Fibrotic idiopathic interstitial pneumonias: mortality is linked to a decline in gas transfer

Background and objective: Baseline clinical and physiological features and changes in these parameters over time are known predictors of survival in patients with fibrotic idiopathic interstitial pneumonia (IIP). Pulmonary hypertension is common in advanced fibrotic IIP, and has a negative impact on survival. Serial pulmonary function profiles, indicative of increasing vascular impairment in patients with IIP, and in particular, selective reductions in gas transfer, have not been studied previously. Methods: Predictors of event‐free survival time were investigated in a cohort of Dutch patients with IPF and fibrotic non‐specific interstitial pneumonia (n = 117). Pulmonary function test data were prospectively collected from November 1993 to December 2005. Multivariate Cox regression models were developed to identify the prognostic relevance to survival of variables related to baseline demographics, histopathology, pulmonary function and the 6‐ and 12‐month changes in pulmonary function parameters. Results: Different survival patterns were observed for patients with different histopathological diagnoses. At baseline, FVC was the most important prognostic factor. At the 6‐month follow up, change in transfer coefficient (K_CO, DL_CO/V_A), and at the 12‐month follow up, age, baseline K_CO and 12‐month change in FVC and K_CO, were independent predictors of event‐free survival. Conclusions: Apart from histopathology, change in K_CO over time appeared to be the most consistent and powerful predictor of survival in these patients. The decline in K_CO may be indicative of increasing vascular impairment, which may have a major impact on survival, in patients with fibrotic IIP.     

Exercise capacity and haemodynamics in patients with sickle cell disease with pulmonary hypertension treated with bosentan: results of the ASSET studies

Doppler‐defined pulmonary hypertension (PH) in sickle cell disease (SCD) is associated with 40% mortality at 40 months. To assess the effect of bosentan in SCD‐PH, two randomized, double‐blind, placebo‐controlled, 16‐week studies were initiated. Safety concerns are particularly relevant in SCD due to comorbid conditions. ASSET‐1 and ‐2 enrolled patients with pulmonary arterial hypertension (PAH) and pulmonary venous hypertension (PH), respectively. Haemodynamics and 6‐min walk distance (6MWD) were obtained at baseline and week 16. The studies were terminated due to slow site initiation and patient enrolment (n = 26). Bosentan appeared to be well tolerated. Although sample sizes were limited, in ASSET‐1 at baseline, 6MWD correlated with cardiac output (CO; P = 0·006) with non‐significant inverse correlations between 6MWD and pulmonary vascular resistance (PVR; P = 0·07) and between 6MWD and right atrial pressure (P = 0·08). In ASSET‐2 at baseline, there was a non‐significant correlation between 6MWD and CO (P = 0·06). Due to limited sample sizes, efficacy endpoints were not analysed. However, in both studies, non‐significant increases in CO were observed with bosentan compared to placebo. Similarly, non‐significant decreases in PVR were observed with bosentan. Limited data in SCD‐PH suggest that a low 6MWD predicts a low CO. Standard‐dose bosentan appears to be well tolerated. Further investigation is warranted. Clinicaltrials.gov registration numbers NCT00310830, NCT00313196, NCT00360087.     

Exercise capacity in idiopathic pulmonary fibrosis: the effect of pulmonary hypertension

Background and objective: Increased pulmonary arterial pressure (PAP) usually coexists with impaired lung function in IPF. Data on the effect of pulmonary hypertension (PH) on cardiopulmonary responses during exercise in IPF patients is very limited. We sought to investigate the impact of PH on exercise capacity and the correlation between systolic PAP (sPAP) and pulmonary function testing, as well as cardiopulmonary exercise parameters, in patients with IPF and PH. Methods: Eighty‐one consecutive patients with IPF, who were evaluated over a 6‐year period, were retrospectively studied. Patients underwent pulmonary function testing, Doppler echocardiography and maximal cardiopulmonary exercise testing. PH was defined as sPAP > 35 mm Hg. Results: PH was diagnosed in 57% of the patients. Categorization of patients according to severity of PH indicated a significant reduction in maximum work rate, peak O₂ uptake, anaerobic threshold and peak O₂ pulse in those with sPAP > 50 mm Hg. In IPF patients with PH, estimated sPAP correlated with peak O₂ uptake, anaerobic threshold, peak O₂ pulse and end‐tidal CO₂ at anaerobic threshold, while the strongest correlation was between sPAP and ventilatory equivalent for CO₂ at anaerobic threshold (r = 0.611, P < 0.001). There were no differences in pulmonary function or exercise parameters indicative of lung volume reduction, across the patient categories, and none of these parameters correlated with sPAP. Conclusions: PH has a negative impact on exercise capacity in IPF patients. In IPF patients with PH, resting sPAP correlated with exercise parameters indicative of gas exchange and circulatory impairment, but not with defective lung mechanics.     

Haemodynamic effects of an acute vasodilator challenge in heart failure patients with reduced ejection fraction and different forms of post‐capillary pulmonary hypertension

Aims

The most recent European guidelines have proposed new definitions of pulmonary hypertension (PH) in left heart disease, to better approach the characteristics required to reflect the presence of pulmonary vascular disease. The purpose of this study was to assess whether different haemodynamic definitions of post‐capillary PH imply a different reversibility of PH in response to acute vasodilator administration in heart failure patients with reduced ejection fraction and PH (HFrEF‐PH).

Methods and results

Right heart catheterization and reversibility testing was performed in 156 HFrEF‐PH patients. Patients were classified as combined post‐capillary and pre‐capillary pulmonary hypertension (Cpc‐PH) vs. isolated post‐capillary pulmonary hypertension (Ipc‐PH) and on the basis of diastolic pulmonary gradient (DPG) ≥ 7 vs. < 7 mmHg or of transpulmonary gradient (TPG) >12 vs. ≤12 mmHg. After vasodilator administration, Cpc‐PH patients showed a greater per cent improvement in pulmonary vascular resistance (PVR), DPG and TPG as compared with Ipc‐PH patients (all P_int < 0.001); only pulmonary compliance (PCa) improved less in Cpc‐PH than in Ipc‐PH patients (P_int = 0.007). However, despite vasodilatation, Cpc‐PH patients remained in an unfavourable portion of the inverse hyperbolic relationship between PVR and PCa. The number of patients in whom PVR was reduced below 2.5 wood units was similar in Cpc‐PH, DPG ≥7 mmHg and TPG >12 mmHg groups (28.3, 26.7 and 18.9%, respectively).

Conclusion

Although substantial improvements in PVR, DPG and TPG were observed in Cpc‐PH patients after acute vasodilator administration, this response was associated with persistent abnormalities in the PVR vs. PCa relationship. The link between baseline right heart haemodynamics and pulmonary vascular disease remains elusive.

     

Assessment of pulmonary hypertension in the pediatric catheterization laboratory: Current insights from the magic registry

Objectives: To assess protocols, demographics, and hemodynamics in pediatric patients undergoing catheterization for pulmonary hypertension (PH). Background: Pediatric specific data is limited on PH. Methods: Review of the Mid‐Atlantic Group of Interventional Cardiology (MAGIC) collaboration PH registry dataset. Results: Between November 2003 and October 2008, seven institutions submitted data from 177 initial catheterizations in pediatric patients with suspected PH. Pulmonary arterial hypertension associated with congenital heart disease (APAH‐CHD) (n = 61, 34%) was more common than idiopathic PAH (IPAH) (n = 36, 20%). IPAH patients were older with higher mean pulmonary arterial pressures (mPAP) (P < 0.01). Oxygen lowered mPAP in patients with IPAH (P < 0.01) and associated PAH not related to congenital heart disease (APAH‐non CHD) (P < 0.01). A synergistic effect was seen with inhaled Nitric Oxide (iNO) (P < 0.01). Overall 9/30 (29%) patients with IPAH and 8/48 (16%) patients with APAH‐non CHD were reactive to vasodilator testing. Oxygen lowered pulmonary vascular resistance index (PVRI) in patients with APAH‐CHD (P < 0.01). There was no additive effect with iNO but a subset of patients required iNO to lower PVRI below 5 WU·m². General anesthesia (GA) lowered systemic arterial pressure (P < 0.01) with no difference between GA and procedural sedation on mPAP or PVRI. Adverse events were rare (n = 7) with no procedural deaths. Conclusions: Pediatric patients with PH demonstrate a higher incidence of APAH‐CHD and neonatal specific disorders compared to adults. Pediatric PH patients may demonstrate baseline mPAP < 40 mm Hg but > 50% systemic illustrating the difficulty in applying adult criteria to children with PH. Catheterization in children with PH is relatively safe. © 2010 Wiley‐Liss, Inc.     

Long-term outcomes from bronchoscopic lung volume reduction using a bronchial prosthesis

Background and objective: We evaluated long‐term safety and lung function outcomes in a cohort of patients with severe upper‐zone heterogeneous emphysema who underwent bronchoscopic lung volume reduction (BLVR) performed with the Emphasys one‐way valve. Methods: A retrospective cohort study was undertaken to assess long‐term outcomes in 23 consecutive patients who underwent upper lobe BLVR between July 2001 and November 2003 as part of a first‐in‐humans study. Long‐term follow up (>12 months) was available in 16/23 patients (median duration of follow up 64 months (range 15–90 months)). Both unilateral (n = 4) and bilateral (n = 12) BLVR procedures were performed with a mean of 6 (range 3–11) valves being inserted. Changes in pulmonary function tests were assessed longitudinally following the procedure. Results: 13/16 and 11/16 patients showed post‐procedure improvements in FEV₁ and DL_CO, respectively. However, early improvements in pulmonary function were not sustained with only 6/16 patients still showing improved lung function at the end of follow up. There were no significant improvements in other indices of pulmonary function. Three patients, in the absence of clinical benefit, proceeded to lung transplantation at 15, 16 and 44 months post BLVR. Four patients died during the course of the study at 27, 29, 39 and 50 months post procedure. Conclusions: BLVR with the Emphasys one‐way valve has an acceptable safety profile and in select patients may achieve long‐term sustained improvements in pulmonary function.     

Lipoprotein-associated phospholipase A₂ activity and mass in relation to vascular disease and nonvascular mortality

Abstract. Heart Protection Study Collaborative Group (Clinical Trial Service Unit, University of Oxford, Oxford, UK) Lipoprotein‐associated phospholipase A₂ activity and mass in relation to vascular disease and nonvascular mortality. J Intern Med 2010; 268 :348–358. Objectives. To assess whether associations of circulating lipoprotein‐associated phospholipase A₂ (Lp‐PLA₂) with vascular disease are independent of other risk factors. Methods. Lp‐PLA₂ activity and mass, lipids and other characteristics were measured at baseline in 19 037 individuals at high risk of vascular disease in a randomized trial of simvastatin with 5‐year average follow‐up. Results. Lp‐PLA₂ activity and mass were correlated with each other (r = 0.56), lipids and other vascular risk factors. The moderate association of Lp‐PLA₂ activity with occlusive coronary events (n = 2531) in analyses adjusted for nonlipid factors (hazard ratio per 1 SD [HR] 1.11, 95% CI 1.06–1.15) became nonsignificant after further adjustment for apolipoproteins (HR 1.02, 0.97–1.06). Such adjustment also attenuated HRs with Lp‐PLA₂ mass from 1.08 (1.03–1.12) to 1.05 (1.01–1.09). By contrast, the HR with apolipoprotein‐B100 of 1.15 (1.10–1.19) was only slightly attenuated to 1.14 (1.09–1.19) after further adjustment for apolipoprotein A₁ and Lp‐PLA₂. Age‐ and sex‐adjusted HRs for other cardiac events (n = 1007) with either Lp‐PLA₂ activity or mass were about 1.20, but HRs reduced after adjustment for nonlipid factors (activity: 1.11, 1.04–1.18; mass: 1.08, 1.02–1.15). Adjusted HRs for ischaemic stroke (n = 900) were weak and nonsignificant and for nonvascular mortality (n = 1040) were 1.01 (0.94–1.09) with activity and 1.12 (1.05–1.19) with mass. Simvastatin reduced Lp‐PLA₂ levels by about one‐quarter, but simvastatin’s vascular protection did not vary with baseline Lp‐PLA₂ concentration. Conclusions. Associations of Lp‐PLA₂ with occlusive coronary events depend considerably on lipid levels, whereas those with other cardiac events appear to reflect confounding from cardiovascular medication and prior vascular disease.     

The use of sildenafil to treat pulmonary hypertension associated with interstitial lung disease

Background and objective: Limited data suggest a benefit following sildenafil treatment in patients with pulmonary hypertension (PH) and interstitial lung disease (ILD). The role of sildenafil in the management of PH in ILD is not clear. We report our experience of ILD patients with PH after 6‐month sildenafil therapy. Methods: We reviewed 15 patients (mean age 55 ± 15 years; 8 men) with ILD (mean FVC 52.6 ± 15.4%) and PH (mean right ventricular systolic pressure 73.8 ± 17.8 mm Hg). Median brain natriuretic peptide: 37 (5–452) pmol/L; mean 6MWD: 156 ± 101 m. Results: Following 6‐month treatment with sildenafil, brain natriuretic peptide levels were lower (n = 12, P = 0.03), 6MWD was higher (n = 6, P < 0.05), but no change in right ventricular systolic pressure (n = 11) was demonstrated. Conclusions: Our observations suggest that sildenafil may be useful in the management of PH in ILD. Controlled trials are warranted before therapeutic recommendations can be made.     

Pulmonary function over 2 years in diabetic patients treated with prandial inhaled Technosphere Insulin or usual antidiabetes treatment: a randomized trial

Aims: Development of inhaled insulin has increased the need to understand its pulmonary safety. This study evaluated pulmonary function changes in diabetes patients receiving inhaled Technosphere Insulin (TI) or usual antidiabetes treatment (usual care). Methods: This randomized, open‐label study was conducted at 220 sites (25 July 2005 to 29 August 2008). Pulmonary function tests [forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), total lung capacity (TLC) and lung diffusion capacity for carbon monoxide (DL_CO)] were prospectively followed over 2 years in patients with type 1 or type 2 diabetes receiving TI (n = 730) or usual care (n = 824), along with a cohort without diabetes not receiving any specific therapy (n = 145). Results: Baseline demographics and pulmonary function were similar between diabetes treatment groups. Lung function declined from baseline in all groups. TI was non‐inferior to usual care for mean change in FEV₁ from baseline to month 24 [mean (s.e.m.) 0.037 (0.0119) l; 95% CI 0.014 to 0.060] using mixed‐model repeated‐measure with a pre‐specified non‐inferiority margin of 50 ml/year. After a greater initial decline at month 3 with TI, rate of change (slope) in FEV₁, FVC and DL_CO (months 3–24) was not statistically different between treatment groups. TI was well tolerated; no serious safety concerns emerged. The most common respiratory event associated with TI was mild, transient cough, occurring within minutes of inhalation. Conclusions: Observed changes in lung function with TI were small, occurred early after therapy initiation, remained non‐progressive over 2 years and were unlikely to be clinically meaningful.     

Aerosolized iloprost for pulmonary vasoreactivity testing in children with long‐standing pulmonary hypertension related to congenital heart disease

Background: In congenital heart disease with increased pulmonary blood flow and pressure, progressive changes in the vascular structure can lead to irreversible pulmonary hypertension (PH). Pulmonary hemodynamic parameters are used to determine whether surgical correction is no longer indicated. In this study, aerosolized iloprost was used to assess pulmonary vasoreactivity in children with long‐standing PH related to congenital heart disease. Methods: Children with long‐standing and severe PH secondary to congenital heart disease were included in this study. Various hemodynamic parameters were measured before and after iloprost inhalation (0.5 μg/kg), and vascular resistance was determined. Responders to the iloprost test were defined as those with a decrease in both pulmonary vascular resistance (PVR) and pulmonary‐to‐systemic vascular resistance ratio (R_p/R_s) of >10%. Results: Eighteen children aged between 7 months and 13 years with long‐standing and severe PH secondary to congenital heart disease were studied. Thirteen children had a positive response, resulting in a mean (± SD) decrease of PVR from 9.3 ± 4.6 to 4.6 ± 2.7 Wood U · m² (P < 0.001), and a mean decrease of R_p/R_s from 0.54 ± 0.37 to 0.24 ± 0.14 (P = 0.005). Conclusions: Iloprost‐induced pulmonary vasodilator responses vary among children with PH related to congenital heart disease. The use of inhale iloprost in the cardiac catheterization laboratory results in pulmonary vasoreactivity for some of these children particularly a reduction in PVR and the pulmonary‐to‐systemic vascular resistance ratio. © 2008 Wiley‐Liss, Inc.     

Percutaneous pulmonary valve implantation preceded by routine prestenting with a bare metal stent

Objectives: To evaluate the effectiveness and safety of percutaneous pulmonary valve implantation (PPVI) with routine prestenting with a bare metal stent (BMS). Background: PPVI is a relatively new method of treating patients with repaired congenital heart disease (CHD). Results of PPVI performed with routine prestenting have never been reported. Methods: Consecutive patients who underwent PPVI for homograft dysfunction with prestenting with BMS were studied. The schedule of follow‐up assessment comprised clinical evaluation, cardiovascular magnetic resonance, transthoracic echocardiography, and chest X‐ray to screen for device integrity. Results: PPVI was performed with no serious complications in all patients (n = 10, mean age 26.8 ± 4.0 years, 60% males). In nine patients with significant pulmonary stenosis, peak right ventricular outflow tract (RVOT) gradient was reduced from a mean of 80.6 ± 22.7 to 38.8 ± 10.4 mm Hg on the day following implantation (P = 0.001). At 1‐month and 6‐month follow‐ups, mean RVOT gradient was 34.0 ± 9.8 and 32.0 ± 12.2 mm Hg, respectively. In patients with significant pulmonary regurgitation, mean pulmonary regurgitation fraction decreased from 19% ± 6% to 2% ± 1% (P = 0.0008). Relief of RVOT obstruction and restoration of pulmonary valve competence were associated with significant decrease in right ventricular (RV) end‐diastolic and end‐systolic volumes (125.5 ± 48.6 to 109.2 ± 42.9 mL/m²; P = 0.002 and 68.4 ± 41.5 vs. 50.9 ± 40.6 mL/m²; P = 0.001) as well as improvement in RV ejection fraction (48.8% ± 13.1% to 57.6% ± 14.4%; P = 0.003) and New York Heart Association class (P = 0.003). All patients completed 6‐month follow‐up. No stent fractures were observed. Conclusions: PPVI with routine prestenting with BMS is a safe and effective method of treatment in patients with repaired CHD. © 2010 Wiley‐Liss, Inc.     

Clinical outcomes in real‐world patients with type 2 diabetes switching from first‐ to second‐generation basal insulin analogues: Comparative effectiveness of insulin glargine 300 units/mL and insulin degludec in the DELIVER D+ cohort study

Aims

To compare clinical outcomes in patients with type 2 diabetes (T2D) switching from insulin glargine 100 units/mL (Gla‐100) or insulin detemir (IDet) to insulin glargine 300 units/mL (Gla‐300) or insulin degludec (IDeg).

Materials and Methods

We conducted a retrospective, observational study of electronic medical records for Gla‐300/IDeg adult switchers (March 1, 2015 to January 31, 2017) with active records for 12‐month baseline (glycated haemoglobin [HbA1c] used a 6‐month baseline period) and 6‐month follow‐up periods. Gla‐300 and IDeg switchers were propensity score‐matched using baseline demographic and clinical characteristics. Outcomes were HbA1c change and goal attainment (among patients with HbA1c captured at follow‐up), and hypoglycaemia with fixed follow‐up (intention‐to‐treat [ITT]; 6 months) and variable follow‐up (on‐treatment [OT]; to discontinuation or 6 months).

Results

Each matched cohort comprised 1592 patients. The mean decrease in HbA1c and HbA1c goal (<7.0% [53 mmol/mol] and <8.0% [64 mmol/mol]) attainment rates were similar for Gla‐300 (n = 742) and IDeg (n = 727) switchers. Using fixed follow‐up (ITT method), hypoglycaemia incidence decreased significantly from baseline with Gla‐300 (all hypoglycaemia: 15.6% to 12.7%; P = .006; hypoglycaemia associated with inpatient/emergency department [ED] encounter: 5.3% to 3.5%; P = .007), but not with IDeg. After adjusting for baseline hypoglycaemia, no significant differences in hypoglycaemia incidence and event rate were found at follow‐up (ITT) for Gla‐300 vs IDeg. Using variable follow‐up (OT), hypoglycaemia incidence was similar in both groups, but Gla‐300 switchers had a lower inpatient/ED hypoglycaemia event rate at follow‐up (adjusted rate ratio 0.56; P = .016).

Conclusions

In a real‐world setting, switching from Gla‐100 or IDet to Gla‐300 or IDeg was associated with similar improvements in glycaemic control and hypoglycaemia in adult patients with T2D.     

Feasibility,acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition,physical activity,emotional regulation,and family

Childhood obesity is a growing problem with a complex aetiology, for which multidisciplinary interventions are required. Our programme describes a novel structured psychosocial family‐based intervention targeting the emotional regulation in childhood obesity, using a train trip metaphor aimed at improving healthy lifestyles for the family. The aims were (a) to describe the feasibility and acceptability of this psychosocial family‐based intervention among children with overweight or obesity in primary care and (b) to examine the effectiveness of the “ENTREN‐F” programme (with family intervention) compared with the “ENTREN” programme (without family intervention) among Spanish children regarding anthropometric variables, physical activity, emotional well‐being, and family functioning. Children were randomly allocated to either ENTREN‐F programme (n = 30) or psychological intervention for children (ENTREN, n = 40), and assessments were carried out over time (T₀ baseline vs. T₁ post/6‐month vs. T₂ 6‐month follow‐up). Both parent groups expressed high levels of satisfaction with the interventions. ENTREN‐F resulted in higher adherence to treatment and was more effective in improving z–body mass index, reducing children's anxiety, and increasing family adaptability than the ENTREN programme. There were no significant changes in parents' emotional well‐being and expressed emotion. Both groups improved in the children's emotional well‐being and light physical activity. In summary, this multidisciplinary psychosocial family‐based intervention was succesful.     

Baseline Lower Extremity Strength and Subsequent Decline in Functional Performance at 6‐Year Follow‐Up in Persons with Lower Extremity Peripheral Arterial Disease

OBJECTIVES: To evaluate associations between baseline lower extremity strength and decline in functional performance over 6 years of follow‐up in men and women with lower extremity peripheral arterial disease (PAD). DESIGN: Prospective observational study. SETTING: Three Chicago‐area hospitals. PARTICIPANTS: Three hundred seventy‐four men and women with PAD. MEASUREMENTS: Baseline isometric hip extension, hip flexion, knee flexion, and knee extension strength were measured using a musculoskeletal fitness evaluation chair. Usual and fastest‐paced 4‐m walking speed, 6‐minute walk, and Short Physical Performance Battery (SPPB) were assessed at baseline and annually thereafter. Analyses were adjusted for age, sex, race, ankle–brachial index (ABI), comorbidities, and other confounders. RESULTS: In women with PAD, weaker baseline hip and knee flexion strength were associated with faster average annual decline in usual‐pace 4‐m walking speed (P trend <.001 and .02, respectively) and SPPB (P trend=.02 and .01, respectively). In women, weaker hip extension strength was associated with faster decline in usual‐pace 4‐m walking speed and SPPB (P trend=.01 and <.01, respectively). There were no significant associations between baseline strength and decline in 6‐minute walk in women. There were no significant associations between any baseline strength measure and functional decline in men. CONCLUSION: Weaker baseline leg strength is associated with faster functional decline in nonendurance measures of functional performance in women with PAD but not in men with PAD.     

Left atrial volume and N-terminal pro-B type natriuretic peptide are associated with elevated pulmonary artery pressure in patients with systemic sclerosis

Early detection of pulmonary hypertension (PH) in patients with systemic sclerosis (SSc) is essential as it leads to substantial morbidity and mortality irrespective of its etiology. The aim of our study was to determine whether noninvasive biochemical and/or echocardiographic indices can predict the presence of PH in these patients. We prospectively studied 66 patients (mean age of 57.7?±?12.1 years, 63 women) with SSc without clinical manifestations of heart failure. All patients underwent standard and tissue Doppler echocardiography. Plasma N-terminal pro-B type natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) levels were also measured. In 24 (36%) patients, the diagnosis of PH was established by echocardiography (systolic pulmonary artery pressure value ≥40 mmHg). Left atrial (LA) volume, NT-proBNP, ADMA, ratio of early transmitral filling velocity to early diastolic velocity of the mitral annulus (mitral E/E _m), and right ventricular myocardial performance index (MPI) were univariate predictors of PH. In multivariate analysis, NT-proBNP, LA volume, and right ventricular MPI were independent predictors of PH in SSc patients. LA volume and NT-proBNP may be useful noninvasive markers for the prediction of elevated pulmonary artery pressure in patients with SSc. These parameters should be considered when assessing this population for risk stratification and for identification of patients demanding further investigation and institution of specific therapy for the disease at the time when it is most likely to be effective.     

The estimated pulmonary artery pressure can be elevated in Behçet's syndrome

Objectives

To determine the frequency of elevated systolic pulmonary artery pressure (sPAP) estimated by echocardiography in Behçet’s syndrome (BS) patients with pulmonary artery involvement (PAI), in healthy controls and in diseased controls with systemic sclerosis (SSc), as well as in BS patients without PAI.

Methods

We studied 3 groups of patients with BS (patients with PAI: n = 30, with vascular disease but without PAI: n = 26 and without vascular disease: n = 21), patients with SSc (n = 23) and healthy controls (n = 22). Systolic pulmonary artery pressure (sPAP) was estimated by echocardiography. The upper limit for a normal sPAP was arbitrarily set at 35 mmHg. We also evaluated cardiac function by echocardiography. Pulmonary function tests, a six-minute walking test (six-MWT) and several serum biomarkers were also studied.

Results

The frequency of patients with an elevated sPAP was significantly higher only among BS patients with PAI (17%) and among patients with SSc (26%). In addition, DL_CO was decreased and pro-BNP levels were increased in BS patients with PAI, which are similar to the results in patients with SSc. Furthermore, BS patients with PAI also had mild RV diastolic dysfunction.

Conclusions

When BS involves the pulmonary arteries, it can cause mild elevations in the estimated sPAP, decrease in DL_CO, mild cardiac dysfunction and increase in pro-BNP levels. These findings suggest that BS can also affect the small/micro vessels of the heart and the lungs in addition to the well-recognized large vessel disease.     

Assessment of Right Ventricular Afterload in COPD

Background: We aimed to study whether pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) could be predicted by conventional echo Doppler and novel tissue Doppler imaging (TDI) in a population of chronic obstructive pulmonary disease (COPD) free of LV disease and co-morbidities.Methods: Echocardiography and right heart catheterization was performed in 100 outpatients with COPD. By echocardiography the time-integral of the TDI index, right ventricular systolic velocity (RVSmVTI) and pulmonary acceleration-time (PAAcT) were measured and adjusted for heart rate. The COPD patients were randomly divided in a derivation (n = 50) and a validation cohort (n = 50). Results: PH (mean pulmonary artery pressure (mPAP) ≥ 25mmHg) and elevated PVR ≥ 2Wood unit (WU) were predicted by satisfactory area under the curve for RVSmVTI of 0.93 and 0.93 and for PAAcT of 0.96 and 0.96, respectively. Both echo indices were 100% feasible, contrasting 84% feasibility for parameters relying on contrast enhanced tricuspid-regurgitation. RVSmVTI and PAAcT showed best correlations to invasive measured mPAP, but less so to PVR. PAAcT was accurate in 90- and 78% and RVSmVTI in 90- and 84% in the calculation of mPAP and PVR, respectively. Conclusions: Heart rate adjusted-PAAcT and RVSmVTI are simple and reproducible methods that correlate well with pulmonary artery pressure and PVR and showed high accuracy in detecting PH and increased PVR in patients with COPD. Taken into account the high feasibility of these two echo indices, they should be considered in the echocardiographic assessment of COPD patients.     

Predictors of recurrence in patients undergoing cryoballoon ablation for treatment of atrial fibrillation: the independent role of sleep-disordered breathing

Predictors of AF Recurrence After Cryoballoon PVI. Introduction: In patients with atrial fibrillation (AF) undergoing pulmonary vein isolation, cryoballoon technique (cryoPVI) has been adopted in many centers. This study aimed to evaluate predictors of AF recurrence including impact of sleep‐disordered breathing (SDB). Methods and Results: In 82 patients consecutively assigned to cryoPVI cardiorespiratory screening for SDB, assessment of medical history, ECG, echocardiography, standard laboratory measurement, and blood gas analysis were performed prior to intervention. After a 3‐month blanking period, a 7‐day Holter ECG was performed at 3, 6 and then every 6 months to determine AF recurrence. Seventy‐five patients (69 paroxysmal AF, 6 persistent AF, 22 female, age 60 ± 9 years) completed at least 6‐month follow‐up. Median follow‐up of 12 months (interquartile range 6–18 months) confirmed maintenance of sinus rhythm in 69.4% of these patients. Stepwise forward regression model revealed moderate to severe SDB (cut‐off apnea‐hypopnea‐index (AHI) ≥ 15 per hour; Hazard Ratio (HR) 2.95, P = 0.04), early recurrence of AF (HR 8.74, P < 0.001), persistent AF (HR 7.16, P < 0.001), preprocedural class III‐antiarrhythmic drug treatment (HR 3.63, P = 0.02), but not SDB per se (AHI ≥ 5 per hour) as independent predictors for AF recurrence. Conclusion: Moderate to severe SDB is a treatable condition that independently predicts AF recurrence in patients undergoing cryoPVI. Screening for SDB and adequate treatment may improve long‐term success of cryoPVI. (J Cardiovasc Electrophysiol, Vol. 23, pp. 18‐25, January 2012)