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Nakano Y, Adachi S, Imai R, Yoshida M, Shimokata S, Murohara T, Kondo T. Mortality, Recurrent Thromboembolism and Major Bleeding in Cancer-Associated and Non-Cancer Pulmonary Embolism Patients Treated With Direct Oral Anticoagulants. Circ J 2024; 88:243-250. [PMID: 33853991 DOI: 10.1253/circj.cj-20-1247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a potentially fatal form of venous thromboembolism (VTE). This study compares the mortality, incidence of recurrent VTE, and incidence of major bleeding between non-cancer and cancer-associated PE patients treated with direct oral anticoagulants (DOACs).Methods and Results:This was a retrospective, observational, single-center study involving 130 consecutive patients (87 with active cancer; 43 without cancer) who received DOAC treatment for PE between January 2016 and December 2019. Kaplan-Meier analysis showed significantly higher mortality in cancer-associated PE patients than in non-cancer patients (35/87 [40%] vs. 1/43 [2%], P<0.001, log-rank test, HR 18.6 [95% CI: 2.5-136.0]). In contrast, the cumulative incidences of recurrent VTE and major bleeding were comparable between the 2 groups. Among the cancer-associated PE patients, the incidence for the composite outcome of recurrent VTE or major bleeding was significantly higher in patients undergoing chemotherapy than in those not undergoing chemotherapy (9/37 [24%] vs. 2/50 [4%], P=0.004, log-rank test, HR 6.9 [95% CI: 1.5-32.0]). CONCLUSIONS Although cancer-associated PE patients treated with DOACs showed higher mortality compared with non-cancer patients, presumably because of the presence of cancer, the risk of recurrent VTE or major bleeding was comparable between the 2 groups. Thus, DOAC is an important treatment option for cancer-associated PE, although underlying cancer-related risks (e.g., chemotherapy) remain.
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Affiliation(s)
- Yoshihisa Nakano
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Hospital
| | - Ryo Imai
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine
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Adachi S, Kikuchi R, Shimokata S, Suzuki A, Yoshida M, Imai R, Nakano Y, Kondo T, Murohara T. Endostatin and Vascular Endothelial Growth Factor-A 165b May Contribute to Classification of Pulmonary Hypertension. Circ Rep 2021; 3:161-169. [PMID: 33738349 PMCID: PMC7956881 DOI: 10.1253/circrep.cr-20-0096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background: Pulmonary hypertension (PH) is characterized by dysregulation of small pulmonary arteries. In addition to endostatin (ES), placenta growth factor (PlGF), vascular endothelial growth factor-A (VEGF-A), and the anti-angiogenesis isoform of VEGF-A (VEGF-A165b) are associated with PH. However, the usefulness of these biomarkers in PH in unknown. We investigated whether these 4 biomarkers are related to PH classification. Methods and Results: Between July 2015 and August 2017, 33 control patients and 107 PH patients were enrolled in the study. Among the PH patients, 48 had pulmonary arterial hypertension (PAH), 5 had left heart disease-associated PH (LHD-PH), 4 had lung disease-associated PH (LD-PH), and 50 had chronic thromboembolic PH (CTEPH). Among the PAH patients, 16 had idiopathic PAH (IPAH) and 17 had connective tissue disease-associated PAH (CTD-PAH). PlGF, total VEGF-A, and VEGF-A165b levels were measured in the control and PH groups. ES was only measured in the PH group. VEGF-A165b levels were significantly higher in the LD-PH group than in the PAH, LHD-PH, and CTEPH groups (all P<0.001). PlGF levels were significantly higher in the CTD-PAH group than in the IPAH and control groups. ES levels were significantly correlated with the 6-min walk distance (P<0.001), B-type natriuretic peptide (P<0.001), and pulmonary vascular resistance (P=0.008). Conclusions: ES could detect CTD-PAH in PAH and may be an indicator of PH severity. VEGF-A165b was useful in detecting LD-PH.
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Affiliation(s)
- Shiro Adachi
- Department of Cardiology, Nagoya University Hospital Nagoya Japan
| | - Ryosuke Kikuchi
- Department of Medical Technique, Nagoya University Hospital Nagoya Japan
| | | | - Atsuo Suzuki
- Department of Medical Technique, Nagoya University Hospital Nagoya Japan
| | - Masahiro Yoshida
- Department of Cardiology, Nagoya University Hospital Nagoya Japan
| | - Ryo Imai
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Yoshihisa Nakano
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
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Nakano Y, Okumura N, Imai R, Yoshida M, Shimokata S, Adachi S, Murohara T, Kondo T. Impact of higher detection rate of residual pulmonary thromboemboli one-year after acute pulmonary embolism: modified CT scan imaging method with modified CT obstruction index. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Recently, post pulmonary embolism (PE) syndrome or chronic thromboembolic disease after acute PE, has been recognized as important long-term complications. Furthermore, patients may develop with chronic thromboembolic pulmonary hypertension.
Purpose
We aimed to evaluate the frequency of residual pulmonary thromboemboli after acute PE by using our “higher”-resolution CT scan imaging method to detect residual thromboemboli down to sub-segmental pulmonary arteries.
Methods
This study was a prospective multi-center observational study. We enrolled consecutive 34 patients with acute symptomatic PE whose informed consent was obtained, and followed up for one year. One year after the onset of acute PE, patients were referred to our hospital and multiple examination including CT scan, 6-minute walk test (6MWT), questionnaire of SF-36, echocardiography and laboratory testing were performed. Additionally, we have modified the CT obstruction index (CTOI) to quantitatively evaluate the thromboemboli down to sub-segmental pulmonary arteries.
Results
Mean age was 60.5±15.8 years, and 56% were male. No patient was categorized as low recurrent VTE risk which was caused by transient factors, one patient was associated with active cancer, and 12% had known thrombophilia. In 85% of the patients, this onset was the first obvious episode of PE. At diagnosis, elevated B-type natriuretic peptide (BNP) (≥100 pg/ml) or N-terminal (NT)-proBNP (≥500 pg/ml) was observed in 45% of the patients. Median tricuspid regurgitation peak gradient (TRPG) by echocardiography was 30.9 (19.3–50.1) mmHg. Among all, 35% of the patients received single-drug approach with DOACs. At discharge, all of the patients except two were treated with DOACs.
One year after the onset, 21% of the patient were in NYHA II and others were in NYHA I. It was notable that pulmonary thromboemboli was detected by our CT scan in 76% of the patients. Modified CTOI was median 11.9 (1.8–24.4) % as shown in the figure.
In multiple regression analysis, TRPG at diagnosis and BNP at one month were significantly associated with mCTOI (β=0.536, p=0.002 and β=−0.482, p=0.003, respectively). Additionally, lowest SpO2 during 6MWT after one year from the onset, tended to inversely associate with mCTOI (β=−0.341, p=0.052).
Conclusions
Using our modified CT scan imaging method and modified CTOI, residual pulmonary thromboemboli was able to be detected more frequently than the previous studies. Residual pulmonary thromboemboli could be one of the cause of the post PE syndrome and lead to exercise-induced desaturation.
Figures
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- Y Nakano
- Nagoya University, Graduate School of Medicine, Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya, Japan
| | - N Okumura
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - R Imai
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - M Yoshida
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - S Shimokata
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - S Adachi
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - T Murohara
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - T Kondo
- Nagoya University, Graduate School of Medicine, Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya, Japan
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Nakano Y, Imai R, Yoshida M, Shimokata S, Adachi S, Murohara T, Kondo T. Clinical course of pulmonary embolism patients treated with DOACs: comparing prognosis, recurrent thromboembolism, and major bleeding between patients with and without cancer. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Venous thromboembolism (VTE) is the third frequent acute cardiovascular syndrome in the Europe and Japan. Since direct oral anticoagulants (DOACs) are widely used now, the morbidity and mortality of pulmonary embolism (PE) patients especially associated with cancer needs to be re-evaluated.
Purpose
We evaluated the clinical course of patients with PE mainly treated with DOACs.
Methods
This retrospective observational study was conducted in a single center. The data were collected from the medical record of consecutive patients who received inpatient treatment of PE. In this study, we have compared PE patients with cancer (cancer PE) to those without cancer (non-cancer PE) and evaluated the mortality, recurrent of VTE and major bleedings.
Results
In total, 140 patients were enrolled: 94 patients were cancer-related, and 46 patients were without cancer (Table). The type of the tumor in cancer PE patients were as follows: gastric 8 (9%), esophageal 5 (5%), pancreatic 12 (13%), lung 14 (15%), lymphoma 2 (2%), gynecologic 17 (18%), renal 2 (2%), bile duct 8 (9%), colon 12 (13%), and others 17 (18%).
Kaplan-Meier curve showed that the cumulative all-cause mortality was significantly higher in the cancer PE group (35/94 (37%) vs. 2/46 (4%), P<0.001 (log rank), HR 10.3 [95% CI:2.5–43.3]). The cumulative incidence of recurrent VTE was significantly higher in the cancer PE group (7/94 (7%) vs. 0/46, P=0.03 (log rank)). There was no significant difference in the cumulative incidence of major bleeding between the cancer PE group and the non-cancer PE group (8/94 (9%) vs. 5/46 (11%)).
Conclusions
The risk of recurrent VTE was still higher in cancer PE patients compared to non-cancer PE patients, although DOACs were used. Meanwhile the incidence of major bleeding was comparable in both groups, the risk of bleeding might be acceptable with using DOACs especially in cancer PE patients.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- Y Nakano
- Nagoya University, Graduate School of Medicine, Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya, Japan
| | - R Imai
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - M Yoshida
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - S Shimokata
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - S Adachi
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - T Murohara
- Nagoya University, Graduate School of Medicine, Department of Cardiology, Nagoya, Japan
| | - T Kondo
- Nagoya University, Graduate School of Medicine, Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya, Japan
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Imai R, Adachi S, Yoshida M, Shimokata S, Nakano Y, Okumura N, Murohara T, Kondo T. Single-center prognostic validation of the risk assessment of the 2015 ESC/ERS guidelines in patients with pulmonary arterial hypertension in Japan. Can J Physiol Pharmacol 2020; 98:653-658. [PMID: 32924564 DOI: 10.1139/cjpp-2019-0640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The 2015 European Society of Cardiology/European Respiratory Society guidelines for the diagnosis and treatment of pulmonary hypertension include a multidimensional risk assessment for patients with pulmonary arterial hypertension (PAH). However, prognostic validations of this risk assessment are limited, especially outside Europe. Here, we validated the risk assessment strategy in PAH patients in our institution in Japan. Eighty consecutive PAH patients who underwent right heart catheterization between November 2006 and December 2018 were analyzed. Patients were classified as low, intermediate, or high risk by using a simplified version of the risk assessment that included seven variables: World Health Organization functional class, 6-min walking distance, peak oxygen consumption, brain natriuretic peptide, right atrial pressure, mixed venous oxygen saturation, and cardiac index. The high-risk group showed significantly higher mortality than the low- or intermediate-risk group at baseline (P < 0.001 for both comparisons), and the mortalities in the intermediate- and low-risk groups were both low (P = 0.989). At follow-up, patients who improved to or maintained a low-risk status showed better survival than those who did not (P = 0.041). Our data suggest that this risk assessment can predict higher mortality risk and long-term survival in PAH patients in Japan.
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Affiliation(s)
- Ryo Imai
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
| | - Masahiro Yoshida
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Adachi S, Shimokata S, Yoshida M, Imai R, Nakano Y, Okumura N, Suzuki S, Murohara T, Kondo T. Addition of a bilateral access form of peripheral extracorporeal membrane oxygenation rescued a patient with idiopathic pulmonary arterial hypertension who developed circulatory collapse immediately after childbirth. Pulm Circ 2020; 10:2045894020910140. [PMID: 32166020 PMCID: PMC7052457 DOI: 10.1177/2045894020910140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/05/2020] [Indexed: 11/15/2022] Open
Abstract
Pregnancy is not advised for patients with Pulmonary hypertension (PH) because of high risk of PH crisis. However, some patients have undiagnosed idiopathic pulmonary arterial hypertension (IPAH) before pregnancy. Upfront combination therapy has high efficacy for patients with IPAH. However, some patients are unable to stand until upfront combination therapy has worked sufficiently. The extracorporeal membrane oxygenation (ECMO) system has been proposed as a bridging therapy to recovery for patients with IPAH. Here, we report a case where a novel form of peripheral ECMO assist plus upfront combination therapy containing intravenous epoprostenol rescued a female patient diagnosed with IPAH just after childbirth. Following this treatment, the patient could successfully transition from intravenous epoprostenol to oral selexipag.
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Affiliation(s)
- Shiro Adachi
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Yoshida
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
| | - Ryo Imai
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Susumu Suzuki
- Department of Cardiology, Handa City Hospital, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Hirashiki A, Adachi S, Okumura N, Nakano Y, Shimokata S, Shimizu A, Arai H, Toba K, Murohara T, Kondo T. Medium-term health-related quality of life in patients with pulmonary arterial hypertension treated with goal-oriented sequential combination therapy based on exercise capacity. Health Qual Life Outcomes 2019; 17:103. [PMID: 31200710 PMCID: PMC6570916 DOI: 10.1186/s12955-019-1178-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/10/2019] [Indexed: 11/14/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) remains a life-threatening condition, despite modern therapies. We prospectively investigated the therapeutic health-related quality of life (HRQOL) effects of goal-oriented sequential combination therapy based on exercise capacity in patients newly diagnosed with PAH. Methods To examine the changes in HRQOL in PAH patients, we treated 30 patients newly diagnosed with PAH with goal-oriented sequential combination therapy based on exercise capacity. We monitored exercise capacity by cardiopulmonary exercise testing and observed the benefit of using a peak VO2 cut-off of 15 mL/kg/min to guide combination therapy. First-line treatment was an endothelin receptor antagonist (ERA); second-line treatment was the addition of a phosphodiesterase-5 inhibitor (PDE-5I). At baseline and at 3, 6, and 12 months, HRQOL was evaluated by using the eight-item Medical Outcomes Survey Short Form Health Survey. Results At 12 months, 100% of PAH patients were receiving an ERA, and 82% an ERA + PDE-5I. The mean physical component summary (PCS) score was 33.5 at baseline, 41.2 at 3 months, 40.8 at 6 months, and 42.0 at 12 months, and the mean mental component summary (MCS) scores were 45.6, 47.0, 50.0, and 50.1, respectively. PCS score was significantly greater at 3 months than at baseline (P = 0.035). MCS score was comparable at 3 months and at baseline, but was significantly greater at 6 and 12 months than at baseline (P = 0.033, P = 0.028, respectively). Thus, PCS score improved soon after initiation of therapy, and MCS score improved later. Conclusions Together, these results suggest that goal-oriented sequential combination therapy based on exercise capacity improves HRQOL in patients with PAH.
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Affiliation(s)
- Akihiro Hirashiki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan. .,Department of Cardiology, National Center for Geriatrics and Gerontology, 7-430, Morioka-cho, Obu, Aichi, Morioka, 474-8511, Japan.
| | - Shiro Adachi
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
| | - Naoki Okumura
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
| | - Atsuya Shimizu
- Department of Cardiology, National Center for Geriatrics and Gerontology, 7-430, Morioka-cho, Obu, Aichi, Morioka, 474-8511, Japan
| | - Hidenori Arai
- Department of Cardiology, National Center for Geriatrics and Gerontology, 7-430, Morioka-cho, Obu, Aichi, Morioka, 474-8511, Japan
| | - Kenji Toba
- Department of Cardiology, National Center for Geriatrics and Gerontology, 7-430, Morioka-cho, Obu, Aichi, Morioka, 474-8511, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
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Hirashiki A, Kondo T, Adachi S, Nakano Y, Kamimura Y, Shimokata S, Okumura N, Shimizu A, Washimi Y, Arai H, Murohara T. Goal-Oriented Sequential Combination Therapy Evaluated Using Cardiopulmonary Exercise Parameters for the Treatment of Newly Diagnosed Pulmonary Arterial Hypertension - Goal-Oriented Therapy Evaluated by Cardiopulmonary Exercise Testing for Pulmonary Arterial Hypertension (GOOD EYE). Circ Rep 2019; 1:303-311. [PMID: 33693154 PMCID: PMC7892494 DOI: 10.1253/circrep.cr-19-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background:
Many treatment options are available for pulmonary arterial hypertension (PAH), but specific recommendations for long-term treatment are unavailable. We compared prognosis in PAH patients receiving goal-oriented, sequential combination therapy evaluated using cardiopulmonary exercise testing (CPX) parameters or conventional empiric therapy. Methods and Results:
The Goal-Oriented Therapy Evaluated by Cardiopulmonary Exercise Testing for Pulmonary Arterial Hypertension (GOOD EYE) study was a multicenter, retrospective/prospective study in which a total of 129 patients with newly diagnosed PAH were enrolled (goal-oriented sequential combination therapy, n=42; conventional empiric therapy, n=87). Patients in the goal-oriented therapy group received sequential combination therapy, the efficacy of which was regularly evaluated using CPX parameters. Patients in the conventional empiric therapy group received conventional empiric therapy. The primary endpoint was cardiovascular death. In the goal-oriented therapy group, plasma brain natriuretic peptide, mean pulmonary arterial pressure, pulmonary vascular resistance, and 6-min walk test were significantly improved at 12 months compared with baseline. Survival in the goal-oriented therapy group at 1, 2, and 3 years (97.6%, 95.2%, and 86.0%, respectively) tended to be higher than that in the conventional empiric therapy group (P=0.082). Conclusions:
Goal-oriented sequential combination therapy evaluated using CPX parameters may be associated with a favorable prognosis compared with conventional empiric therapy in patients with newly diagnosed PAH.
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Affiliation(s)
- Akihiro Hirashiki
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan.,Department of Cardiology, National Center for Geriatrics and Gerontology Obu Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan.,Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Yoshihiro Kamimura
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Naoki Okumura
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine Nagoya Japan
| | - Atsuya Shimizu
- Department of Cardiology, National Center for Geriatrics and Gerontology Obu Japan
| | - Yukihiko Washimi
- Department of Cardiology, National Center for Geriatrics and Gerontology Obu Japan
| | - Hidenori Arai
- Department of Cardiology, National Center for Geriatrics and Gerontology Obu Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine Nagoya Japan
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Kamimura Y, Okumura N, Adachi S, Shimokata S, Tajima F, Nakano Y, Hirashiki A, Murohara T, Kondo T. Usefulness of scoring right ventricular function for assessment of prognostic factors in patients with chronic thromboembolic pulmonary hypertension. Heart Vessels 2018; 33:1220-1228. [PMID: 29704099 PMCID: PMC6133067 DOI: 10.1007/s00380-018-1168-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/20/2018] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) function is associated with prognosis in chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to establish an RV dysfunction score using RV echocardiographic parameters to clarify the clinical characteristics in patients with CTEPH and to compare RV dysfunction score with parameters such as World Health Organization (WHO) functional class, hemodynamics, exercise capacity, and plasma BNP level. We enrolled 35 inpatients with CTEPH (mean age, 62 ± 15 years, 15 males). We constructed ‘an RV dysfunction score’ calculated as the summation of each point awarded for the presence of four parameters: tricuspid annular plane systolic excursion (TAPSE) < 16 mm, 1 point; tissue Doppler-derived tricuspid lateral annular systolic velocity (S′) < 10 cm/s, 1 point; right ventricular fractional area change (RVFAC) < 35%, 1 point; and right ventricular myocardial performance index (RV-MPI) > 0.4, 1 point. TAPSE, S′, RVFAC, and RV-MPI was 18.7 ± 4.8 mm, 11.9 ± 3.1 cm/s, 33.5 ± 13.9%, and 0.39 ± 0.2, respectively. The RV dysfunction score was associated with symptom [WHO functional class (p = 0.026)], hemodynamics [mean PAP (p = 0.01), cardiac index (p = 0.009), pulmonary vascular resistance (p = 0.001), and SvO2 (p = 0.039)], exercise capacity [6-min walk distance (p = 0.046), peakVO2 (p = 0.016), and VE/VCO2 slope (p = 0.031)], and plasma BNP level (p = 0.005). This RV dysfunction score using the four RV echocardiographic parameters could be a simple and useful scoring system to evaluate prognostic factors in patients with CTEPH.
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Affiliation(s)
- Yoshihiro Kamimura
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8550, Japan
| | - Naoki Okumura
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan
| | - Shiro Adachi
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan
| | - Shigetake Shimokata
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8550, Japan
| | - Fumitaka Tajima
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8550, Japan
| | - Yoshihisa Nakano
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Hirashiki
- Department of Cardiology, National Center for Geriatrics and Gerontology, Morioka-cho 7-430, Obu, 474-8511, Japan
| | - Toyoaki Murohara
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8550, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan.
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Nakano Y, Okumura N, Adachi S, Shimokata S, Tajima F, Kamimura Y, Murohara T, Kondo T. Left ventricular end-diastolic dimension and septal e' are predictors of cardiac index at rest, while tricuspid annular plane systolic excursion is a predictor of peak oxygen uptake in patients with pulmonary hypertension. Heart Vessels 2017; 33:521-528. [PMID: 29143104 PMCID: PMC5911277 DOI: 10.1007/s00380-017-1086-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/01/2017] [Indexed: 01/07/2023]
Abstract
Little is known regarding a correlation of hemodynamics at rest or exercise capacity with echocardiographic parameters in patients with pulmonary hypertension (PH). To clarify these potential correlations, we performed transthoracic echocardiography, right heart catheterization, and cardiopulmonary exercise testing in 53 patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Left ventricular end-diastolic dimension (LVDd), early diastolic velocity of the septal mitral annulus (septal e'), tricuspid regurgitation peak gradient (TRPG), and tricuspid annular plane systolic excursion (TAPSE) were significantly correlated with cardiac index (LVDd; r = 0.477, P < 0.001, septal e'; r = 0.463, P = 0.001, TRPG; r = - 0.455, P = 0.001 and TAPSE; r = 0.406, P = 0.003, respectively). Multiple regression analysis revealed that LVDd and septal e' were significantly associated with cardiac index (CI) and stroke volume index at rest. Among the exercise capacity markers evaluated, TAPSE, TRPG, and LVDd were significantly correlated with peak oxygen uptake (TAPSE; r = 0.534, P < 0.001, TRPG; r = - 0.466, P = 0.001 and LVDd; r = 0.411, P = 0.002, respectively). Multiple regression analysis showed that TAPSE was significantly associated with peak oxygen uptake (VO2). In PAH and CTEPH patients, LVDd and septal e' were significantly associated with CI at rest, whereas TAPSE was significantly associated with peak VO2. Echocardiographic parameters may predict the prognostic factors of PAH and CTEPH patients.
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Affiliation(s)
- Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Okumura
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan
| | - Shiro Adachi
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Tajima
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Kamimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, 466-8560, Japan.
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11
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Adachi S, Okumura N, Tajima F, Shimokata S, Kamimura Y, Nakano Y, Murohara T, Kondo T. P5192Effects of balloon pulmonary angioplasty were modest in patients with inoperable central-type chronic thromboembolic pulmonary hypertension. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p5192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Okumura N, Tajima F, Nakano Y, Shimokata S, Kamimura Y, Adachi S, Kondo T, Murohara T. P1429Right ventricular myocardial performance index is a useful parameter for evaluating right ventricular ejection fraction using by computed tomography in patients with CTEPH. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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Nakano Y, Okumura N, Adachi S, Shimokata S, Kamimura Y, Tajima F, Murohara T, Kondo T. P5423Left ventricular end-diastolic dimension, septal e prime and tricuspid annular plane systolic excursion are useful for evaluating conditions of patients with pulmonary hypertension. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p5423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Hirashiki A, Adachi S, Nakano Y, Kamimura Y, Shimokata S, Takeshita K, Shimizu A, Toba K, Murohara T, Kondo T. Circulatory power and ventilatory power over time under goal-oriented sequential combination therapy for pulmonary arterial hypertension. Pulm Circ 2017; 7:448-454. [PMID: 28597753 PMCID: PMC5467935 DOI: 10.1177/2045893217703954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Many therapeutic options are available for patients with pulmonary arterial hypertension (PAH). However, little is known about the effects of sequential combination therapy on exercise capacity. Here we monitored exercise capacity by cardiopulmonary exercise testing (CPX) and observed the benefit of using a peak VO2 cutoff of 15 mL/kg/min to guide combination therapy. Thirty patients newly diagnosed with PAH were treated with goal-oriented sequential combination therapy. Endothelin receptor antagonists (ERA) were the first-line treatment, with phosphodiesterase type 5 inhibitors (PDE-5i) as the preferred combination partner. The patients underwent cardiac catheterization at baseline and after 12 months and CPX at baseline and after three, six, and 12 months. Circulatory power (CP) was defined as the product of peak O2 uptake and peak systolic blood pressure (SBP); ventilatory power (VP) was defined as peak SBP divided by the minute ventilation–CO2 production slope. After 12 months, ERA had been administered to 100% of the study patients and PDE-5i to 82%. Mean CP at baseline and after three, six, and 12 months was 1807, 2063, 2248, and 2245 mmHg·min/mL/kg, respectively, and mean VP was 2.93, 3.53, 4.16, and 3.68 mmHg, respectively. CP was greater after 6 months than at baseline (P = 0.047); VP was greater after three months than at baseline (P = 0.019) and further improved at six months compared with three months (P = 0.040). Therefore, repeated CPX assessment, including measurement of CP and VP, can provide useful information regarding the efficacy of goal-oriented treatment for PAH.
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Affiliation(s)
- Akihiro Hirashiki
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,2 Department of Cardiology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Shiro Adachi
- 3 Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Kamimura
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigetake Shimokata
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyosuke Takeshita
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsuya Shimizu
- 2 Department of Cardiology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kenji Toba
- 2 Department of Cardiology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Toyoaki Murohara
- 1 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- 3 Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Hirashiki A, Adachi S, Nakano Y, Kamimura Y, Shimokata S, Takeshita K, Murohara T, Kondo T. Effects of bosentan on peripheral endothelial function in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension. Pulm Circ 2016; 6:168-73. [PMID: 27252842 DOI: 10.1086/685715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Endothelin receptor antagonists (ERAs) have been shown to improve the prognosis of patients with pulmonary arterial hypertension (PAH). However, the effect of the oral dual ERA bosentan on peripheral endothelial dysfunction (PED), as assessed by flow-mediated vasodilation (FMD), in patients with pulmonary hypertension is not well characterized. We investigated the effect of bosentan on PED in patients with PAH or inoperable chronic thromboembolic pulmonary hypertension (CTEPH). A total of 18 patients with PAH and 8 with CTEPH were treated with bosentan. All patients underwent FMD assessment before and after 3 months of bosentan treatment. Whereas FMD increased from 6.01% ± 2.42% at baseline to 8.07% ± 3.18% after 3 months (P < 0.0001) in patients with PAH, those with CTEPH showed no change in FMD after bosentan therapy. In addition, FMD at baseline showed no correlation with pulmonary vascular resistance (r = 0.09) or plasma brain natriuretic peptide levels (r = -0.23) in patients with PAH. Bosentan treatment ameliorated PED in patients with PAH but not in those with inoperable CTEPH. In addition, FMD did not correlate with PAH severity.
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Affiliation(s)
- Akihiro Hirashiki
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Kamimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigetake Shimokata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyosuke Takeshita
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
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