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      Interpretación de la relación presión-flujo en la hipertensión arterial pulmonar idiopática Translated title: Pressure-flow relationships interpretation in idiopathic pulmonary arterial hypertension

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          Abstract

          Objetivo: Conocer más de la relación presión arterial pulmonar media/índice cardiaco y sus perfiles en enfermos con hipertensión arterial pulmonar idiopática. Métodos: La presión arterial pulmonar media/índice cardiaco y la presión extrapolada al eje de cero flujo se obtuvo en 40 enfermos respirando aire ambiente, oxígeno 99.5% e hidralazina. Se obtuvieron dos grupos de acuerdo a criterios de "respuesta vasodilatadora aguda", respondedores (n = 20) y no respondedores (n = 20). Se analizó este criterio versus el propuesto por la Task Force de la Sociedad Europea de Cardiología en la población respondedora. Resultados: La presión arterial pulmonar media/Índice cardiaco se ubicó de forma anormal en el diagrama de presión-flujo de la cohorte total, (p < 0.01). Sin alteraciones en el intercambio gaseoso o mecánica pulmonar. Para los enfermos respondedores versus no respondedores, la pendiente fue anormal 2.2 (95%IC:1.1-3.3) vs. 5.89 (95%IC:4.69-7.11) mm Hg/L min/m² e incremento de la presión extrapolada al eje de cero flujo (38.2 ± 7.5 a 66.3 ± 7.5 mm Hg, p < 0.01). Sin diferencias con oxígeno al 99.5%. Con vasodilatador, la presión arterial pulmonar media disminuyó (52.1 ± 9.5 a 40 ± 5.5 mm Hg, p < 0.01) vs. no se modificó (96.2 ± 8.5 vs. 90 ± 7.5 mmHg, p = 0.3), pendiente 1.15 (95%IC:0.68-1.62) vs. 1.28 (95%IC:0.78-1.78) mmHg/Lmin/m², la presión extrapolada al eje de cero flujo no cambió vs. incrementó (69.4 ± 7.8 a 85.1 ± 8.5 mm Hg, p < 0.01), en relación al control. En no respondedores con vasodilatador, la presión arterial pulmonar media/índice cardiaco (90 ± 7.5 mmHg, pendiente:1.28; 95%IC: 0.78 - 1.78 mm Hg/L min/m²) fue diferente al comparar respondedores con menor o mayor de 40 mm Hg de presión arterial pulmonar media. Presiones 34 ± 3 vs. 45 ± 4 mm Hg y pendientes 1.14 (95%IC: 0.67 -1.61 vs. 2.22 (95%IC: 1.35 - 3.09 mm Hg/L min/m²), respectivamente p < 0.01. Conclusiones: Las anormalidades de la relación presión arterial pulmonar media/Índice cardiaco reflejan el incremento de las resistencias vasculares pulmonares reales a nivel arteriolar pulmonar en enfermos con hipertensión arterial pulmonar idiopática. Ambos criterios de respuesta vasodilatadora aguda son de utilidad para identificar respondedores y no, en esta población de enfermos.

          Translated abstract

          Objectives: We analyze exercise-derived mean pulmonary artery pressure/cardiac index relationship to expand the concepts regarding its nature and to better identify "responders" in idiopathic pulmonary arterial hypertension patients. Methods: Mean pulmonary artery pressure/cardiac index relationship and extrapolated pressure to zero flow were obtained in 40 patients' breathing room air, oxygen 99.5% and hydralazine. The hemodynamic characteristics were analyzed for the cohort and separate for responders (n = 20) and non responders (n = 20) according to the acute response to vasodilator. We tested this previous criteria versus the Task Force on diagnosis and treatment prescribed by the European Society of Cardiology. Results: The mean pulmonary arterial pressure/cardiac index was located abnormally in the pressure-flow diagram of the total cohort (p < 0.01). No alterations in gas exchange or lung mechanics. For patients responders versus non-responders, the slope was abnormal 2.2 (95% CI:1.1-3.3) vs. 5.89 (95% CI: 4.69 - 7.11), mm Hg/L min/m² and increased extrapolated pressure to zero flow (38.2 ± 7.5 to 66.3 ± 7.5 mm Hg, p <0.01). Without difference with oxygen 99.5%. With vasodilator effect, mean pulmonary arterial pressure decreased (52.1 ± 9.5 to 40 ± 5.5 mm Hg, p <0.01) versus it did not change (96.2 ± 8.5 versus 90 ± 7.5 mm Hg, p=0.3), slope 1.15 (95% CI: 0.68 - 1.62) vs. 1.28 (95% CI: 0.78-1.78) mmHg/L min/m², the extrapolated pressure to zero flow did not change (69.4 ± 7.8 to 85.1 ± 8.5 mm Hg), p <0.01, compared to control. In non-responders with vasodilator, mean pulmonary arterial pressure/cardiac index (90 ± 7.5 mmHg, slope: 1.28, 95% CI :0.78 - 1.78 mm Hg/L min/m²) was different between responders < or > 40 mmHg mean pulmonary arterial pressure. Pressures were 34 ± 3 vs. 45 ± 4 mm Hg and slopes 1.14 (95% CI: 0.67 - 1.61) vs. 2.22(95% CI: 1.35 - 3.09) mm Hg/L min/m², p <0.01, respectively.. Conclusions: Abnormalities of the mean pulmonary arterial pressure/cardiac index relationship exercise-derived seems to reflect "mainly arteriolar" increased lineal pulmonary vascular resistance in idiopathic pulmonary arterial hypertension patients. Both acute vasodilator response criteria are useful to identify responders and not responders in this patient population.

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          Most cited references 72

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          Survival in patients with primary pulmonary hypertension. Results from a national prospective registry.

          To characterize mortality in persons diagnosed with primary pulmonary hypertension and to investigate factors associated with survival. Registry with prospective follow-up. Thirty-two clinical centers in the United States participating in the Patient Registry for the Characterization of Primary Pulmonary Hypertension supported by the National Heart, Lung, and Blood Institute. Patients (194) diagnosed at clinical centers between 1 July 1981 and 31 December 1985 and followed through 8 August 1988. At diagnosis, measurements of hemodynamic variables, pulmonary function, and gas exchange variables were taken in addition to information on demographic variables, medical history, and life-style. Patients were followed for survival at 6-month intervals. The estimated median survival of these patients was 2.8 years (95% Cl, 1.9 to 3.7 years). Estimated single-year survival rates were as follows: at 1 year, 68% (Cl, 61% to 75%); at 3 years, 48% (Cl, 41% to 55%); and at 5 years, 34% (Cl, 24% to 44%). Variables associated with poor survival included a New York Heart Association (NYHA) functional class of III or IV, presence of Raynaud phenomenon, elevated mean right atrial pressure, elevated mean pulmonary artery pressure, decreased cardiac index, and decreased diffusing capacity for carbon monoxide (DLCO). Drug therapy at entry or discharge was not associated with survival duration. Mortality was most closely associated with right ventricular hemodynamic function and can be characterized by means of an equation using three variables: mean pulmonary artery pressure, mean right atrial pressure, and cardiac index. Such an equation, once validated prospectively, could be used as an adjunct in planning treatment strategies and allocating medical resources.
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            CIRCULATION

             K Nielsen (1972)
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              Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension.

              Characteristics of patients with idiopathic pulmonary arterial hypertension (IPAH) who benefit from long-term calcium channel blockers (CCB) are unknown. Acute pulmonary vasodilator testing with epoprostenol or nitric oxide was performed in 557 IPAH patients. Acute responders, defined by a fall in both mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) >20%, received long-term oral CCB. Patients who benefit from long-term CCB were defined as those being in New York Heart Association (NYHA) functional class I or II after at least 1 year on CCB monotherapy. Among the 70 patients who displayed acute pulmonary vasoreactivity (12.6%; 95% CI, 9.8% to 15.3%) and received CCB therapy, only 38 showed long-term improvement (6.8%; 95% CI, 4.7% to 8.9%). Long-term CCB responders had less severe disease at baseline than patients who failed. During acute vasodilator testing, long-term CCB responders displayed a more pronounced fall in mean PAP (-39+/-11% versus -26+/-7%; P<0.0001), reaching an absolute value of mean PAP lower than that measured in patients who failed (33+/-8 versus 46+/-10 mm Hg; P<0.0001). After 7.0+/-4.1 years, all but 1 long-term CCB responders were alive in NYHA class I or II, with a sustained hemodynamic improvement. In the group of patients who failed on CCB, the 5-year survival rate was 48%. Long-term CCB responders represent <10% of IPAH patients evaluated in a pulmonary vascular referral center. During acute vasodilator testing, these patients showed significantly lower levels of both mean PAP and PVR, which reached near-normal values.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                acm
                Archivos de cardiología de México
                Arch. Cardiol. Méx.
                Elsevier (México )
                1405-9940
                September 2010
                : 80
                : 3
                : 163-173
                Affiliations
                [1 ] Instituto Nacional de Cardiología Ignacio Chávez Mexico
                [2 ] Instituto Nacional de Cardiología Ignacio Chávez Mexico
                Article
                S1405-99402010000300004
                Product
                Product Information: website
                Categories
                Cardiac & Cardiovascular Systems

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