of left ventricular diastolic dysfunction (LVDD), presence of occult LVDD has not been sufficiently investigated. This retrospective study aimed to reveal the prevalence and determinants of occult LVDD in patients with SSc by exercise stress test. Forty-five SSc patients (age, 63 ± 13 years; men/women, 6/39) with normal pulmonary artery pressure and pulmonary artery wedge pressure (PAWP) at rest underwent a symptom-limited exercise test with right heart catheterization using a supine cycle ergometer; haemodynamic parameters at rest, leg raise and during exercise were evaluated. Occult LVDD defined PAWP ≥ 25 mmHg during exercise was seen in 13 patients (29%). Higher PAWP, lower pulmonary vascular resistance and diastolic pulmonary pressure gradient, larger left atrium at rest, and higher PAWP during leg raise (15 ± 4 vs 10 ± 4 mmHg in non-LVDD group, p < 0.001) were observed in the occult LVDD group. The area under the ROC curve for PAWP after leg raise was largest at 0.83 (95% CI: 0.70–0.95, p = 0.001). About one-third (29%) of SSc patients with normal haemodynamics at rest showed occult LVDD. A higher PAWP after leg raise could be useful for detecting occult LVDD.
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11
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Rallidis LS, Papangelopoulou K, Makavos G, Varounis C, Anthi A, Orfanos SE. Low-Dose Dobutamine Stress Echocardiography for the Early Detection of Pulmonary Arterial Hypertension in Selected Patients with Systemic Sclerosis Whose Resting Echocardiography Is Non-Diagnostic for Pulmonary Hypertension. J Clin Med 2021; 10:jcm10173972. [PMID: 34501420 PMCID: PMC8432002 DOI: 10.3390/jcm10173972] [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: 07/23/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) has limited application in systemic sclerosis (SSc). We examined DSE usefulness in revealing pulmonary arterial hypertension (PAH) in selected SSc patients whose resting echocardiography for pulmonary hypertension (PH) was non-diagnostic. METHODS Forty SSc patients underwent right heart catheterization (RHC) and, simultaneously, low-dose DSE (incremental doses up to 20 μg/kg/min). Inclusion criteria were: preserved left and right ventricular (RV) function (tricuspid annulus plane systolic excursion [TAPSE] ≥ 16 mm and tissue Doppler imaging-derived systolic velocity of tricuspid annulus [RVS'] > 10 cm/s), normal pulmonary function tests, and baseline maximal tricuspid regurgitation (TR) velocity of 2.7-3.2 m/s. RESULTS Of 36 patients who completed DSE, resting RHC diagnosed PAH in 12 patients (33.3%). At 20 μg/kg/min, patients with PAH had higher TR velocity, higher pulmonary arterial pressure measured by RHC, and lower RV inotropic response compared with patients without PAH. A cut-off value of maximal TR velocity >3.1 m/s had a sensitivity of 80%, a specificity of 84.2%, and an accuracy of 82.4% for the detection of PAH. CONCLUSIONS Low-dose DSE has a satisfactory diagnostic accuracy for the early detection of PAH in highly selected SSc patients whose baseline echocardiographic measurements for PH lie in the gray zone.
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Affiliation(s)
- Loukianos S. Rallidis
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
- Correspondence: ; Tel.: +30-210-992-9106
| | - Konstantina Papangelopoulou
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Georgios Makavos
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Christos Varounis
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Anastasia Anthi
- Second Department of Critical Care and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece;
| | - Stylianos E. Orfanos
- First Department of Critical Care and Pulmonary Hypertension Center, Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece;
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12
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The Role of Exercise Doppler Echocardiography to Unmask Pulmonary Arterial Hypertension in Selected Patients with Systemic Sclerosis and Equivocal Baseline Echocardiographic Values for Pulmonary Hypertension. Diagnostics (Basel) 2021; 11:diagnostics11071200. [PMID: 34359284 PMCID: PMC8307336 DOI: 10.3390/diagnostics11071200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 02/06/2023] Open
Abstract
Recently, a lower mean pulmonary arterial pressure (PAP) cutoff of >20 mmHg for pulmonary hypertension (PH) definition has been proposed. We examined whether exercise Doppler echocardiography (EDE) can unmask PA hypertension (PAH) in systemic sclerosis (SSc) patients whose baseline echocardiography for PH is equivocal. We enrolled 49 patients with SSc who underwent treadmill EDE. Tricuspid regurgitation (TR) velocity was recorded immediately after EDE. Inotropic reserve of right ventricle (RV) was assessed by the change (post-prior to exercise) of tissue Doppler imaging-derived peak systolic velocity (S) of tricuspid annulus. Inclusion criteria comprised preserved left and RV function, and baseline TR velocity between 2.7 and 3.2 m/s. All patients had right-heart catheterization (RHC) within 48 h after EDE. From 46 patients with good quality of post-exercise TR velocity, RHC confirmed PAH in 21 (45.6%). Post-exercise TR velocity >3.4 m/s had a sensitivity of 90.5%, a specificity of 80% and an accuracy of 84.8% in detecting PAH. Inotropic reserve of RV was positively correlated with maximum achieved workload in METs (r = 0.571, p < 0.001). EDE has a good diagnostic accuracy for the identification of PAH in selected SSc patients whose baseline echocardiographic measurements for PH lie in the gray zone, and it is also potentially useful in assessing RV contractile reserve.
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Madonna R, Fabiani S, Morganti R, Forniti A, Mazzola M, Menichetti F, De Caterina R. Exercise-induced pulmonary hypertension in HIV patients: Association with poor clinical and immunological status. Vascul Pharmacol 2021; 139:106888. [PMID: 34182165 DOI: 10.1016/j.vph.2021.106888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIM Exercise-induced pulmonary hypertension (Ex-PH) may represent the earliest sign of pulmonary arterial hypertension (PAH) in human immunodeficiency virus (HIV) patients. We investigated its association with clinical and immunological status, virologic control, and response to antiviral therapy. METHODS In 32 consecutive HIV patients with either low (n = 29) or intermediate probability (n = 3) of PH at rest, we evaluated the association of isolated ExPH with: time to HIV diagnosis; CD4+ T-cell count; clinical progression to acquired immunodeficiency syndrome (AIDS); development of resistance to antiretroviral therapy (ART); HIV RNA levels; time to beginning of ART; current use of protease inhibitors; combination of ART with boosters (ritonavir or cobicistat); immuno-virologic response to ART; and ART discontinuation. Isolated ExPH at stress echocardiography (ESE) was defined as absence of PH at rest and systolic pulmonary arterial pressure (sPAP) >45 mmHg or a >20 mmHg increase during low-intensity exercise cardiac output (<10 L/min). RESULTS In our cohort, 22% (n = 7) of the enrolled population developed ExPH which was inversely related to CD4+ T-cell count (p = 0.047), time to HIV diagnosis (p = 0.014) and time to onset of ART (p = 0.041). Patients with ExPH had a worse functional class than patients without ExPH (p < 0.001). ExPH and AIDS showed a trend (p = 0.093) to a direct relationship. AIDS patients had a higher pulmonary vascular resistance compared to patients without ExPH (p = 0.020) at rest echocardiography. CONCLUSIONS The presence of isolated ExPH associates with a worse clinical status and poor immunological control in HIV patients. Assessment of ExPH by ESE may help identify subgroups of HIV patients with a propensity to develop subclinical impairment of pulmonary circulation following poor control of HIV infection.
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Affiliation(s)
- Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Silvia Fabiani
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | | | - Arianna Forniti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Raffaele De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
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14
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Leuchte HH, Halank M, Held M, Borst M, Ewert R, Klose H, Lange TJ, Meyer FJ, Skowasch D, Wilkens H, Seyfarth HJ. [Differential Diagnosis of Pulmonary Hypertension Using the Example of Collagenosis-associated PAH in the Context of Chronic Lung and Left Heart Disease]. Pneumologie 2021; 75:122-137. [PMID: 33578434 DOI: 10.1055/a-1204-3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension (PH) can be diagnosed in the context of connective tissue diseases (CTD) as well as in elderly patients with multiple comorbidities. A correct clinical differential diagnosis and classification is essential before adequate therapeutic decisions can be made. Differential diagnosis of PH in CTD comprises associated pulmonary arterial hypertension (APAH), group 2 or 3 PH (PH arising from left heart or chronic lung disease), chronic thromboembolic PH (PH) and group 5 (e. g. in the context of terminal renal insufficiency). This is also true of elderly patients in whom the decision has to be made if the increasing number of coincident diseases lead to PH or have to be interpreted as comorbidities. In this manuscript, the differential diagnosis of PH is elucidated, focusing on CTD, in the context of left heart disease and chronic lung disease. Furthermore, criteria are presented facilitating an objective approach in this context.
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Affiliation(s)
- H H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, Mitglied des DZL
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - M Held
- Klinikum Würzburg Mitte, Standort Missioklinik, Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Würzburg
| | - M Borst
- Medizinische Klinik 1 Caritas-Krankenhaus Bad Mergentheim gemeinnützige GmbH, Bad Mergentheim
| | - R Ewert
- Universitätsmedizin Greifswald. Klinik für Innere Medizin B, Bereich Pneumologie, Greifswald
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Pneumologie, Uniklinik Homburg, Homburg
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
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15
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Takase T, Taniguchi M, Hirano Y, Nakazawa G, Miyazaki S, Iwanaga Y. Sex difference in pulmonary hypertension in the evaluation by exercise echocardiography. Pulm Circ 2021; 11:2045894020988453. [PMID: 33614017 PMCID: PMC7869067 DOI: 10.1177/2045894020988453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Male patients with pulmonary hypertension have poor survival than their female counterparts. Poor right ventricular function in men may be one of the major determinants of poor prognosis. This study aimed to investigate the difference in hemodynamics during exercise between men and women by exercise echocardiography. Consecutive patients with pulmonary hypertension who underwent right heart catheterization were enrolled, and survival was analyzed. In patients who underwent exercise echocardiography, the change in tricuspid regurgitation pressure gradient during exercise was calculated at multiple stages (low-, moderate-, and high-load exercise), and the mortality was also recorded. In a total of 93 patients, although there were no differences in pulmonary artery pressure and vascular resistance between sexes, male patients showed poor survival. In patients with exercise echocardiography, change in tricuspid regurgitation pressure gradient at low-load (25 W) exercise was significantly lower in men, although that at maximum-load exercise was not different between men and women. In the Kaplan-Meier analysis, in a median follow-up duration of 1760 days, male patients and those with lower change in tricuspid regurgitation pressure gradient at low-load exercise showed poorer survival (P = 0.002 and 0.026, respectively). In the Cox proportional hazards analysis, the change in tricuspid regurgitation pressure gradient at low-load exercise was independently associated with poor survival after adjustment for age and sex. In conclusion, a lower change in tricuspid regurgitation pressure gradient at low-load exercise was observed in male patients and was a prognostic marker, which may be associated, at least in part, with poorer prognosis in male patients with pulmonary hypertension.
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Affiliation(s)
- Toru Takase
- Faculty of Medicine, Division of Cardiology, Kindai University, Osakasayama, Japan
| | - Mitsugu Taniguchi
- Division of Cardiology, Osaka Pref. Saiseikai Tondabayashi Hospital, Tondabayashi, Japan
| | - Yutaka Hirano
- Faculty of Medicine, Division of Cardiology, Kindai University, Osakasayama, Japan
| | - Gaku Nakazawa
- Faculty of Medicine, Division of Cardiology, Kindai University, Osakasayama, Japan
| | - Shunichi Miyazaki
- Division of Cardiology, Osaka Pref. Saiseikai Tondabayashi Hospital, Tondabayashi, Japan
| | - Yoshitaka Iwanaga
- Faculty of Medicine, Division of Cardiology, Kindai University, Osakasayama, Japan.,Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
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16
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Song J, Hinderhofer K, Kaufmann LT, Benjamin N, Fischer C, Grünig E, Eichstaedt CA. BMPR2 Promoter Variants Effect Gene Expression in Pulmonary Arterial Hypertension Patients. Genes (Basel) 2020; 11:genes11101168. [PMID: 33036198 PMCID: PMC7601247 DOI: 10.3390/genes11101168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 01/20/2023] Open
Abstract
Pathogenic variants have been identified in 85% of heritable pulmonary arterial hypertension (PAH) patients. These variants were mainly located in the bone morphogenetic protein receptor 2 (BMPR2) gene. However, the penetrance of BMPR2 variants was reduced leading to a disease manifestation in only 30% of carriers. In these PAH patients, further modifiers such as additional pathogenic BMPR2 promoter variants could contribute to disease manifestation. Therefore, the aim of this study was to identify BMPR2 promoter variants in PAH patients and to analyze their transcriptional effect on gene expression and disease manifestation. BMPR2 promoter variants were identified in PAH patients and cloned into plasmids. These were transfected into human pulmonary artery smooth muscle cells to determine their respective transcriptional activity. Nine different BMPR2 promoter variants were identified in seven PAH families and three idiopathic PAH patients. Seven of the variants (c.-575A>T, c.-586dupT, c.-910C>T, c.-930_-928dupGGC, c.-933_-928dupGGCGGC, c.-930_-928delGGC and c.-1141C>T) led to a significantly decreased transcriptional activity. This study identified novel BMPR2 promoter variants which may affect BMPR2 gene expression in PAH patients. They could contribute to disease manifestations at least in some families. Further studies are needed to investigate the frequency of BMPR2 promoter variants and their impact on penetrance and disease manifestation.
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Affiliation(s)
- Jie Song
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (J.S.); (K.H.); (L.T.K.); (C.F.)
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha 410011, China
- Centre for Pulmonary Hypertension, Thoraxklinik gGmbH Heidelberg at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (N.B.); (E.G.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Katrin Hinderhofer
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (J.S.); (K.H.); (L.T.K.); (C.F.)
| | - Lilian T. Kaufmann
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (J.S.); (K.H.); (L.T.K.); (C.F.)
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik gGmbH Heidelberg at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (N.B.); (E.G.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Christine Fischer
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (J.S.); (K.H.); (L.T.K.); (C.F.)
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik gGmbH Heidelberg at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (N.B.); (E.G.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Christina A. Eichstaedt
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (J.S.); (K.H.); (L.T.K.); (C.F.)
- Centre for Pulmonary Hypertension, Thoraxklinik gGmbH Heidelberg at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (N.B.); (E.G.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-396-1221; Fax: +49-6221-396-1222
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17
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Di Benedetto P, Guggino G, Manzi G, Ruscitti P, Berardicurti O, Panzera N, Grazia N, Badagliacca R, Riccieri V, Vizza CD, Radchenko G, Liakouli V, Ciccia F, Cipriani P, Giacomelli R. Interleukin-32 in systemic sclerosis, a potential new biomarker for pulmonary arterial hypertension. Arthritis Res Ther 2020; 22:127. [PMID: 32487240 PMCID: PMC7268373 DOI: 10.1186/s13075-020-02218-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a severe complication of systemic sclerosis (SSc), associated with a progressive elevation in pulmonary vascular resistance and subsequent right heart failure and death. Due to unspecific symptoms, the diagnosis of PAH is often delayed. On this basis, it is of great value to improve current diagnostic methods and develop new strategies for evaluating patients with suspected PAH. Interleukin-32 (IL-32) is a proinflammatory cytokine expressed in damaged vascular cells, and the present study aimed to assess if this cytokine could be a new biomarker of PAH during SSc. Methods The IL-32 expression was evaluated in the sera and skin samples of 18 SSc-PAH patients, 21 SSc patients without PAH, 15 patients with idiopathic PAH (iPAH) and 14 healthy controls (HCs), by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry (IHC). Receiver-operating characteristic (ROC) curves were performed to evaluate the cut-off of IL-32 in identifying patients with PAH. Furthermore, in SSc patients, correlation analyses were performed between IL-32 sera levels and mean pulmonary artery pressure (mPAP) evaluated by right heart catheterization (RHC) and systolic pulmonary artery pressure (sPAP), obtained by echocardiography. Additionally, the number of skin IL-32+ cells was correlated with modified Rodnan skin score (mRSS). Results In SSc-PAH patients, IL-32 sera levels were significantly higher when compared with SSc patients without PAH and patients affected by iPAH. The analysis of ROC curve showed that IL-32 sera levels above 11.12 pg/ml were able to predict patients with PAH (sensitivity = 90%, specificity = 100%). Furthermore, the IL-32 sera levels of patients with SSc correlated with both mPAP and sPAP. In the skin derived from SSc-PAH patients, the number of IL-32+ cells was significantly increased when compared with the skin derived from SSc patients without PAH, correlating with the mRSS. Conclusion Our study suggested that sera determination of IL-32 may be a promising approach to evaluate the presence of PAH in SSc patients and together with longitudinal future studies could help to increase the understanding how these biomarkers mirror the vascular changes and the inflammatory process during SSc.
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Affiliation(s)
- Paola Di Benedetto
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giuliana Guggino
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Onorina Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Noemi Panzera
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Nicolò Grazia
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Valeria Riccieri
- Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Ganna Radchenko
- Secondary Hypertension Department with Pulmonary Hypertension Center, State Institute National Scientific Center "MD Strazhesko Institute of Cardiology" of Ukrainian National Academy of Medical Science, Kyiv, Ukraine
| | - Vasiliki Liakouli
- Rheumatology Section, Department of Clinical and Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Ciccia
- Rheumatology Section, Department of Clinical and Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
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18
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Ni JR, Yan PJ, Liu SD, Hu Y, Yang KH, Song B, Lei JQ. Diagnostic accuracy of transthoracic echocardiography for pulmonary hypertension: a systematic review and meta-analysis. BMJ Open 2019; 9:e033084. [PMID: 31871259 PMCID: PMC6937087 DOI: 10.1136/bmjopen-2019-033084] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of transthoracic echocardiography (TTE) in patients with pulmonary hypertension (PH). DESIGN Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA Embase, Cochrane Library for clinical trials, PubMed and Web of Science were used to search studies from inception to 19 June, 2019. Studies using both TTE and right heart catheterisation (RHC) to diagnose PH were included. MAIN RESULTS A total of 27 studies involving 4386 subjects were considered as eligible for analysis. TTE had a pooled sensitivity of 85%, a pooled specificity of 74%, a pooled positive likelihood ratio of 3.2, a pooled negative likelihood ratio of 0.20, a pooled diagnostic OR of 16 and finally an area under the summary receiver operating characteristic curve of 0.88. The subgroup with the shortest time interval between TTE and RHC had the best diagnostic effect, with sensitivity, specificity and area under the curve (AUC) of 88%, 90% and 0.94, respectively. TTE had lower sensitivity (81%), specificity (61%) and AUC (0.73) in the subgroup of patients with definite lung diseases. Subgroup analysis also showed that different thresholds of TTE resulted in a different diagnostic performance in the diagnosis of PH. CONCLUSION TTE has a clinical value in diagnosing PH, although it cannot yet replace RHC considered as the gold standard. The accuracy of TTE may be improved by shortening the time interval between TTE and RHC and by developing an appropriate threshold. TTE may not be suitable to assess pulmonary arterial pressure in patients with pulmonary diseases. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019123289.
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Affiliation(s)
- Jin-Rong Ni
- The First Hospital (the First Clinical Medical School) of Lanzhou University, Lanzhou, China
- Department of Cardiovascular Surgery, the First Hospital of Lanzhou University, Lanzhou, China
- Intelligent Imaging Medical Engineering Research Center of Gansu province, Lanzhou, China
- Precision Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu province, Lanzhou, China
| | - Pei-Jing Yan
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, China
- Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence-based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Shi-Dong Liu
- The First Hospital (the First Clinical Medical School) of Lanzhou University, Lanzhou, China
- Department of Cardiovascular Surgery, the First Hospital of Lanzhou University, Lanzhou, China
| | - Yuan Hu
- Department of Cardiovascular Surgery, the First Hospital of Lanzhou University, Lanzhou, China
| | - Ke-Hu Yang
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, China
- Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence-based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Bing Song
- Department of Cardiovascular Surgery, the First Hospital of Lanzhou University, Lanzhou, China
| | - Jun-Qiang Lei
- The First Hospital (the First Clinical Medical School) of Lanzhou University, Lanzhou, China
- Intelligent Imaging Medical Engineering Research Center of Gansu province, Lanzhou, China
- Precision Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu province, Lanzhou, China
- Department of Radiology, the First Hospital of Lanzhou University, Lanzhou, China
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19
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Quinn KA, Wappel SR, Kuru T, Steen VD. Exercise Echocardiography Predicts Future Development of Pulmonary Hypertension in a High-risk Cohort of Patients with Systemic Sclerosis. J Rheumatol 2019; 47:708-713. [DOI: 10.3899/jrheum.190226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2019] [Indexed: 01/05/2023]
Abstract
Objective.To evaluate whether a positive exercise echocardiogram (EE) predicts future development of pulmonary arterial hypertension (PAH) in a high-risk cohort of patients with systemic sclerosis (SSc).Methods.Patients with SSc with features associated with an increased risk for PAH were recruited into a prospective, observational cohort. All patients underwent clinical assessment and EE. A positive EE was defined as an increase of ≥ 20 mmHg in the right ventricular systolic pressure with exercise. All patients with positive EE underwent right heart catheterization (RHC).Results.The study included 85 patients. In the positive EE cohort, 10 of 43 patients (23%) developed resting pulmonary hypertension (PH) on RHC over a mean 4-year followup period [4 with PAH, 5 with pulmonary venous hypertension (PVH), and 1 with PH associated with interstitial lung disease]. In the persistently negative EE cohort, only 3 of 42 patients (7%) developed resting PH (1 PAH, 2 PVH; p = 0.04). Of the remaining 33 patients in the positive EE group who did not develop resting PH, 22 (67%) had a persistently positive EE over an average 5-year followup period.Conclusion.In this high-risk cohort of patients with SSc, a positive EE may predict the future development of resting PH. In addition, a majority of patients may have a persistently positive EE for years without progression to resting PH. Finally, a consistently negative EE may identify patients at low risk for future PH.
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20
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Shaikh F, Anklesaria Z, Shagroni T, Saggar R, Gargani L, Bossone E, Ryan M, Channick R, Saggar R. A review of exercise pulmonary hypertension in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:225-237. [PMID: 35382504 DOI: 10.1177/2397198319851653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/06/2019] [Indexed: 11/16/2022]
Abstract
In general, pulmonary vascular disease has important negative prognostic implications, regardless of the associated condition or underlying mechanism. In this regard, systemic sclerosis is of particular interest as it is the most common connective tissue disease associated with pulmonary hypertension, and a well-recognized at-risk population. In the setting of systemic sclerosis and unexplained dyspnea, the concept of using exercise to probe for underlying pulmonary vascular disease has acquired significant interest. In theory, a diagnosis of systemic sclerosis-associated exercise pulmonary hypertension may allow for earlier therapeutic intervention and a favorable alteration in the natural history of the pulmonary vascular disease. In the context of underlying systemic sclerosis, the purpose of this article is to provide a comprehensive review of the evolving definition of exercise pulmonary hypertension, the current role and methodologies for non-invasive and invasive exercise testing, and the importance of the right ventricle.
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Affiliation(s)
- Faisal Shaikh
- University of California-Los Angeles, Los Angeles, CA, USA
| | | | | | - Rajeev Saggar
- Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Michael Ryan
- Central Coast Chest Consultants, San Luis Obispo, CA, USA
| | | | - Rajan Saggar
- University of California-Los Angeles, Los Angeles, CA, USA
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21
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Eichstaedt CA, Benjamin N, Xanthouli P, Marra AM, Grünig E. The role of rehabilitation in patients with pulmonary arterial hypertension. Curr Opin Pulm Med 2019; 25:398-404. [PMID: 31365372 DOI: 10.1097/mcp.0000000000000609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current review summarizes the latest evidence of the effects of exercise training for pulmonary hypertension patients demonstrated by six randomized controlled trails and 20 further studies. As the availability of exercise training is still limited it is important to raise awareness of the body of evidence showing the benefit for the patients and the limitations. RECENT FINDINGS The effects of exercise training on exercise capacity, hemodynamics as well as quality of life are described as well as different settings and components of exercise training. Associated adverse events are critically reviewed and strategies for avoidance of these events discussed. Lastly, the most important issues of availability and reimbursement of a specialized exercise training program are examined and the future path is outlined to improve patient access. SUMMARY The latest publications on this topic strengthen the call for international multicenter randomized controlled trials to establish the feasibility of exercise training in different healthcare systems and to enhance patient access to these programs.
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Affiliation(s)
- Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
- Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
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22
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Weatherald J, Montani D, Jevnikar M, Jaïs X, Savale L, Humbert M. Screening for pulmonary arterial hypertension in systemic sclerosis. Eur Respir Rev 2019; 28:28/153/190023. [PMID: 31366460 PMCID: PMC9488700 DOI: 10.1183/16000617.0023-2019] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/08/2019] [Indexed: 01/01/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a dreaded complication of systemic sclerosis (SSc) that occurs in ∼10% of patients. Most individuals present with severe symptoms, significant functional impairment and severe haemodynamics at diagnosis, and survival after PAH diagnosis is poor. Therefore, early diagnosis through systematic screening of asymptomatic patients has the potential to identify PAH at an early stage. Current evidence suggests that early diagnosis and treatment of PAH in patients with SSc may lead to better clinical outcomes. Annual screening may include echocardiography, but this can miss some patients due to suboptimal visualisation or insufficient tricuspid regurgitation. Other options for screening include the DETECT algorithm or the use of a combination of pulmonary function testing (forced vital capacity/diffusing capacity of the lung for carbon monoxide ratio) and N-terminal-pro-brain natriuretic peptide levels. Symptomatic patients, those with an elevated tricuspid regurgitation velocity on echocardiogram with or without secondary echocardiographic features of PAH, and those who screen positive on the DETECT or other pulmonary function test algorithms should undergo right heart catheterisation. Exercise echocardiography or cardiopulmonary exercise testing, nailfold capillaroscopy and molecular biomarkers are promising but, as yet, unproven potential options. Future screening studies should employ systematic catheterisation to define the true predictive values for PAH. Screening can detect PAH at an early stage of the disease, which permits earlier medical interventions and may improve outcomes in systemic sclerosis patients.bit.ly/2Q5akGu
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Affiliation(s)
- Jason Weatherald
- Dept of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - David Montani
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Xavier Jaïs
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France .,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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23
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Sawada H, Mitani Y, Nakayama T, Fukushima H, Kogaki S, Igarashi T, Ichida F, Ono Y, Nakanishi T, Doi S, Ishikawa S, Matsushima M, Yamada O, Saji T. Detection of Pediatric Pulmonary Arterial Hypertension by School Electrocardiography Mass Screening. Am J Respir Crit Care Med 2019; 199:1397-1406. [DOI: 10.1164/rccm.201802-0375oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Hirofumi Sawada
- Department of Pediatrics, Mie University School of Medicine, Mie, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University School of Medicine, Mie, Japan
| | - Tomotaka Nakayama
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Fukushima
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Shigetoyo Kogaki
- Department of Pediatrics, Osaka University School of Medicine, Osaka, Japan
| | - Takehiro Igarashi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Fukiko Ichida
- Department of Pediatrics, Toyama University School of Medicine, Toyama, Japan
| | - Yasuo Ono
- Department of Cardiology, Shizuoka Children’s Hospital, Shizuoka, Japan
| | - Toshio Nakanishi
- Department of Pediatric Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Shozaburo Doi
- Department of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shiro Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital, Fukuoka, Japan; and
| | - Masaki Matsushima
- Department of Pediatric Cardiology, Social Insurance Chukyo Hospital, Aichi, Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tsutomu Saji
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
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24
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Kovacs G, Olschewski H. Potential role of exercise echocardiography and right heart catheterization in the detection of early pulmonary vascular disease in patients with systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:219-224. [DOI: 10.1177/2397198319849805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/04/2019] [Indexed: 11/17/2022]
Abstract
Pulmonary vascular disease represents one of the most frequent complications in systemic sclerosis leading to increased mortality. The recognition and appropriate clinical management of early pulmonary vascular disease could significantly improve the prognosis of affected patients. Early pulmonary vascular disease is characterized by the histological signs of pulmonary vascular remodeling, mildly increased mean pulmonary arterial pressure (21–24 mmHg) at rest, abnormal pulmonary hemodynamics during exercise, decreased exercise capacity, and a high risk for development of pulmonary arterial hypertension. Pulmonary hemodynamics can be investigated during exercise by echocardiography or by right heart catheterization both representing important clinical tools for the screening and confirmation of early pulmonary vascular disease. Further studies are needed to better understand the clinical course of systemic sclerosis patients with early pulmonary vascular disease and to define the characteristics of patients that will or will not profit from pulmonary arterial hypertension treatment.
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Affiliation(s)
- Gabor Kovacs
- Division of Pulmonology, University Clinic for Internal Medicine, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, University Clinic for Internal Medicine, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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25
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Yang S, Wu J, Lei S, Song R, Cai YY, Wu SJ. Abnormal pulmonary artery systolic pressure response after exercise in systemic sclerosis patients: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2019; 98:e14342. [PMID: 30732161 PMCID: PMC6380788 DOI: 10.1097/md.0000000000014342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pulmonary artery systolic pressure (PASP) is an important parameter for detecting pulmonary arterial hypertension (PAH). The difference between rest PASP and post-exercise PASP (ΔPASP) may play a role in predicting and screening resting PAH. The aim of this study is to analyze ΔPASP in systemic sclerosis (SSc) patients with PAH or non-PAH and suggest a cutoff value of ΔPASP for detection of PAH. METHODS PubMed, Embase, and Web of Science were searched for relevant publications up to July 7, 2018. Characteristics of control, no PAH, exercise-induced PAH (EIPH) and PAH subgroups in SSc patients were extracted. R 3.5.0 with the "meta" package was used to conduct this meta-analysis. RESULTS Twelve articles involving 1279 patients were included in this study. The subgroups meta-analysis showed pooled mean ΔPASP in different subgroups: control group (8.6 mmHg, 95% CI: 6.9-10.5), no PAH group (12.2 mmHg, 95% CI: 11.2-13.2), EIPH group (26.0 mmHg, 95% CI: 24.2-27.7) and PAH group (36.2 mmHg, 95% CI: 29.7-42.7). CONCLUSION Combining the results of our study with the previous studies, an abnormal increase in PASP after exercise could indicate the development of PAH in SSc patients. In addition, if ΔPASP>29 mmHg, a high suspicion of PAH should be raised.
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Affiliation(s)
- Song Yang
- Department of Radiology, The Second XiangYa hospital, Central South University
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
| | - Jing Wu
- Department of Radiology, The Second XiangYa hospital, Central South University
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
| | - Si Lei
- Department of Respiratory Medicine, The Second XiangYa hospital, Central South University
- Research Unit of Respiratory Disease, Central South University, No. 139 Middle Renmin Road
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
| | - Rong Song
- Department of Respiratory Medicine, The Second XiangYa hospital, Central South University
- Research Unit of Respiratory Disease, Central South University, No. 139 Middle Renmin Road
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
| | - Ye-yu Cai
- Department of Radiology, The Second XiangYa hospital, Central South University
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
| | - Shang-jie Wu
- Department of Respiratory Medicine, The Second XiangYa hospital, Central South University
- Research Unit of Respiratory Disease, Central South University, No. 139 Middle Renmin Road
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, PR China
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26
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Kovacs G, Dumitrescu D, Barner A, Greiner S, Grünig E, Hager A, Köhler T, Kozlik-Feldmann R, Kruck I, Lammers AE, Mereles D, Meyer A, Meyer J, Pabst S, Seyfarth HJ, Sinning C, Sorichter S, Stähler G, Wilkens H, Held M. Definition, clinical classification and initial diagnosis of pulmonary hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:11-19. [DOI: 10.1016/j.ijcard.2018.08.083] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/26/2022]
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27
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Ferrara F, Gargani L, Armstrong WF, Agoston G, Cittadini A, Citro R, D'Alto M, D'Andrea A, Dellegrottaglie S, De Luca N, Di Salvo G, Ghio S, Grünig E, Guazzi M, Kasprzak JD, Kolias TJ, Kovacs G, Lancellotti P, La Gerche A, Limongelli G, Marra AM, Moreo A, Ostenfeld E, Pieri F, Pratali L, Rudski LG, Saggar R, Saggar R, Scalese M, Selton-Suty C, Serra W, Stanziola AA, Voilliot D, Vriz O, Naeije R, Bossone E. The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications. Heart Fail Clin 2018; 14:443-465. [PMID: 29966641 DOI: 10.1016/j.hfc.2018.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.
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Affiliation(s)
| | - Luna Gargani
- Institute of Clinical Physiology-C.N.R., Pisa, Italy
| | - William F Armstrong
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Gergely Agoston
- Department of Family Medicine, University of Szeged, Szeged, Hungary
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Rodolfo Citro
- Heart Department, University Hospital of Salerno, Salerno, Italy
| | - Michele D'Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Santo Dellegrottaglie
- Division of Cardiology, Ospedale Medico-Chirurgico Accreditato Villa dei Fiori, Acerra, Naples, Italy; Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicola De Luca
- Hypertension Research Center "CIRIAPA", Federico II University, Napoli, Italy
| | | | - Stefano Ghio
- Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic, Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Guazzi
- Heart Failure Unit, Cardiopulmonary Laboratory, University Cardiology Department, IRCCS Policlinico San Donato University Hospital, Milan, Italy
| | | | - Theodore John Kolias
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Liege, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | | | - Giuseppe Limongelli
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy; Institute of Cardiovascular Sciences, University College of London, London, UK
| | | | | | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Francesco Pieri
- Department of Heart, Thorax and Vessels, Azienda Ospedaliero Universitaria, Florence, Italy
| | | | - Lawrence G Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Rajan Saggar
- Lung and Heart-Lung Transplant Program, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; Pulmonary Hypertension Program, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Rajeev Saggar
- Lung Institute Banner University Medical Center-Phoenix, University of Arizona, Phoenix, AZ, USA
| | - Marco Scalese
- Institute of Clinical Physiology-C.N.R., Pisa, Italy
| | | | - Walter Serra
- Cardiology Unit, Surgery Department, University Hospital of Parma, Italy
| | - Anna Agnese Stanziola
- Department of Respiratory Diseases, Monaldi Hospital, University "Federico II", Naples, Italy
| | - Damien Voilliot
- Centre Hospitalier Lunéville, Service de Cardiologie, Lunéville, France
| | - Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Eduardo Bossone
- Cardiology Division, Heart Department, "Cava de' Tirreni and Amalfi Coast" Hospital, University of Salerno, Salerno, Italy.
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28
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Korff S, Enders-Gier P, Uhlmann L, Aurich M, Greiner S, Hirschberg K, Katus HA, Mereles D. Systolic pulmonary artery pressure assessed during routine exercise Doppler echocardiography: insights of a real-world setting in patients with elevated pulmonary pressures. Int J Cardiovasc Imaging 2018; 34:1215-1225. [PMID: 29552698 DOI: 10.1007/s10554-018-1340-2] [Citation(s) in RCA: 2] [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: 01/10/2018] [Accepted: 03/15/2018] [Indexed: 01/12/2023]
Abstract
Pulmonary hypertension is a marker of disease severity. Exercise Doppler echocardiography (EDE) has proven to be feasible and reliable to assess pulmonary pressure. Increase in systolic pulmonary artery pressure (sPAP) has diagnostic and prognostic value in controlled studies. However, its value when assessed during routine examination in patients with cardiopulmonary diseases and resting sPAP > 35 mmHg is not clearly defined. Clinical documentation and offline reevaluation of digitally stored EDE examinations of patients with appropriate clinical indications for EDE were analyzed. N = 278 patients with sPAP at rest > 35 mmHg met inclusion criteria. One patient was lost to follow-up. Mean age of patients was 72 ± 10 years, 178 (64%) of the study population were men. There were no relevant differences among survivors and non-survivors concerning comorbidities. Exercise performance (3.6 ± 1.2 vs. 4.9 ± 1.4 MET, p < 0.001) was lower, whereas sPAP during exercise was higher (67.3 ± 14.7 vs. 62.1 ± 13.2 mmHg, p = 0.027) in non-survivors. Univariate predictors of all-cause mortality were NYHA functional class III (HR = 2.56, p < 0.001), ≥ 2-vessels coronary artery disease (CAD) (HR = 1.93, p = 0.04), left atrial diameter > 45 mm (HR = 2.58, p < 0.001), rest sPAP > 42 mmHg (HR = 1.94, p = 0.010) and ΔsPAP increase ≥ 0.23 mmHg/Watt (HF = 1.92, p = 0.010). After multivariate analysis, NYHA functional class III (HR = 2.35, p < 0.001), LA diameter (HR = 2.28, p = 0.003) and sPAP increase ≥ 0.23 mmHg/Watt (HF = 2.19, p = 0.002) remained significant predictors of mortality, whereas a double product (HR = 0.42, p = 0.005) was associated with better prognosis. sPAP assessment during routine EDE provides relevant prognostic information comparable to findings in studies in selected populations. A higher sPAP increase at lower exercise performance shows significant association with increased of mortality.
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Affiliation(s)
- Susanne Korff
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Patricia Enders-Gier
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Matthias Aurich
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Sebastian Greiner
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Kristof Hirschberg
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany
| | - Derliz Mereles
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany.
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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30
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Naeije R, Saggar R, Badesch D, Rajagopalan S, Gargani L, Rischard F, Ferrara F, Marra AM, D' Alto M, Bull TM, Saggar R, Grünig E, Bossone E. Exercise-Induced Pulmonary Hypertension: Translating Pathophysiological Concepts Into Clinical Practice. Chest 2018; 154:10-15. [PMID: 29382472 DOI: 10.1016/j.chest.2018.01.022] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/18/2017] [Accepted: 01/05/2018] [Indexed: 11/18/2022] Open
Abstract
Exercise stress testing of the pulmonary circulation for the diagnosis of latent or early-stage pulmonary hypertension (PH) is gaining acceptance. There is emerging consensus to define exercise-induced PH by a mean pulmonary artery pressure > 30 mm Hg at a cardiac output < 10 L/min and a total pulmonary vascular resistance> 3 Wood units at maximum exercise, in the absence of PH at rest. Exercise-induced PH has been reported in association with a bone morphogenetic receptor-2 gene mutation, in systemic sclerosis, in left heart conditions, in chronic lung diseases, and in chronic pulmonary thromboembolism. Exercise-induced PH is a cause of decreased exercise capacity, may precede the development of manifest PH in a proportion of patients, and is associated with a decreased life expectancy. Exercise stress testing of the pulmonary circulation has to be dynamic and rely on measurements of the components of the pulmonary vascular equation during, not after exercise. Noninvasive imaging measurements may be sufficiently accurate in experienced hands, but suffer from lack of precision, so that invasive measurements are required for individual decision-making. Exercise-induced PH is caused either by pulmonary vasoconstriction, pulmonary vascular remodeling, or by increased upstream transmission of pulmonary venous pressure. This differential diagnosis is clinical. Left heart disease as a cause of exercise-induced PH can be further ascertained by a pulmonary artery wedge pressure above or below 20 mm Hg at a cardiac output < 10 L/min or a pulmonary artery wedge pressure-flow relationship above or below 2 mm Hg/L/min during exercise.
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Affiliation(s)
- Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Rajeev Saggar
- Department of Medicine, University of Arizona, Phoenix, AZ
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sanjay Rajagopalan
- Cardiovascular Research Institute, Case Western Reserve School of Medicine, Cleveland, OH
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Franz Rischard
- Division of Cardiology, University of Arizona, Tucson, AZ
| | - Francesco Ferrara
- 'Cava de' Tirreni and Amalfi Coast' Hospital, Division of Cardiology, Heart Department, University Hospital, Salerno, Italy
| | | | - Michele D' Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rajan Saggar
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital, Heidelberg, Germany; German Center of Lung Research, Germany
| | - Eduardo Bossone
- 'Cava de' Tirreni and Amalfi Coast' Hospital, Division of Cardiology, Heart Department, University Hospital, Salerno, Italy.
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31
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Marra AM, Grünig E. Assessment of pulmonary vascular response to exercise with Doppler-echocardiography: state of the art? J Thorac Dis 2017; 9:3607-3608. [PMID: 29268353 DOI: 10.21037/jtd.2017.09.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alberto M Marra
- Department of Cardiovascular Imaging, IRCCS S.D.N., Naples, Italy
| | - Ekkehard Grünig
- Centre for pulmonary hypertension, Thorax Clinic Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center (TLRC), the German Center for Lung Research (DZL), Heidelberg, Germany
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32
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Kovacs G, Herve P, Barbera JA, Chaouat A, Chemla D, Condliffe R, Garcia G, Grünig E, Howard L, Humbert M, Lau E, Laveneziana P, Lewis GD, Naeije R, Peacock A, Rosenkranz S, Saggar R, Ulrich S, Vizza D, Vonk Noordegraaf A, Olschewski H. An official European Respiratory Society statement: pulmonary haemodynamics during exercise. Eur Respir J 2017; 50:50/5/1700578. [DOI: 10.1183/13993003.00578-2017] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/08/2017] [Indexed: 01/18/2023]
Abstract
There is growing recognition of the clinical importance of pulmonary haemodynamics during exercise, but several questions remain to be elucidated. The goal of this statement is to assess the scientific evidence in this field in order to provide a basis for future recommendations.Right heart catheterisation is the gold standard method to assess pulmonary haemodynamics at rest and during exercise. Exercise echocardiography and cardiopulmonary exercise testing represent non-invasive tools with evolving clinical applications. The term “exercise pulmonary hypertension” may be the most adequate to describe an abnormal pulmonary haemodynamic response characterised by an excessive pulmonary arterial pressure (PAP) increase in relation to flow during exercise. Exercise pulmonary hypertension may be defined as the presence of resting mean PAP <25 mmHg and mean PAP >30 mmHg during exercise with total pulmonary resistance >3 Wood units. Exercise pulmonary hypertension represents the haemodynamic appearance of early pulmonary vascular disease, left heart disease, lung disease or a combination of these conditions. Exercise pulmonary hypertension is associated with the presence of a modest elevation of resting mean PAP and requires clinical follow-up, particularly if risk factors for pulmonary hypertension are present. There is a lack of robust clinical evidence on targeted medical therapy for exercise pulmonary hypertension.
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33
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Evaluation of end-tidal CO2 pressure at the anaerobic threshold for detecting and assessing pulmonary hypertension. Heart Vessels 2017; 32:1350-1357. [DOI: 10.1007/s00380-017-0999-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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34
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Crowe T, Jayasekera G, Peacock AJ. Non-invasive imaging of global and regional cardiac function in pulmonary hypertension. Pulm Circ 2017; 8:2045893217742000. [PMID: 29064323 PMCID: PMC5753990 DOI: 10.1177/2045893217742000] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Pulmonary hypertension (PH) is a progressive illness characterized by elevated pulmonary artery pressure; however, the main cause of mortality in PH patients is right ventricular (RV) failure. Historically, improving the hemodynamics of pulmonary circulation was the focus of treatment; however, it is now evident that cardiac response to a given level of pulmonary hemodynamic overload is variable but plays an important role in the subsequent prognosis. Non-invasive tests of RV function to determine prognosis and response to treatment in patients with PH is essential. Although the right ventricle is the focus of attention, it is clear that cardiac interaction can cause left ventricular dysfunction, thus biventricular assessment is paramount. There is also focus on the atrial chambers in their contribution to cardiac function in PH. Furthermore, there is evidence of regional dysfunction of the two ventricles in PH, so it would be useful to understand both global and regional components of dysfunction. In order to understand global and regional cardiac function in PH, the most obvious non-invasive imaging techniques are echocardiography and cardiac magnetic resonance imaging (CMRI). Both techniques have their advantages and disadvantages. Echocardiography is widely available, relatively inexpensive, provides information regarding RV function, and can be used to estimate RV pressures. CMRI, although expensive and less accessible, is the gold standard of biventricular functional measurements. The advent of 3D echocardiography and techniques including strain analysis and stress echocardiography have improved the usefulness of echocardiography while new CMRI technology allows the measurement of strain and measuring cardiac function during stress including exercise. In this review, we have analyzed the advantages and disadvantages of the two techniques and discuss pre-existing and novel forms of analysis where echocardiography and CMRI can be used to examine atrial, ventricular, and interventricular function in patients with PH at rest and under stress.
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Affiliation(s)
- Tim Crowe
- 41444 Cardiac and Vascular Imaging Group, Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Geeshath Jayasekera
- 41444 Cardiac and Vascular Imaging Group, Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Andrew J Peacock
- 41444 Cardiac and Vascular Imaging Group, Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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35
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Giacomelli R, Di Cesare E, Cipriani P, Ruscitti P, Di Sibio A, Liakouli V, Gennarelli A, Carubbi F, Splendiani A, Berardicurti O, Di Benedetto P, Ciccia F, Guggino G, Radchenko G, Triolo G, Masciocchi C. Pharmacological stress, rest perfusion and delayed enhancement cardiac magnetic resonance identifies very early cardiac involvement in systemic sclerosis patients of recent onset. Int J Rheum Dis 2017; 20:1247-1260. [DOI: 10.1111/1756-185x.13107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Roberto Giacomelli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences; Division of Cardiac Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Paola Cipriani
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Piero Ruscitti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Di Sibio
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Vasiliki Liakouli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Antonio Gennarelli
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Francesco Carubbi
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Onorina Berardicurti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Paola Di Benedetto
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Francesco Ciccia
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Giuliana Guggino
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Ganna Radchenko
- Institute of Cardiology of Ukrainian National Academy of Medical Science; Kyiv Ukraine
| | - Giovanni Triolo
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
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36
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Affiliation(s)
- Guido Claessen
- From the Department of Cardiovascular Sciences, KU Leuven, Belgium (G.C., A.L.G.); Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium (G.C.); and Baker Heart and Diabetes Institute, Melbourne, Australia (A.L.G.)
| | - Andre La Gerche
- From the Department of Cardiovascular Sciences, KU Leuven, Belgium (G.C., A.L.G.); Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium (G.C.); and Baker Heart and Diabetes Institute, Melbourne, Australia (A.L.G.)
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37
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Dumitrescu D, Nagel C, Kovacs G, Bollmann T, Halank M, Winkler J, Hellmich M, Grünig E, Olschewski H, Ewert R, Rosenkranz S. Cardiopulmonary exercise testing for detecting pulmonary arterial hypertension in systemic sclerosis. Heart 2017; 103:774-782. [PMID: 28062514 DOI: 10.1136/heartjnl-2016-309981] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a devastating disease with limited survival and occurs as a frequent complication in patients with systemic sclerosis (SSc). A definite diagnosis of PAH is obtained by right heart catheterisation (RHC); however, the initial suspicion is raised by non-invasive methods. We assessed the diagnostic accuracy of key parameters derived from cardiopulmonary exercise testing (CPET) for detecting and ruling out SSc-associated PAH. METHODS In a multicentre setting, we prospectively evaluated 173 consecutive patients with SSc without known PAH, but with clinical suspicion of PAH. Each patient underwent CPET and RHC. RESULTS RHC identified PAH in 48 patients (27.8%), postcapillary pulmonary hypertension (PH) in 10 patients (5.8%) and ruled out PH in 115 patients (66.5%). CPET parameters correlated significantly with pulmonary haemodynamics. PeakVO2 and VE/VCO2 showed highest correlations with pulmonary arterial pressure, transpulmonary pressure gradient and pulmonary vascular resistance. Several parameters showed high sensitivity and specificity for PAH detection by receiver operating characteristic analysis. However, peakVO2 showed highest diagnostic accuracy (sensitivity 87.5%, specificity 74.8% at a threshold level of 13.8 mL/min/kg). A peakVO2 of >18.7 mL/kg/min was reached by 38/173 patients (22%) and excluded PAH in our cohort (negative predictive value 1.0). A nadir VE/VCO2 ratio of >45.5 showed a positive predictive value of 1.0. Diagnostic accuracy was highest in patients with low pulmonary arterial wedge pressure (<12 mm Hg). There were no study-related serious adverse events. CONCLUSIONS CPET is a safe and valuable method in the non-invasive detection of SSc-associated PAH. It may be particularly beneficial for reducing unnecessary RHC procedures.
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Affiliation(s)
- Daniel Dumitrescu
- Herzzentrum der Universität zu Köln, Klinik III für Innere Medizin, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Germany
| | - Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg, Heidelberg, Germany.,Lung Center, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Ludwig Boltzmann Institute for Lung Vascular Research, and Medical University of Graz, Graz, Austria
| | - Tom Bollmann
- Department of Internal Medicine B-Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Greifswald, Germany
| | - Michael Halank
- Department of Internal Medicine I, Carl Gustav Carus University Hospital, Technical University of Dresden, Dresden, Germany
| | - Jörg Winkler
- Klinik für Innere Medizin I, University of Leipzig, Leipzig, Germany
| | - Martin Hellmich
- Universitätsklinikum Köln, Institut für Medizinische Statistik, Cologne, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg, Heidelberg, Germany
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Ludwig Boltzmann Institute for Lung Vascular Research, and Medical University of Graz, Graz, Austria
| | - Ralf Ewert
- Department of Internal Medicine B-Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Greifswald, Germany
| | - Stephan Rosenkranz
- Herzzentrum der Universität zu Köln, Klinik III für Innere Medizin, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Germany
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38
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D'Andrea A, Limongelli G, Baldini L, Verrengia M, Carbone A, Di Palma E, Vastarella R, Masarone D, Tagliamonte G, Riegler L, Calabrò R, Russo MG, Bossone E, Pacileo G. Exercise speckle-tracking strain imaging demonstrates impaired right ventricular contractile reserve in hypertrophic cardiomyopathy. Int J Cardiol 2017; 227:209-216. [DOI: 10.1016/j.ijcard.2016.11.150] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/06/2016] [Indexed: 11/15/2022]
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Eichstaedt CA, Song J, Benjamin N, Harutyunova S, Fischer C, Grünig E, Hinderhofer K. EIF2AK4 mutation as "second hit" in hereditary pulmonary arterial hypertension. Respir Res 2016; 17:141. [PMID: 27809840 PMCID: PMC5095976 DOI: 10.1186/s12931-016-0457-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/24/2016] [Indexed: 01/08/2023] Open
Abstract
Background Mutations in the eukaryotic translation initiation factor 2α kinase 4 (EIF2AK4) gene have recently been identified in recessively inherited veno-occlusive disease. In this study we assessed if EIF2AK4 mutations occur also in a family with autosomal dominantly inherited pulmonary arterial hypertension (HPAH) and incomplete penetrance of bone morphogenic protein receptor 2 (BMPR2) mutations. Methods Clinical examinations in a family with 10 members included physical examination, electrocardiogram, (stress)-echocardiography and lung function. Manifest PAH was confirmed by right heart catheterisation in three affected subjects. Genetic analysis was performed using a new PAH-specific gene panel analysis with next generation sequencing of all known PAH and further candidate genes. Identified variants were confirmed by Sanger sequencing. Results All living family members with manifest HPAH carried two pathogenic heterozygous mutations: a frame shift mutation in the BMPR2 gene and a novel splice site mutation in the EIF2AK4 gene. Two family members who carried the BMPR2 mutation only did not develop manifest HPAH. Conclusions This is the first study suggesting that EIF2AK4 can also contribute to autosomal dominantly inherited HPAH. Up to now it has only been identified in a recessive form of HPAH. Only those family members with a co-occurrence of two mutations developed manifest HPAH. Thus, the EIF2AK4 and BMRPR2 mutations support the “second hit” hypothesis explaining the variable penetrance of HPAH in this family. Hence, the assessment of all known PAH genes in families with a known mutation might assist in predictions about the clinical manifestation in so far non-affected mutation carriers.
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Affiliation(s)
- Christina A Eichstaedt
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Jie Song
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension at the Thoraxclinic, University Hospital Heidelberg, Heidelberg, 69126, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Katrin Hinderhofer
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a progressive disease of the pulmonary vasculature characterized by increased vascular resistance and pressure overload of the right ventricle. This review aims to describe the diagnostic and prognostic role of echocardiography in pulmonary hypertension with particular consideration of relative strengths, weaknesses and new advances. RECENT FINDINGS Although right heart catheterization (RHC) remains the gold standard, echocardiography represents an accessible and feasible real-world tool for screening, differential diagnostic, follow-up assessments and risk stratification in pulmonary hypertension. In the context of clinical scenario and multimaging approach, echocardiography provides accurate measurements of pulmonary haemodynamics, either at rest and/or during exercise, and is particularly useful in ruling out secondary causes of pulmonary hypertension and/or detecting preclinical stages. The use of advanced noninvasive imaging techniques may provide additional information in assessing right heart structure and function. SUMMARY Advances in echocardiography and the multimodality imaging approach continue to provide new understandings and opportunities for the study of the right heart-pulmonary circulation unit in pulmonary hypertension.
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41
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Parasuraman S, Walker S, Loudon BL, Gollop ND, Wilson AM, Lowery C, Frenneaux MP. Assessment of pulmonary artery pressure by echocardiography-A comprehensive review. IJC HEART & VASCULATURE 2016; 12:45-51. [PMID: 28616542 PMCID: PMC5454185 DOI: 10.1016/j.ijcha.2016.05.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/02/2016] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is a pathological haemodynamic condition defined as an increase in mean pulmonary arterial pressure ≥ 25 mmHg at rest, assessed using gold standard investigation by right heart catheterisation. Pulmonary hypertension could be a complication of cardiac or pulmonary disease, or a primary disorder of small pulmonary arteries. Elevated pulmonary pressure (PAP) is associated with increased mortality, irrespective of the aetiology. The gold standard for diagnosis is invasive right heart catheterisation, but this has its own inherent risks. In the past 30 years, immense technological improvements in echocardiography have increased its sensitivity for quantifying pulmonary artery pressure (PAP) and it is now recognised as a safe and readily available alternative to right heart catheterisation. In the future, scores combining various echo techniques can approach the gold standard in terms of sensitivity and accuracy, thereby reducing the need for repeated invasive assessments in these patients. Raised artery pulmonary pressure (PAP) is associated with increased mortality. We review the eight published echo techniques to assess PAP by echocardiography. Knowledge of all the echo techniques could avoid need for invasive tests. A scoring system combining various echo-derived measurements of PAP is needed.
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Affiliation(s)
| | - Seamus Walker
- Norwich and Norfolk University Hospital, Norwich, United Kingdom
| | - Brodie L Loudon
- University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Nicholas D Gollop
- University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Andrew M Wilson
- University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Crystal Lowery
- University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Michael P Frenneaux
- Norwich Medical School, Bob-Champion Research and Education Building, James Watson Road, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, United Kingdom
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42
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Baptista R, Serra S, Martins R, Teixeira R, Castro G, Salvador MJ, Pereira da Silva JA, Santos L, Monteiro P, Pêgo M. Exercise echocardiography for the assessment of pulmonary hypertension in systemic sclerosis: a systematic review. Arthritis Res Ther 2016; 18:153. [PMID: 27368695 PMCID: PMC4930605 DOI: 10.1186/s13075-016-1051-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/20/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) complicates the course of systemic sclerosis (SSc) and is associated with poor prognosis. The elevation of systolic pulmonary arterial pressure (sPAP) during exercise in patients with SSc with normal resting haemodynamics may anticipate the development of PAH. Exercise echocardiography (ExEcho) has been proposed as a useful technique to identify exercise-induced increases in sPAP, but it is unclear how to clinically interpret these findings. In this systematic review, we summarize the available evidence on the role of exercise echocardiography to estimate exercise-induced elevations in pulmonary and left heart filling pressures in patients with systemic sclerosis. METHODS We conducted a systematic review of the literature using MEDLINE, Cochrane Library and Web of Knowledge, using the vocabulary terms: ('systemic sclerosis' OR 'scleroderma') AND ('exercise echocardiography') AND ('pulmonary hypertension'). Studies including patients with SSc without a prior diagnosis of PAH, and subjected to exercise echocardiography were included. All searches were limited to English and were augmented by review of bibliographic references from the included studies. The quality of evidence was assessed by the Effective Public Health Practice Project system. RESULTS We identified 15 studies enrolling 1242 patients, who were mostly middle-aged and female. Several exercise methods were used (cycloergometer, treadmill and Master's two step), with different protocols and positions (supine, semi-supine, upright); definition of a positive test also varied widely. Resting estimated sPAP levels varied from 18 to 35 mm Hg, all in the normal range. The weighted means for estimated sPAP were 22.2 ± 2.9 mmHg at rest and 43.0 ± 4.3 mmHg on exercise; more than half of the studies reported mean exercise sPAP ≥40 mmHg. The assessment of left ventricular diastolic function on peak exercise was reported in a minority of studies; however, when assessed, surrogate variables of left ventricular (LV) diastolic dysfunction were associated with higher sPAP on exercise. CONCLUSIONS We found very high heterogeneity in the methods, the protocols and the estimated sPAP response to exercise. LV diastolic dysfunction was common and was associated with greater elevation of sPAP on exercise.
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Affiliation(s)
- Rui Baptista
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Sara Serra
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rui Martins
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
| | - Rogério Teixeira
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Graça Castro
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
| | - Maria João Salvador
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José António Pereira da Silva
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lèlita Santos
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Mariano Pêgo
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
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43
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Right atrial morphology and function in patients with systemic sclerosis compared to healthy controls: a two-dimensional strain study. Clin Rheumatol 2016; 35:1733-42. [DOI: 10.1007/s10067-016-3279-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/12/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
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44
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Kusunose K, Yamada H. Rest and exercise echocardiography for early detection of pulmonary hypertension. J Echocardiogr 2015; 14:2-12. [PMID: 26620849 DOI: 10.1007/s12574-015-0268-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 02/03/2023]
Abstract
Early detection of pulmonary hypertension (PH) is essential to ensure that patients receive timely and appropriate treatment for this progressive disease. Rest and exercise echocardiography has been used to screen patients in an attempt to identify early stage PH. However, current PH guidelines recommend against exercise tests because of the lack of evidence. We reviewed previous studies to discuss the current standpoint concerning rest and exercise echocardiography in PH. Around 20 exercise echocardiography studies were included to assess the cutoff value for exercise-induced pulmonary hypertension (EIPH). Approximately 40 exercise echocardiography studies were also included to evaluate the pulmonary artery pressure-flow relationship as assessed by the slope of the mean pulmonary artery pressure and cardiac output (ΔmPAP/ΔQ). There were several EIPH and ΔmPAP/ΔQ reference values in individuals with pulmonary vascular disease. We believed that assessing the ΔmPAP/ΔQ makes sense from a physiological standpoint, and the clinical value should be confirmed in future studies. Exercise echocardiography is an appealing alternative in PH. Further studies are needed to assess the prognostic value of the pulmonary artery pressure-flow relationship in high-risk subjects.
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Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, Japan.
| | - Hirotsugu Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, Japan.
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45
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Abstract
Noninvasive imaging of the heart plays an important role in the diagnosis and management of pulmonary hypertension (PH), and several well-established techniques are available for assessing performance of the right ventricle, the key determinant of patient survival. While right heart catheterisation is mandatory for establishing a diagnosis of PH, echocardiography is the most important screening tool for early detection of PH. Cardiac magnetic resonance imaging (CMRI) is also a reliable and practical tool that can be used as part of the diagnostic work-up. Echocardiography can measure a range of haemodynamic and anatomical variables (e.g. pericardial effusion and pulmonary artery pressure), whereas CMRI provides complementary information to echocardiography via high-resolution, three-dimensional imaging. Together with echocardiography and CMRI, techniques such as high-resolution computed tomography and positron emission tomography may also be valuable for screening, monitoring and follow-up assessments of patients with PH, but their clinical relevance has yet to be established. Technological advances have produced new variants of echocardiography, CMRI and positron emission tomography, and these permit closer examination of myocardial architecture, motion and deformation. Integrating these new tools into clinical practice in the future may lead to more precise noninvasive determination of diagnosis, risk and prognosis for PH.
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46
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Chia EM, Lau EMT, Xuan W, Celermajer DS, Thomas L. Exercise testing can unmask right ventricular dysfunction in systemic sclerosis patients with normal resting pulmonary artery pressure. Int J Cardiol 2015; 204:179-86. [PMID: 26681539 DOI: 10.1016/j.ijcard.2015.11.186] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/21/2015] [Accepted: 11/28/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a frequent complication of systemic sclerosis (SSc). Diagnosis usually occurs late and often after the development of irreversible right heart dysfunction. Exercise testing is increasingly used for assessing right ventricular (RV) function when resting hemodynamics do not account for symptoms. We hypothesized that SSc patients without resting pulmonary hypertension could have impaired exercise capacity and RV contractile reserve with exercise thus unmasking early RV dysfunction and pulmonary vascular disease. METHODS Treadmill exercise stress echocardiography with concurrent expired gas analysis was performed in 25 SSc patients with normal resting pulmonary arterial pressure (PAP) and healthy controls (n = 50). Additionally, controls and SSc patients were compared to those with established PAH (n = 23). Parameters of RV systolic function (RV fractional area change (FAC), Doppler tissue (DTI) s' velocity, systolic strain and strain rate (S-Sr)) were evaluated at baseline and post-exercise with the difference (Δ) being contractile reserve. RESULTS RV contractile reserve was reduced in the SSc group with normal resting PAP, compared with healthy controls (Δs': 6.1 ± 2.3 vs 8.0 ± 2.2 cm s(-1), p < 0.001; and ΔS-Sr: 2.3 ± 0.5 vs 2.6 ± 0.2s(-1), p = 0.02) in association with a significantly higher mean PAP with exercise (25.5 ± 6.6 vs 19.9 ± 7.2 mmHg, p < 0.001). PAH patients demonstrated the lowest levels of contractile reserve (Δs', Δ strain, ΔS-Sr and ΔFAC, all p < 0.05). CONCLUSION Exercise stress testing unmasks reduced RV contractile reserve in SSc patients with normal resting PAP. Subclinical RV dysfunction during exercise may be a surrogate for early pulmonary vascular disease in SSc patients.
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Affiliation(s)
| | - Edmund M T Lau
- Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Wei Xuan
- Liverpool Hospital, Sydney, Australia
| | - David S Celermajer
- Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Liza Thomas
- Liverpool Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Australia.
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