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Montani D, Thoré P, Mignard X, Jaïs X, Boucly A, Jevnikar M, Seferian A, Jutant EM, Cottin V, Fadel E, Simonneau G, Savale L, Sitbon O, Humbert M. Clinical Phenotype and Outcomes of Pulmonary Hypertension Associated with Myeloproliferative Neoplasms: A Population-based Study. Am J Respir Crit Care Med 2023; 208:600-612. [PMID: 37311222 DOI: 10.1164/rccm.202210-1941oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/13/2023] [Indexed: 06/15/2023] Open
Abstract
Rationale: Precapillary pulmonary hypertension (PH) is a rare and largely unrecognized complication of myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (MF). Objectives: To describe characteristics and outcomes of MPN-associated PH. Methods: We report clinical, functional, and hemodynamic characteristics, classification, and outcomes of patients with PV, ET, or primary MF in the French PH registry. Measurements and Main Results: Ninety patients with MPN (42 PV, 35 ET, 13 primary MF) presented with precapillary PH with severe hemodynamic impairment, with a median mean pulmonary arterial pressure and pulmonary vascular resistance of 42 mm Hg and 6.7 Wood units, respectively, and impaired clinical conditions, with 71% in New York Heart Association functional classes III/IV and having a median 6-minute-walk distance of 310 m. Half of the patients were diagnosed with chronic thromboembolic PH (CTEPH); the other half were considered to have group 5 PH. MF was preferentially associated with group 5 PH, whereas PV and ET were generally related to CTEPH. Proximal lesions were diagnosed in half of the patients with CTEPH. Thromboendarterectomy was performed in 18 selected patients with high risk of complications (5 early deaths). Overall survival at 1, 3, and 5 years was 67%, 50%, and 34% in group 5 PH and 81%, 66%, and 42% in CTEPH, respectively. Conclusions: PH is a life-threatening condition potentially occurring in MPN. There are multiple mechanisms, with equal diagnoses of CTEPH and group 5 PH. Physicians should be aware that PH strongly affects the burden of patients with MPN, especially in group 5 PH, with unknown pathophysiological mechanisms.
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Affiliation(s)
- David Montani
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Pierre Thoré
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory Medicine, Histiocytosis National Referral Center, Hôpital Saint-Louis, Paris, France
- School of Medicine, Université Paris Cité, Paris, France
| | - Xavier Mignard
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Xavier Jaïs
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Athénaïs Boucly
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Mitja Jevnikar
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Andrei Seferian
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Etienne-Marie Jutant
- Department of Pneumology, University Hospital of Poitiers, Institut National de la Santé et de la Recherche Médicale Centre D'investigation Clinique 1402, University of Poitiers, Poitiers, France; and
| | - Vincent Cottin
- Centre Hospitalier Universitaire de Lyon Hospices Civils de Lyon, Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares, Groupement Hospitalier Est, Hôpital Louis Pradel, Bron, France
| | - Elie Fadel
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
- Department of Thoracic Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Gérald Simonneau
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Laurent Savale
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Olivier Sitbon
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies and
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Leiva O, Ren S, Neuberg D, Bhatt A, Jenkins A, Rosovsky R, Karp Leaf R, Goodarzi K, Hobbs G. Pulmonary hypertension is associated with poor cardiovascular and hematologic outcomes in patients with myeloproliferative neoplasms and cardiovascular disease. Int J Hematol 2023; 117:90-99. [PMID: 36183283 DOI: 10.1007/s12185-022-03454-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 01/07/2023]
Abstract
Cardiovascular events and hematologic progression to myelofibrosis or leukemia are leading causes of morbidity and mortality among patients with myeloproliferative neoplasms (MPN). Pulmonary hypertension (PH) is also associated with MPN and cardiovascular disease (CVD), though its prognostic significance in MPN is not well characterized. Our primary objective was to investigate the effect of PH, defined as right-ventricular systolic pressure (RVSP) ≥ 50 mmHg on echocardiogram or mean pulmonary artery pressure (mPAP) ≥ 20 on right heart catheterization, on cardiovascular and all-cause mortality and hematologic progression in patients with MPN and CVD (atrial fibrillation, heart failure hospitalization, and myocardial infarction after MPN diagnosis). Of the 197 patients included (86 ET, 80 PV, 31 PMF), 92 (47%) had PH and 98 (50%) were male. All-cause mortality (58 vs 37%, p = 0.004), cardiovascular death (35 vs 9%, p < 0.0001), and hematologic progression (23 vs 11%, p = 0.037) occurred more frequently in patients with PH. Multivariable competing-risk and proportional hazards regression showed that PH was associated with increased risk of all-cause death (adjusted hazard ratio [HR], 1.80, 95% CI 1.10-2.93), CV death (adjusted subdistribution HR 3.71, 95% CI 1.58-8.73), and hematologic progression (adjusted subdistribution HR 1.99, 95% CI 1.21-3.27).
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Department of Medicine, New York University Langone Health, New York, NY, USA
| | - Siyang Ren
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ankeet Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Jenkins
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rachel Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Rebecca Karp Leaf
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Katayoon Goodarzi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA.
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Combination Therapy With Pulmonary Vasodilatation and JAK2 Inhibition for Pulmonary Hypertension With Polycythemia Vera. CJC Open 2022; 5:90-92. [PMID: 36700179 PMCID: PMC9869346 DOI: 10.1016/j.cjco.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022] Open
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Leiva O, Hobbs G, Ravid K, Libby P. Cardiovascular Disease in Myeloproliferative Neoplasms: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:166-182. [PMID: 35818539 PMCID: PMC9270630 DOI: 10.1016/j.jaccao.2022.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 11/24/2022] Open
Abstract
Myeloproliferative neoplasms are associated with increased risk for thrombotic complications. These conditions most commonly involve somatic mutations in genes that lead to constitutive activation of the Janus-associated kinase signaling pathway (eg, Janus kinase 2, calreticulin, myeloproliferative leukemia protein). Acquired gain-of-function mutations in these genes, particularly Janus kinase 2, can cause a spectrum of disorders, ranging from clonal hematopoiesis of indeterminate potential, a recently recognized age-related promoter of cardiovascular disease, to frank hematologic malignancy. Beyond thrombosis, patients with myeloproliferative neoplasms can develop other cardiovascular conditions, including heart failure and pulmonary hypertension. The authors review the pathophysiologic mechanisms of cardiovascular complications of myeloproliferative neoplasms, which involve inflammation, prothrombotic and profibrotic factors (including transforming growth factor-beta and lysyl oxidase), and abnormal function of circulating clones of mutated leukocytes and platelets from affected individuals. Anti-inflammatory therapies may provide cardiovascular benefit in patients with myeloproliferative neoplasms, a hypothesis that requires rigorous evaluation in clinical trials.
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Key Words
- ASXL1, additional sex Combs-like 1
- CHIP, clonal hematopoiesis of indeterminate potential
- DNMT3a, DNA methyltransferase 3 alpha
- IL, interleukin
- JAK, Janus-associated kinase
- JAK2, Janus kinase 2
- LOX, lysyl oxidase
- MPL, myeloproliferative leukemia protein
- MPN, myeloproliferative neoplasm
- STAT, signal transducer and activator of transcription
- TET2, tet methylcytosine dioxygenase 2
- TGF, transforming growth factor
- atherosclerosis
- cardiovascular complications
- clonal hematopoiesis
- myeloproliferative neoplasms
- thrombosis
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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He Y, Xie M, Liu X. Dyspnoea and diffuse pulmonary nodules in a patient with pulmonary veno-occlusive disease: a case report and literature review. J Int Med Res 2021; 49:300060520986689. [PMID: 33478317 PMCID: PMC7841870 DOI: 10.1177/0300060520986689] [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] [Indexed: 11/15/2022] Open
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare type of pulmonary hypertension characterized by capillary damage or arterial pulmonary hypertension. Early lung transplantation is the only effective treatment for PVOD because of the lack of specificity in its clinical manifestations and its rapid progression and poor prognosis. A 28-year-old woman presented with exertional dyspnoea. A chest computed tomography scan revealed diffuse centrilobular ground glass opacities in both lungs, a ratio of the transverse diameter of the main pulmonary trunk to the ascending aorta of >1, and enlargement of the right ventricle and right atrium. A right atrial floating catheter test showed right ventricular pressure of 82/0/4 mmHg, mean pulmonary artery pressure of 83/34/53 mmHg, and pulmonary artery wedge pressure of 15/8/12 mmHg. A mutation was found in the eukaryotic translation initiation factor 2 alpha kinase 4 (EIF2AK4) gene. Thus, the patient was diagnosed with PVOD and subsequently given standard bosentan treatment (62.5 mg twice a day). However, after 6 months of follow-up, there was no significant improvement in the pulmonary artery pressure or activity tolerance (6-minute walking test). Therefore, cardiopulmonary transplantation was performed. Early diagnosis and timely treatment of PVOD may improve the patient’s prognosis.
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Affiliation(s)
- Yuanzhou He
- Department of Respiratory Diseases, Tongji Hospital, Key Lab of Pulmonary Diseases of Health Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Xie
- Department of Respiratory Diseases, Tongji Hospital, Key Lab of Pulmonary Diseases of Health Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiansheng Liu
- Department of Respiratory Diseases, Tongji Hospital, Key Lab of Pulmonary Diseases of Health Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Khan NA, Ahuja KA, Wang X, Chaisson NF. Evaluation of hemodynamic parameters among patients with myeloproliferative neoplasms and suspected pulmonary hypertension. Leuk Lymphoma 2021; 62:1458-1465. [PMID: 33494630 DOI: 10.1080/10428194.2020.1864351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Myeloproliferative neoplasms (MPNs) are associated with pulmonary hypertension (PH). We studied MPN patients who underwent right-heart-catheterization (RHC) to identify hemodynamic differences between MPN-subtypes. Per RHC, hemodynamics were classified as pre, post or combined pre and post-capillary PH. One-way analysis-of-variance (ANOVA) was used to compare hemodynamic differences among MPN-subtypes. Correlation of RVSP between trans-thoracic echocardiography (TTE) and RHC was evaluated. We included 68 patients. Median age was 63. Fifty-nine percent were male and 87% Caucasian. Polycythemia vera and essential thrombocythemia were the most common subtypes. On TTE, 91.5% had PH. On RHC, only 29% met criteria for pre-capillary PH. No MPN-subtype was more likely than others to have pre-capillary PH. Bland-Altman analysis showed significant intra-person variability between TTE and RHC-derived right ventricular systolic pressures. Post-capillary involvement is more common than precapillary PH in MPN. Type of PH does not appear to differ by MPN-subtype.
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Affiliation(s)
- Nauman A Khan
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Neal F Chaisson
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Lee MW, Ryu H, Choi YS, Song IC, Lee HJ, Yun HJ, Sun BJ, Jeong JO, Jo DY. Pulmonary hypertension in patients with Philadelphia-negative myeloproliferative neoplasms: a single-center retrospective analysis of 225 patients. Blood Res 2020; 55:77-84. [PMID: 32429621 PMCID: PMC7343546 DOI: 10.5045/br.2020.2020001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/16/2020] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Background The prevalence of pulmonary hypertension (PH) in myeloproliferative neoplasms (MPNs) varies among studies. We analyzed the prevalence of PH in Korean patients with Philadelphia-negative (Ph-) MPNs. Methods Medical records of patients with Ph- MPNs [essential thrombocythemia (ET), polycythemia vera (PV), or primary myelofibrosis (PMF)] visiting a single hospital between 1993 and 2019 were reviewed retrospectively. Transthoracic echocardiographic examination (TTE) results were reviewed and PH was diagnosed according to established guidelines. Results Of the 320 MPN (179 ET, 107 PV, and 34 PMF) patients, 225 (121 ET, 83 PV, and 21 PMF) underwent TTE. Of these 225 MPN patients, 19 of 121 (15.7%) ET, 9 of 83 (10.8%) PV, and 6 of 21 (28.6%) PMF patients had PH. PV patients with PH were older [71 (42‒85) vs. 61.5 (26‒91) yr, respectively; P=0.049], predominantly female (male:female ratio, 0.29 vs. 1.96, respectively; P=0.010), had lower hemoglobin levels (15.9±2.6 g/dL vs. 18.4±2.6 g/dL, respectively; P=0.010), and higher platelet counts (616.6±284.2×109/L vs. 437.7±191.7×109/L, respectively; P=0.020) than PV patients without PH. PMF patients with PH had higher monocyte counts (1.3±0.5×109/L vs. 0.8±0.4×109/L, respectively; P=0.031) than those without PH. PH was a risk factor for poor survival in PV (HR, 12.4; 95% CI, 1.8‒86.6). Conclusion PH is common in patients with Ph- MPNs and hence, careful screening for PH is warranted.
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Affiliation(s)
- Myeong-Won Lee
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyewon Ryu
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Yoon-Seok Choi
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Ik-Chan Song
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyo-Jin Lee
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hwan-Jung Yun
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Byung Joo Sun
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Deog-Yeon Jo
- Division of Hematology/Oncology, Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
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The association between pulmonary hypertension and stroke: a systematic review and meta-analysis. Int J Cardiol 2019; 303:78. [PMID: 31864793 DOI: 10.1016/j.ijcard.2019.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 11/22/2022]
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