The impact of ambrisentan and tadalafil upfront combination therapy on cardiac function in scleroderma associated pulmonary arterial hypertension patients: cardiac magnetic resonance feature tracking study.

The aim of this study was to evaluate the effect of upfront combination therapy with ambrisentan and tadalafil on left ventricular (LV) and right ventricular (RV) function in patients with systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH). LV and RV peak longitudinal and circumferential strain and strain rate (SR), which consisted of peak systolic SR (SRs), peak early diastolic SR (SRe), and peak atrial-diastolic SR (SRa) were analyzed using cardiac magnetic resonance imaging (CMRI) data from the recently published ATPAHSS-O trial (ambrisentan and tadalafil upfront combination therapy in SSc-PAH). Twenty-one patients completed the study protocol. Measures of RV systolic function (RV free wall [RVFW] peak longitudinal strain [pLS], RVFW peak longitudinal SRs [pLSRs]) and RV diastolic function (RVFW peak longitudinal SRa [pLSRa], RVFW peak circumferential SRe) were improved after treatment. LV systolic function (LV peak global longitudinal strain [pGLS]) and diastolic function (LV peak global longitudinal SRe [pGLSRe]) were also significantly improved at follow-up. Increased 6-min walk distance was significantly correlated with RVFW pLS and pLSRs, while the decrease in N-terminal pro-brain natriuretic peptide was correlated with LV pGLS. Increased cardiac index was associated with improved LV pGLSRe, and reduction in mean right atrial pressure was correlated with improved RVFW pLS and pLSRa. Combination therapy was associated with a significant improvement in both RV and LV function as assessed by CMR-derived strain and SR. Importantly, the improvement in RV and LV strain and SR correlated with improvements in known prognostic markers of PAH. (Approved by clinicaltrials.gov [NCT01042158] before patient recruitment.).

Impact on survival of warfarin in patients with pulmonary arterial hypertension receiving subcutaneous treprostinil.

INTRODUCTION: Anticoagulation is a common treatment modality in patients with pulmonary arterial hypertension (PAH). Further studies are needed to appropriately assess the risk/benefit ratio of anticoagulation, particularly in PAH patients receiving PAH-specific therapies. AIMS: We use observational long-term data on PAH patients treated with subcutaneous (SQ) treprostinil from a large open-label study. Patients were followed for up to 4 years. The use of warfarin and bleeding events were recorded. RESULTS: At total of 860 patients (age [mean±SD] 46±15 years, 76% female, 83% Caucasian, 49% idiopathic PAH, and 76% New York Heart Association [NYHA] functional class III) were included. All patients received SQ treprostinil (15% also other pulmonary hypertension [PH]-therapies) and 590 (69%) received warfarin during the study. The proportions of women, African American, and idiopathic pulmonary hypertension (IPAH) patients were higher in the group receiving warfarin. A higher proportion of patients with congenital heart disease and portopulmonary hypertension did not receive warfarin. There were no differences in unadjusted long-term survival between PAH patients receiving warfarin or not (log-rank test, P value=.69), even when only considering idiopathic PAH (P=.32). In addition, no difference was found in adjusted long-term survival both in PAH (P=.84) and idiopathic PAH patients (P=.44) based on the use of warfarin. Furthermore, no survival difference based on the use of warfarin were noted between propensity score-matched PAH patients (P=.37). CONCLUSIONS: Long-term anticoagulation with warfarin was not associated with any significant effect on survival in PAH or idiopathic PAH patients treated with SQ treprostinil.

Lung or Heart-Lung Transplant in Pulmonary Arterial Hypertension: What Is the Impact of Systemic Sclerosis?

OBJECTIVES: Little is known about recipient characteristics and outcomes of patients with pulmonary arterial hypertension undergoing lung transplant, particularly those with systemic sclerosis-associated disease. Here, we describe the characteristics and outcomes of patients with pulmonary arterial hypertension undergoing lung transplant, focusing on systemic sclerosis-associated disease. MATERIALS AND METHODS: This retrospective study included pulmonary arterial hypertension patients undergoing lung or heart-lung transplant between July 1992 and August 2013 at a single center. RESULTS: We evaluated 51 patients with pulmonary arterial hypertension (37.3% males; mean age of 45.3 ± 11.9 y). Of 51 patients, 9 (17.6%) had systemic sclerosis-associated pulmonary arterial hypertension. Pulmonary arterial hypertension patients without systemic sclerosis-associated disease had higher mean pulmonary arterial pressure (P = .002), higher pulmonary vascular resistance (P = .008), and were more likely to have severe right ventricular systolic dysfunction (P = .006) than individuals with the disease. Mean hospital stay posttransplant was similar in the 2 groups (42.2 ± 43.3 vs 43.1 ± 19.4 d; P = .20). Higher pretransplant creatinine clearance (P = .0005), forced vital capacity (P = .01), and absence of vasopressor/inotrope use (P = .03) were associated with shorter hospital stay. Mortality for pulmonary arterial hypertension patients with versus without systemic sclerosis-associated disease was 0% versus 13% at 1 year, 29% versus 24% at 2 years, and 86% versus 53% at 5 years. Female sex (hazard ratio, 0.23; 95% confidence interval, 0.08-0.68) and less severe tricuspid regurgitation (hazard ratio, 0.31; 95% confidence interval, 0.11-0.89) were independently associated with long-term survival. CONCLUSIONS: Pulmonary arterial hypertension patients with versus without systemic sclerosis-associated disease have comparable short-term and 2-year outcomes after lung or heart-lung transplant. Female sex and less severe tricuspid regurgitation were independently associated with better long-term survival. These outcomes did not vary when adjusted for the year of transplant.

Effect of Age on Phenotype and Outcomes in Pulmonary Arterial Hypertension Trials.

BACKGROUND: In recent years, the population of patients with pulmonary arterial hypertension (PAH) has changed dramatically, including more advanced age at diagnosis. We hypothesized that older patients have a distinct clinical profile with different disease characteristics and response to intervention. METHODS: All previously published treatment studies for PAH conducted by United Therapeutics including seven randomized, placebo-controlled trials and one extension study were included and analyzed to assess the association of age with various demographic, functional, hemodynamic, and outcome variables. RESULTS: A total of 2,627 patients across three age groups were included: ≤ 50 (n = 1,438, 54.7%), 51 to 64 (n = 780, 29.7%), and ≥ 65 years (n = 409, 15.6%). In comparison with the youngest group, the oldest age group had higher proportions of connective tissue disease-associated etiology (range across the studies, 27%-49% vs 13%-21%), higher proportions of New York Heart Association Functional classes III and IV (74%-91% vs 57%-84%), shorter baseline 6-min walk distance (6MWD) (261-316 vs 335-371 m), better hemodynamic measurements including lower baseline mean pulmonary artery pressure (48-51 vs 58-63 mmHg), and smaller changes in 6MWD from baseline to endpoint (-5.6 to 24 vs 14-43 m). Age remained associated with change in 6MWD when adjusting for covariates in multivariate analyses. CONCLUSIONS: For the first time, using data from large randomized controlled trials, this study characterizes the different phenotype and outcomes of older patients with PAH, which includes different disease etiology, diminished functional status, and decreased response to intervention. This may have significant implications for the management of this patient population and design of future therapy trials.

Ambrisentan and Tadalafil Up-front Combination Therapy in Scleroderma-associated Pulmonary Arterial Hypertension.

BACKGROUND: Scleroderma-associated pulmonary arterial hypertension (SSc-PAH) is a rare disease characterized by a very dismal response to therapy and poor survival. We assessed the effects of up-front combination PAH therapy in patients with SSc-PAH. METHODS: In this prospective, multicenter, open-label trial, 24 treatment-naive patients with SSc-PAH received ambrisentan 10 mg and tadalafil 40 mg daily for 36 weeks. Functional, hemodynamic, and imaging (cardiac magnetic resonance imaging and echocardiography) assessments at baseline and 36 weeks included changes in right ventricular (RV) mass and pulmonary vascular resistance as co-primary endpoints and stroke volume/pulmonary pulse pressure ratio, tricuspid annular plane systolic excursion, 6-minute walk distance, and N-terminal pro-brain natriuretic peptide as secondary endpoints. RESULTS: At 36 weeks, we found that treatment had resulted in significant reductions in median (interquartile range [IQR]) RV mass (28.0 g [IQR, 20.6-32.9] vs. 32.5 g [IQR, 23.2-41.4]; P < 0.05) and median pulmonary vascular resistance (3.1 Wood units [IQR, 2.0-5.7] vs. 6.9 Wood units [IQR, 4.0-12.9]; P < 0.0001) and in improvements in median stroke volume/pulmonary pulse pressure ratio (2.6 ml/mm Hg [IQR, 1.8-3.5] vs. 1.4 ml/mm Hg [IQR 8.9-2.4]; P < 0.0001) and mean ( ± SD) tricuspid annular plane systolic excursion (2.2 ± 0.12 cm vs. 1.65 ± 0.11 cm; P < 0.0001), 6-minute walk distance (395 ± 99 m vs. 343 ± 131 m; P = 0.001), and serum N-terminal pro-brain natriuretic peptide (647 ± 1,127 pg/ml vs. 1,578 ± 2,647 pg/ml; P < 0.05). CONCLUSIONS: Up-front combination therapy with ambrisentan and tadalafil significantly improved hemodynamics, RV structure and function, and functional status in treatment-naive patients with SSc-PAH and may represent a very effective therapy for this patient population. In addition, we identified novel hemodynamic and imaging biomarkers that could have potential value in future clinical trials. Clinical trial registered with www.clinicaltrials.gov (NCT01042158).

Heart rate recovery is an important predictor of outcomes in patients with connective tissue disease-associated pulmonary hypertension.

Reduced heart rate recovery (HRR) after exercise is associated with increased mortality in cardiac and pulmonary diseases. We sought to evaluate the association between HRR after the 6-minute walk test (6MWT) and outcomes in patients with connective tissue disease-associated pulmonary hypertension (CTD-PH). Data were obtained by review of the medical records. HRR was defined as the difference in heart rate at the end of the 6MWT and after 1 minute (HRR1), 2 minutes (HRR2), and 3 minutes (HRR3) of rest. All patients with pulmonary hypertension and a diagnosis of systemic sclerosis, systemic lupus erythematosus, or mixed connective tissue disease who underwent the 6MWT between August 1, 2009, and October 30, 2011, were included (n = 66). By Kaplan-Meier analysis, HRR1, HRR2, and HRR3 at different cutoff points were all good predictors, with HRR1 of <16 being the best predictor of time to clinical worsening (log-rank P < 0.0001), hospitalization (log-rank P = 0.0001), and survival (log-rank P < 0.003). By proportional hazards regression, patients with HRR1 of <16 were at increased risk of clinical worsening (hazard ratio [HR]: 6.4 [95% confidence interval (CI): 2.6-19.2]; P < 0.0001], hospitalization (HR: 6.6 [95% CI: 2.4-23]; P < 0.0001), and death (HR: 4.5 [95% CI: 1.6-15.7]; P = 0.003). Patients in the highest tercile (HRR1 of ≥19) were unlikely to have a clinical worsening event (HR: 0.1 [95% CI: 0.04-0.5]; P = 0.001], to be hospitalized (HR: 0.1 [95% CI: 0.02-0.5]; P = 0.001), or to die (HR: 0.3 [95% CI: 0.07-0.9]; P = 0.04]. In conclusion, in patients with CTD-PH, abnormal HRR1 (defined as HRR1 of <16) after the 6MWT is a strong predictor of clinical worsening, time to clinical worsening, survival, and hospitalization.

Outcomes of ß-blocker use in pulmonary arterial hypertension: a propensity-matched analysis.

The utility and safety of ß-blockers in pulmonary hypertension is controversial. Anecdotal reports suggest that ß-blockers may be harmful in these patients. The aim of our study was to evaluate outcomes of ß-blocker use in pulmonary hypertension.We reviewed patients from our pulmonary hypertension registry between 2000 and 2011. Patients who continued to use ß-blockers were compared to those who never used ß-blockers for all-cause mortality, time to clinical worsening events, defined as death, lung transplantation and hospitalisation due to pulmonary hypertension. We also evaluated the effect of ß-blockers on 6-min walking distance and New York Heart Association (NYHA) functional class.133 patients used ß-blockers and 375 patients never used ß-blockers. Mean±sd age was 57±16 years and the median follow-up period was 78 months. Propensity-matched analysis showed that the adjusted odds ratio (95% CI) for mortality with ß-blocker use was 1.13 (0.69-1.82) and for clinical worsening events was 0.96 (0.55-1.68). No significant difference was noted in probability of survival and time to clinical worsening events. Patients on ß-blockers walked a shorter distance on follow-up 6 min walk test; follow-up NYHA class was similar between groups.Pulmonary hypertension patients receiving ß-blockers had a similar survival and time to clinical worsening events compared to patients not receiving them. Functional outcomes were similar, although ß-blocker use was associated with a tendency towards shorter walking distance.

Association of impaired heart rate recovery with cardiopulmonary complications after lung cancer resection surgery.

OBJECTIVES: Patients who undergo lung resection surgery are at risk for postoperative morbidity and mortality. Appropriate selection of the surgical candidate is crucial in the treatment of lung cancer. Heart rate recovery is a measure of physical fitness. We aimed to investigate the association of impaired heart rate recovery with cardiopulmonary complications after lung resection surgery for treatment of lung cancer. METHODS: Data from consecutive patients who, between 2009 and 2013, underwent heart rate recovery evaluation after 6-minute walk tests before lung resection surgery were retrospectively reviewed. Impaired heart rate recovery was defined as a 12-beat or less decrease in peak heart rate at 1 minute after the 6-minute walk test. Postoperative cardiopulmonary complications were as defined by the Society of Thoracic Surgeons General Thoracic Surgery Database. Logistic regression was performed, including previously known risk factors for postoperative complications after lung resection surgery. RESULTS: A total of 96 patients had heart rate recovery evaluated within 6 months of lung resection surgery for treatment of lung cancer. Thirty-one patients had impaired heart rate recovery, 17 of whom (55%) had cardiopulmonary complications. A total of 65 patients had normal heart rate recovery, 17 of whom (26%) had cardiopulmonary complications. In multivariable logistic regression analysis, impaired heart rate recovery was significantly associated with postoperative cardiopulmonary complications (odds ratio, 4.97; confidence interval, 1.79-13.8; P = .002). No patient died within 30 days after surgery. CONCLUSIONS: Impaired heart rate recovery after the 6-minute walk test is associated with postoperative cardiopulmonary complications in patients who underwent lung resection surgery for treatment of lung cancer.

Heart rate recovery and survival in patients undergoing stereotactic body radiotherapy for treatment of early-stage lung cancer.

OBJECTIVES: Up to 25% of patients with stage I non-small cell lung cancer (NSCLC) are considered high-risk for surgery, due to severe medical comorbidity and/or poor pulmonary reserve. Many of these patients are treated with stereotactic body radiotherapy (SBRT). Prognosis in this subgroup of patients is difficult to determine. We investigated the association of impaired heart rate recovery (HRR) with survival in patients who received SBRT for treatment of early-stage lung cancer. METHODS: We collected data from consecutive patients who, between October 2009 and December 2012, received SBRT for treatment of lung cancer at the Cleveland Clinic, and had 6-minute walk test (6MWT) followed by HRR evaluation performed within six months of initiation of treatment. Impaired HRR was defined as a ≤ 12 beat decrease within the first minute following the 6MWT. Survival analyses were performed using Kaplan-Meier estimates and Cox proportional hazard ratios. RESULTS: Forty nine patients who received SBRT for treatment of early-stage lung cancer had HRR data available. Thirty two (65%) patients had impaired HRR following the 6MWT. In univariable and multivariable Cox regression analyses, impaired HRR was associated with poorer survival (HR: 11.0, 95% CI: 1.42 - 84.4, p = 0.004, and HR: 15.8, 95% CI: 1.96 - 128.0, p = 0.010, respectively). The 2-year overall survival rates were 52.6% for those with impaired HRR, and 94.1% for those with normal HRR. CONCLUSION: Impaired HRR was associated with poorer survival in patients who received SBRT for treatment of early-stage lung cancer. HRR following the 6MWT can be one of the factors considered in patient selection for treatment with SBRT, along with other medical comorbidities.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Biomarkers in pulmonary arterial hypertension.

The biomarker is an indicaror of a biological or pathological process. Clinical observations, measures or environmental events, or measured laboratory values can all be biomarkers in the appropriate setting. An ideal biomarker reflects the underlying biological process, predicts clinical events, is easily obtainable, is reproducible and is not prohibitively expensive. This typically requires validation in longitudinal cohort studies. Biomarkers may help understand the pathological mechanisms responsible for the disease, help as screening tools, predict disease worsening or decline, and determine adequacy of response to therapeutic interventions.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Perioperative management in patients with pulmonary hypertension.

Patients with pulmonary hypertension (PH) are being encountered more commonly in the perioperative period and this trend is likely to increase as improvements in the recognition, management, and treatment of the disease continue to occur. Management of these patients is challenging due to their tenuous hemodynamic status. Recent advances in the understanding of the patho-physiology, risk factors, monitoring, and treatment of the disease provide an opportunity to reduce the morbidity and mortality associated with PH in the peri-operative period. Management of these patients requires a multi-disciplinary approach and meticulous care that is best provided in centers with vast experience in PH. In this review, we provide a detailed discussion about oerioperative strategies in PH patients, and give evidence-based recommendations, when applicable.

Impaired functional capacity predicts mortality in patients with obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased mortality, for which impaired functional capacity (IFC) has been established as a surrogate. We sought to assess whether IFC is associated with increased mortality in patients with OSA and whether IFC is predictive of increased mortality after accounting for coronary artery disease. METHODS: Patients with OSA who underwent both polysomnography testing and exercise stress echocardiogram were selected. Records were reviewed retrospectively for demographics, comorbidities, stress echocardiographic parameters, and polysomnography data. Univariable and multivariable logistic regression analysis was used to evaluate the association between IFC and overall mortality. We then evaluated the variables associated with IFC in the overall population and in the subgroup with normal Duke treadmill score (DTS). RESULTS: In our cohort, 404 (26%) patients had IFC. The best predictors of IFC were female sex, history of smoking, ejection fraction less than 55, increased body mass index, presence of comorbidities, abnormal exercise echocardiogram, abnormal heart rate recovery, and abnormal DTS. Compared with those without IFC, patients with IFC were 5.1 times more likely to die (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.5-10.5; P < 0.0001) by univariate analysis and 2.7 times more likely to die (OR, 2.7; 95% CI, 1.2-6.1; P = 0.02) by multivariate analysis, when accounting for heart rate recovery, DTS, and sleep apnea severity. Among those without coronary artery disease, patients with IFC were at significantly increased risk of mortality (OR, 4.3; 95% CI, 1.35-13.79; P = 0.0088) compared with those with preserved functional capacity. CONCLUSIONS: In our OSA population, IFC was a strong predictor of increased mortality. Among those with normal DTS, IFC identified a cohort at increased risk of mortality.

Heart rate slopes during 6-min walk test in pulmonary arterial hypertension, other lung diseases, and healthy controls.

Six-minute walk test (6MWT) continues to be a useful tool to determine the functional capacity in patients with vascular and other lung diseases; nevertheless, it has a limited ability to predict prognosis in this context. We tested whether the heart rate (HR) acceleration and decay slopes during the 6-m walk test are different in patients with pulmonary arterial hypertension (PAH), other lung diseases, and healthy controls. In addition, we assessed whether the HR slopes are associated with clinical worsening. Using a portable, signal-morphology-based, impedance cardiograph (PhysioFlow Enduro, Paris, France) with real-time wireless monitoring via a Bluetooth USB adapter we determined beat-by-beat HR. We included 50 subjects in this pilot study, 20 with PAH (all on PAH-specific treatment), 17 with other lung diseases (obstructive [n = 12, 71%] or restrictive lung diseases [5, 29%]), and 13 healthy controls. The beat-by-beat HR curves were significantly different among all three groups of subjects either during the activity or recovery of the 6MWT. HR curves were less steep in PAH than the other two groups (P < 0.001). HR acceleration rates were slower in patients with PAH or other lung diseases with progression of their disease (P < 0.001). In conclusion, the acceleration and decay slopes during 6MWT are different among patients with PAH, other lung diseases, and healthy controls. The HR slopes during 6MWT were steeper in patients without clinical worsening.

Presence and outcomes of kidney disease in patients with pulmonary hypertension.

BACKGROUND AND OBJECTIVES: Pulmonary hypertension is associated with higher mortality rates. The associations of nondialysis-dependent CKD and all-cause mortality in patients with pulmonary hypertension were studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study population included those patients who underwent right heart catheterization for confirmation of pulmonary hypertension between 1996 and January 2011. Pulmonary hypertension was defined as the presence of mean pulmonary artery pressure ≥ 25 mmHg at rest measured by right heart catheterization. CKD was defined as the presence of two measurements of eGFR<60 ml/min per 1.73 m(2) 90 days apart. The risk factors associated with CKD as well as the association between CKD and death in those patients with pulmonary hypertension using logistic regression and Cox proportional hazard models were examined. RESULTS: Of 1088 patients with pulmonary hypertension, 388 (36%) patients had CKD: 340 patients had stage 3 CKD, and 48 (4%) patients had stage 4 CKD. In the multivariable analysis, older age, higher hemoglobin, and higher mean right atrial pressures were independently associated with CKD. During a median follow-up of 3.2 years (interquartile range=1.5-5.6 years), 559 patients died. After adjusting for relevant covariates, presence of stage 3 CKD (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.66) and stage 4 CKD (hazard ratio, 2.69; 95% confidence interval, 1.88 to 3.86) was associated with all-cause mortality in those patients with pulmonary hypertension. When eGFR was examined as a continuous measure, a 5 ml/min per 1.73 m(2) lower eGFR was associated with a 5% (95% confidence interval, 1.03 to 1.07) higher hazard for death. This higher risk with CKD was similar irrespective of demographics, left ventricular function, and pulmonary capillary wedge pressure. CONCLUSION: In a clinical population referred for right heart catheterization, presence of CKD was associated with higher all-cause mortality in those patients with pulmonary hypertension. Mechanisms that may underlie these associations warrant additional studies.

Clinical characteristics and prediction of pulmonary hypertension in severe emphysema.

BACKGROUND: We explored the prevalence, clinical and physiologic correlates of pulmonary hypertension (PH), and screening strategies in patients with severe emphysema evaluated for the National Emphysema Treatment Trial (NETT). METHODS: Patients undergoing Doppler echocardiography (DE) and right heart catheterization were included. Patients with mean pulmonary arterial pressure ≥ 25 mmHg (PH Group) were compared to the remainder (non-PH Group). RESULTS: Of 797 patients, 302 (38%) had PH and 18 (2.2%) had severe PH. Compared to the non-PH Group, patients with PH had lower % predicted FEV1 (p < 0.001), % predicted diffusion capacity for carbon monoxide (p = 0.006), and resting room air PaO2 (p < 0.001). By multivariate analysis, elevated right ventricular systolic pressure, reduced resting room air PaO2, reduced post-bronchodilator % predicted FEV1, and enlarged pulmonary arteries on computed tomographic scan were the best predictors of PH. A strategy using % predicted FEV1, % predicted DLCO, PaO2, and RVSP was predictive of the presence of pre-capillary PH and was highly predictive of its absence. CONCLUSIONS: Mildly elevated pulmonary artery pressures are found in a significant proportion of patients with severe emphysema. However, severe PH is uncommon in the absence of co-morbidities. Simple non-invasive tests may be helpful in screening patients for pre-capillary PH in severe emphysema but none is reliably predictive of its presence.

Electrocardiography at diagnosis and close to the time of death in pulmonary arterial hypertension.

BACKGROUND: Scarce information exits on the electrocardiographic (ECG) characteristics of pulmonary arterial hypertension (PAH) patients close to their death and whether observed abnormalities progress from the time of PAH diagnosis. METHODS: We analyzed the characteristics of the ECG performed at initial diagnosis, during the course of the disease and close to the time of death on consecutive PAH patients followed at our institution between June 2008 and December 2010. RESULTS: We included 50 patients with PAH (76% women) with mean (SD) age of 58 (14) years. Median heart rate (83 vs 89 bpm, P = 0.001), PR interval (167 vs 176 ms, P = 0.03), QRS duration (88 vs 90 ms, P = 0.02), R/S ratio in lead V1 (1 vs 2, P = 0.01), and QTc duration (431 vs 444 ms, P = 0.02) significantly increased from the initial to the last ECG. In addition, the frontal QRS axis rotated to the right (97 vs 112 degrees, P = 0.003) and we more commonly observed right bundle branch block (5% vs 8%, P = 0.03) and negative T waves in inferior leads (31% vs 60%, P = 0.004). No patient had normal ECG at the time of death. CONCLUSIONS: Significant changes progressively occur in a variety of ECG parameters between the time of the initial PAH diagnosis and close to death.

Value of impedance cardiography during 6-minute walk test in pulmonary hypertension.

BACKGROUND: Methods that predict prognosis and response to therapy in pulmonary hypertension (PH) are lacking. We tested whether the noninvasive estimation of hemodynamic parameters during 6-minute walk test (6MWT) in PH patients provides information that can improve the value of the test. METHODS: We estimated hemodynamic parameters during the 6MWT using a portable, signal-morphology-based, impedance cardiograph (PhysioFlow Enduro) with real-time wireless monitoring via a bluetooth USB adapter. RESULTS: We recruited 48 subjects in the study (30 with PH and 18 healthy controls). PH patients had significantly lower maximum stroke volume (SV) and CI and slower cardiac output (CO) acceleration and decelerations slopes during the test when compared with healthy controls. In PH patients, CI change was associated with total distance walked (R = 0.62; P < 0.001) and percentage of predicted (R = 0.4, P = 0.03), HR recovery at 1 minute (0.57, P < 0.001), 2 minutes (0.65, P < 0.001), and 3 minutes (0.66, P < 0.001). Interestingly, in PH patients CO change during the test was predominantly related to an increase in SV instead of HR. CONCLUSIONS: Estimation of hemodynamic parameters such as cardiac index during 6-minute walk test is feasible and may provide useful information in patients with PH. Clin Trans Sci 2013; Volume #: 1-7.

Perioperative risk and management in patients with pulmonary hypertension.

Pulmonary hypertension (PH) is a known risk factor for perioperative complications. Unlike in the case of cardiac surgery, PH is currently not listed as an independent risk factor for postoperative complications in guidelines for the management of noncardiac surgery. Despite the paucity of data, though, patients with PH are often counseled against having elective procedures because early and sudden postoperative deaths have been reported. Patients with PH are unable to accommodate alterations in right ventricular (RV) preload or afterload induced by fluid shifts, medications, or changes in the autonomic nervous system precipitated by hypoxia or hypercapnia. These factors become magnified in situations of added stress such as surgical intervention. Systemic hypotension and arrhythmias may precipitate RV ischemia, further worsening RV function. Patient and surgical characteristics and choice of anesthetic technique are crucial factors in perioperative management. The two main principles of perioperative management are the prevention of systemic hypotension (risk of RV ischemia) and the prevention of acute elevations in pulmonary arterial pressure (risk of RV failure). Close monitoring, optimization of systemic BP, pain control, oxygenation and ventilation, avoidance of exacerbating factors, and use of vasopressors and pulmonary vasodilators as necessary are essential elements of management. Understanding the pathophysiology, cause, and severity of PH in the individual perioperative patient allows accurate risk assessment, optimization of PH and RV function prior to surgery, and appropriate intraoperative and postoperative management.

Long-term continuous positive airway pressure therapy normalizes high exhaled nitric oxide levels in obstructive sleep apnea.

STUDY OBJECTIVES: Upper airway inflammation and oxidative stress have been implicated in the pathogenesis of obstructive sleep apnea (OSA) and may be linked to cardiovascular consequences. We prospectively examined fraction of exhaled nitric oxide (FENO), a surrogate marker of upper airway inflammation using a portable nitric oxide analyzer (NIOX MINO). DESIGN: In consecutive adult nonsmokers with suspected OSA, FENO was measured immediately before and after polysomnographic studies, and within 1-3 months following continuous positive airway pressure (CPAP) therapy. MEASUREMENT AND RESULTS: FENO levels were increased in the 75 patients with OSA compared to the 29 controls, both before sleep (13.4 ± 6.5 ppb vs. 6.5 ± 3.5; p < 0.001) and after sleep (19.0 ± 7.7 ppb vs. 6.9 ± 3.7; p < 0.001). Furthermore, in patients with OSA, FENO levels were significantly higher post-sleep than pre-sleep (19.0 ± 7.7 ppb vs. 13.4 ± 6.5; p < 0.001), while there was no significant overnight change in patients without OSA. The rise in FENO correlated with the apnea-hypopnea index (r = 0.65, p < 0.001), nadir oxygen saturation (r = 0.54, p < 0.001), and arousal index (r = 0.52, p < 0.001). Thirty-seven of these patients underwent CPAP titration and treatment. Successful titration was associated with a lower overnight increase in FENO (7.2 ± 3.3 vs. 11.0 ± 4.3, p = 0.02). FENO levels declined after 1-3 months of CPAP therapy (11.7 ± 4.4 ppb, p < 0.001). CONCLUSIONS: FENO levels are elevated in OSA, correlate with severity, and decrease after positive pressure therapy. This study supports the role of upper airway inflammation in OSA pathogenesis and a possible role for FENO in monitoring CPAP therapy.