Risk stratification and treatment goals in pulmonary arterial hypertension
Fabio DardiAthénaïs BouclyRaymond L. BenzaRobert P. FrantzValentina MercurioHorst OlschewskiGöran RådegranLewis J. RubinMarius M. Hoeper
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Abstract:
Risk stratification has gained an increasing role in predicting outcomes and guiding the treatment of patients with pulmonary arterial hypertension (PAH). The most predictive prognostic factors are three noninvasive parameters (World Health Organization functional class, 6-min walk distance and natriuretic peptides) that are included in all currently validated risk stratification tools. However, suffering from limitations mainly related to reduced specificity of PAH severity, these variables may not always be adequate in isolation for guiding individualised treatment decisions. Moreover, with effective combination treatment regimens and emerging PAH therapies, markers associated with pulmonary vascular remodelling are expected to become of increasing relevance in guiding the treatment of patients with PAH. While reaching a low mortality risk, assessed with a validated risk tool, remains an important treatment goal, preliminary data suggest that invasive haemodynamics and cardiac imaging may add incremental value in guiding treatment decisions.Keywords:
Risk Stratification
At the beginning of this presentation, the pulmonary hypertension was classified into three groups as follows : 1) Pulmonary pulmonary hypertension 2) Pulmonary hypertension in congenital cardiovascular disease 3) Pulmonary hypertension due to the left heart disease This (3) pulmonary hypertension due to the left heart disorder corresponds to the passive pulmonary hypertension (Wood, P.) and is accompanied by the elevation of the pulmonary venous pressure. Pulmonary hypertension due to left to right shunt in congenital cardiovascular disease (2) is equivalent to the hyperkinetic pulmonary hypertension. And pulmonary pulmonary hypertension (1) is caused by the disease of the lung and/or thorax and has possibility to develop the pulmonary heart disease defined by WHO.
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Objective To study the characteristics of hemodynamic in middle-aged patients with essential hypertension or pre-hypertension.Methods 462 subjects were divided into three groups: the hypertension group,the pre-hypertension group and the normal group.A noninvasive hemodynamic monitoring system(LIFEGARD II) was used for detecting hemodynamic indices: SV,SVR,TFC and LCWI.Hemodynamic indices of three groups were compared with each other,and hemodynamic characteristics were further analyzed in the hypertension group.Results There were significant differences in SBP,DBP,PP,MAP,SVR,SV and LCWI(P0.05) between the hypertension group and the normal group,and in SBP,PP,MAP and SVR(P0.05) between the pre-hypertension group and the normal group.An abnormal SVR level existed in 58.8% of hypertension patients.Conclusions Various degrees of hemodynamic abnormality exist in hypertension/pre-hypertension patients.Noninvasive hemodynamic examination may provide help for individualized therapy of hypertension.
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AIM: To explore the pathophysiological significance of nitric oxide(NO) and nitric oxide synthase(NOS) in congenital heart defects with pulmonary hypertension. METHODS: Twenty-four patients with congenital heart defects were divided into 3 groups: mild pulmonary hypertension group(n=8), moderate or severe pulmonary hypertension group(n=9), and non-pulmonary hypertension group(n=7). NOS mRNA expression was detected in lung tissues with reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: The NOS mRNA expression levels in the patients with moderate or severe pulmonary hypertension were much lower than those in the ones with mild-pulmonary hypertension or non-pulmonary hypertension (P 0.05). There was an inverse correlation between the NOS mRNA expression level and the pulmonary arteriopathy in the patients with pulmonary hypertension (r=-0.833, P0.01). CONCLUSION: In patients with congenital heart defects associated with pulmonary hypertension, NO and NOS play a role in pathological process of pulmonary arteriopathy, and the NOS mRNA expression level was proportional to the severity of pulmonary hypertension or pulmonary arteriopathy.
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In 96 patients with myocardial infarction the indices of central hemodynamics were studied by radiocardiography and the indices of regional circulation in the brain, lungs, liver, and distal parts of the extremity by rheoplethysmography. Peculiarities of regional and central hemodynamics depending on the clinical picture were revealed and the dynamics of the indices being studied were followed from the first to the 40th day of the disease. The authors discuss the mechanisms of the hemodynamic disorders and express their opinion on the expediency of the appropriate approaches to the treatment of patients depending on the hemodynamic changes revealed.
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This chapter contains sections titled: History: role in diagnosis and risk stratification Diagnostic value of symptoms at presentation: angina, anginal equivalents, and atypical presentations Risk stratification: presenting symptoms and other aspects of the history Physical examination: role in diagnosis and risk stratification ECG: role in diagnosis and risk stratification Integration of clinical and ECG data into risk stratification algorithms Conclusions References
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It is essential to control hemodynamics in cardiac surgery. Patients are often monitored extensively in order to optimize hemodynamic performance. However, pre-operative values are normally unknown. Furthermore, hemodynamic goals may seem arbitrary and the lack of an evidence-based consensus may lead to both under- and over-treatment. The aim of this study was to evaluate the variables most commonly used for hemodynamic guidance in the post-operative period.Ten patients scheduled for elective cardiac surgery were followed with invasive hemodynamic monitoring the night before surgery. All data were recorded automatically and electronically.We found considerable inter-patient differences and intra-patient variation. The greatest intra-patient variation was found in the cardiac index (CI), ranging from 1.9 to 5.3 l/min/m(2). Four patients had periodic CI <2.4 l/min/m(2). Eight patients showed SpO2 values < or =92, four of them in more than 15% of the observations. Six patients had an SvO2 <70% in more than 40% of the observations and two an SvO2 < 64% in more than 20% of the observations.This study is unique because hemodynamic reference data in cardiac surgery patients have not been published previously. The intra-patient variations were unexpectedly high in most hemodynamic variables and demonstrate the difficulties of using hemodynamic parameters as a guidance for treatment and indicate that goal-oriented therapy using currently accepted values may result in over-treatment in some patients.
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The purpose of this study was to examine the difference between hemodynamic pressures and parameters obtained pre- compared to post-thermodilution CO measurements. A repeated measures within subject design was conducted with a cardiac surgical cohort. Three measures of hemodynamic pressures and parameters were determined pre- and post-CO measurements (Set 1) and repeated in 30 minutes (Set 2). The sequence was duplicated in four hours (Sets 3 and 4). Hemodynamic pressures lower pre-CO were PAS at Sets 1 and 3, and SBP, DBP, and MAP at Set 3. Hemodynamic parameters lower pre-CO were PVRI at Set 1 and SVRI at Set 3. These pre-post CO differences did not vary by greater than 10%. As the CO injectate volume had minimal effect, hemodynamic pressures may be obtained pre- or post-CO to derive hemodynamic parameters.
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