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      Left ventricular heart failure and pulmonary hypertension

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          Abstract

          In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65–80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging, yet it has direct therapeutic consequences. Despite recent advances in the pathophysiological understanding and clinical assessment, and adjustments in the haemodynamic definitions and classification of PH-LHD, the haemodynamic interrelations in combined post- and pre-capillary PH are complex, definitions and prognostic significance of haemodynamic variables characterizing the degree of pre-capillary PH in LHD remain suboptimal, and there are currently no evidence-based recommendations for the management of PH-LHD. Here, we highlight the prevalence and significance of PH and RV dysfunction in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), and provide insights into the complex pathophysiology of cardiopulmonary interaction in LHD, which may lead to the evolution from a ‘left ventricular phenotype’ to a ‘right ventricular phenotype’ across the natural history of HF. Furthermore, we propose to better define the individual phenotype of PH by integrating the clinical context, non-invasive assessment, and invasive haemodynamic variables in a structured diagnostic work-up. Finally, we challenge current definitions and diagnostic short falls, and discuss gaps in evidence, therapeutic options and the necessity for future developments in this context.

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          Most cited references 76

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          ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association.

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            2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).

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              Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial.

              Results of previous studies support the hypothesis that implantable haemodynamic monitoring systems might reduce rates of hospitalisation in patients with heart failure. We undertook a single-blind trial to assess this approach. Patients with New York Heart Association (NYHA) class III heart failure, irrespective of the left ventricular ejection fraction, and a previous hospital admission for heart failure were enrolled in 64 centres in the USA. They were randomly assigned by use of a centralised electronic system to management with a wireless implantable haemodynamic monitoring (W-IHM) system (treatment group) or to a control group for at least 6 months. Only patients were masked to their assignment group. In the treatment group, clinicians used daily measurement of pulmonary artery pressures in addition to standard of care versus standard of care alone in the control group. The primary efficacy endpoint was the rate of heart-failure-related hospitalisations at 6 months. The safety endpoints assessed at 6 months were freedom from device-related or system-related complications (DSRC) and freedom from pressure-sensor failures. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00531661. In 6 months, 83 heart-failure-related hospitalisations were reported in the treatment group (n=270) compared with 120 in the control group (n=280; rate 0·31 vs 0·44, hazard ratio [HR] 0·70, 95% CI 0·60-0·84, p<0·0001). During the entire follow-up (mean 15 months [SD 7]), the treatment group had a 39% reduction in heart-failure-related hospitalisation compared with the control group (153 vs 253, HR 0·64, 95% CI 0·55-0·75; p<0·0001). Eight patients had DSRC and overall freedom from DSRC was 98·6% (97·3-99·4) compared with a prespecified performance criterion of 80% (p<0·0001); and overall freedom from pressure-sensor failures was 100% (99·3-100·0). Our results are consistent with, and extend, previous findings by definitively showing a significant and large reduction in hospitalisation for patients with NYHA class III heart failure who were managed with a wireless implantable haemodynamic monitoring system. The addition of information about pulmonary artery pressure to clinical signs and symptoms allows for improved heart failure management. CardioMEMS. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                Eur Heart J
                Eur. Heart J
                eurheartj
                ehj
                European Heart Journal
                Oxford University Press
                0195-668X
                1522-9645
                21 March 2016
                27 October 2015
                27 October 2015
                : 37
                : 12 , Focus Issue on Hypertension
                : 942-954
                Affiliations
                [1 ]Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln , Kerpener Str. 62, 50937 Köln, Germany
                [2 ]Cologne Cardiovascular Research Center (CCRC), Universität zu Köln , Köln, Germany
                [3 ]National Heart and Lung Institute (NHLI), Imperial College London , London, UK
                [4 ]Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital London , London, UK
                [5 ]Klinik für Kardiologie und Pneumologie, Herzzentrum, Georg-August-Universität, Universitätsmedizin Göttingen , Göttingen, Germany
                [6 ]German Cardiovascular Research Center (DZHK) , Göttingen, Germany
                [7 ]Division of Cardiology, University of California San Francisco (UCSF) , San Francisco, CA, USA
                [8 ]Department of Pneumology, VU University Medical Center , Amsterdam, The Netherlands
                [9 ]Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles , Brussels, Belgium
                Author notes
                [* ]Corresponding author. Tel: +49 221 478 32356, Fax: +49 221 478 32355, Email: stephan.rosenkranz@ 123456uk-koeln.de
                [†]

                The authors are members of the Working Group on the Pulmonary Circulation and Right Ventricular Function (S.R., J.S.R.G., A.V.-N., and J.-L.V.) and/or the Heart Failure Association (HFA) (R.W.), European Society of Cardiology (ESC), and/or the International Society for Heart and Lung Transplantation (ISHLT) (T.D.M. and J.-L.V.).

                Article
                ehv512
                10.1093/eurheartj/ehv512
                4800173
                26508169
                © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

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                Categories
                Review
                Clinical Update

                Cardiovascular Medicine

                pulmonary hypertension, heart failure, pre-capillary, post-capillary

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