Left and right ventricular power: outputs are the strongest hemodynamic correlates to allow identification of acute responders to vasodilator treatment in idiopathic pulmonary arterial hypertension
El poder del ventrículo derecho y del izquierdo: son parámetros hemodinámicos que correlacionan con la posibilidad de ser respondedor durante el reto agudo con vasodilatadores en la hipertensión arterial pulmonar idiopática
Eulo Lupi-Herreraa, Julio Sandovalb, Javier Figueroaa, Arturo Carrillob, Rebeca Aguirrec, Luis Efren Santos-Martínezd, Tomás Pulidob
a Sub-Direction of Clinical-Research.
b Cardiopulmonary-Department, Instituto Nacional de Cardiología Ignacio Chávez.
c Epidemiology-Department, School of Medicine, UNAM.
d Cardiopulmonary-Department, Instituto Nacional de Cardiología Ignacio Chávez. UMAE Cardiología Centro Médico Nacional Siglo XXI, IMSS.
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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Cardiopulmonary-Department, Instituto Nacional de Cardiología Ignacio Chávez." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Epidemiology-Department, School of Medicine, UNAM." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Cardiopulmonary-Department, Instituto Nacional de Cardiología Ignacio Chávez. UMAE Cardiología Centro Médico Nacional Siglo XXI, IMSS. " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El poder del ventrículo derecho y del izquierdo: son parámetros hemodinámicos que correlacionan con la posibilidad de ser respondedor durante el reto agudo con vasodilatadores en la hipertensión arterial pulmonar idiopática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v81n02-90024005fig5.jpg" "Alto" => 637 "Ancho" => 991 "Tamanyo" => 55228 ] ] "descripcion" => array:1 [ "en" => "90024005fig5.jpg" width="991" height="637" alt="Figure 1. LVPO/RVPO behavior for responders and non-responders at baseline (B), during acute vasodilating (AV) and at long-term (LT) RHC. Differences are noted between B, AV trial, and at LT for the responder cohort; also between responders and non-responders at B, AV, and LT RHC. Lamda-Wilkin" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Abbreviations: <br></br></span>CO = cardiac output<br></br> CPO = cardiac power output <br></br> CCB = calcium channel blockers <br></br> iNO = inhaled nitric oxide <br></br> IPAH = idiopathic pulmonary artery hypertension <br></br> LVPO = left ventricular power output <br></br> mPWP = mean pulmonary wedge pressure <br></br> mPAP = mean pulmonary artery pressure <br></br> mRAP = mean right atrial pressure <br></br> mSAP = mean systemic arterial pressure <br></br> PAH = pulmonary artery hypertension <br></br> PVR = pulmonary vascular resistance <br></br> PVR/SVR = pulmonary vascular-to-systemic resistance ratio <br></br> RHC = right heart catheterization <br></br> RVPO = right ventricular power output <br></br> SVR = systemic vascular resistance</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">The criteria to define a responder or non-responder based on changes in mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) during an acute vasodilation challenge have been questioned in recent years in idiopathic pulmonary artery hypertension (IPAH).<span class="elsevierStyleSup">1-8</span> Instead, a positive acute vasoreactive response is now defined as a reduction of the mPAP ≥ 10 mmHg to an absolute value of mPAP ≤ 40 mmHg, with increased/ unchanged cardiac output (CO).<span class="elsevierStyleSup">8</span> Accordingly, only about 6 to 15% of the IPAH population fulfills these criteria based on a retrospective experience, derived from hemodynamic characteristics of patients who benefited from long-term calcium channel blockers (CCBs) treatment.<span class="elsevierStyleSup">8,9</span></p><p class="elsevierStylePara">Despite significant advances in IPAH, right ventricular failure (RVF) remains the common fatal pathway and consequence of PAH.<span class="elsevierStyleSup">1-8</span> The principles used to determine the external work of the heart can be applied to measure either the hydraulic energy associated with blood flow at "<span class="elsevierStyleItalic">any point in the circulation</span>" or the energy dissipated by flow through a particular vascular bed.<span class="elsevierStyleSup">10</span> Thus, for the RV and pulmonary vascular circuit, it will be the product of flow output and pulmonary artery pressure, the rate of useful work done, or right ventricular power output (RVPO).<span class="elsevierStyleSup">10-12</span> Therefore, by coupling the mPAP and CO domains of the cardiopulmonary system, we will obtain a measure of the RV performance in IPAH. Besides, some studies have shown that left ventricular power output (LVPO) is a good indicator of cardiac function.<span class="elsevierStyleSup">10,11</span> On this functional basis,<span class="elsevierStyleSup">10-12</span> we previously found differences in RVPO in a small cohort of IPAH patients who were considered to be responders or non-responders.<span class="elsevierStyleSup">13</span> To extend this limited hemodynamic observation, the objective of our present study was to investigate the definitive role for RVPO and LVPO to identify better responders among IPAH patients. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Method</span></p><p class="elsevierStylePara">Our protocol was approved by the institutional ethics review commission. All patients were born and raised at an altitude of 2240 m and were permanent residents of Mexico City. The IPAH diagnosis was based on both clinical and hemodynamic criteria and by excluding other conditions known to cause PAH: 1) PAH associated with anorexigens, connective tissue disease, congenital heart disease, portal hypertension, or HVI infection; 2) chronic thromboembolic pulmonary hypertension; and, 3) other chronic respiratory diseases.<span class="elsevierStyleSup">1-4,8 </span>Pulmonary hypertension was defined by a resting mPAP ≥ 25 mmHg during RHC, with a mean pulmonary wedge pressure (mPWP) ≤ 15 mmHg and a PVR greater than three Wood units.<span class="elsevierStyleSup">14,15 </span></p><p class="elsevierStylePara">We retrospectively studied the medical records of 134 consecutive adult patients hospitalized in our institution between 1997 and 2007, with a diagnosis of IPAH. A total of 90 patients fulfilled the following criteria for inclusion in the study: (1) a complete RHC at baseline, (2) an acute I.V. vasodilator-drug challenge to assess vasodilator response, and (3) chronic oral nifedipine therapy was initiated in patients who displayed significant acute pulmonary vasodilatation. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Hemodynamic measurements: </span>Our procedure for RHC has been described previously.<span class="elsevierStyleSup">2,13,16,17</span> The following measurements were obtained: mean right atrial pressure (mRAP), mPAP, mPWP, CO (was measured by triplicate by the thermodilution method),<span class="elsevierStyleSup">2,13,16,17</span> and mean systemic arterial pressure (mSAP). The following parameters were derived using traditional equations: PVR, systemic vascular resistance (SVR), and pulmonary vascular-to-systemic resistance ratio (PVR/SVR). LVPO was calculated as mSAPxCO/451 and RVPO was calculated as mPAPxCO/451.<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">As an important part of our catheterization protocol, we routinely assess the response to oxygen breathing to exclude the role of alveolar hypoxia in the genesis of PAH (our definition of IPAH at our moderate altitude includes the absence of a positive response to 99.9%O<span class="elsevierStyleInf">2</span> breathing).<span class="elsevierStyleSup">16,17</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Acute Vasodilating Trial: </span>For acute vasodilating testing we used adenosine, supported by the studies of Schrader<span class="elsevierStyleSup">18</span> and Sandoval,<span class="elsevierStyleSup">19 </span>who observed a significant correlation between the reduction in PVR resulting from adenosine and that achieved by the administration of nifedipine. Furthermore, adenosine is considered today an acceptable alternative to the preferred vasodilator: inhaled nitric oxide (iNO).<span class="elsevierStyleSup">14,15</span></p><p class="elsevierStylePara">Based on the hemodynamic response, we separated the patients into two groups: responders and non-responders. Our criteria for an "<span class="elsevierStyleItalic">acute positive response</span>" to vasodilators included: 1) a decrease in mPAP, 2) an increase in CO; and, 3) a decrease in PVR (≥ 20% from baseline, respectively).<span class="elsevierStyleSup">2,16 </span>When the above criteria were met, a patient was considered for treatment with nifedipine. <span class="elsevierStyleItalic">"Responder</span>" patients were administered oral doses of nifedipine (10 mg 3-4 times/day); then, daily doses were titrated to 20 mg, 3-4 times/day, provided the patient did not exhibit side effects.<span class="elsevierStyleSup">4</span> Long-term nifedipine responders were defined as patients with hemodynamic improvement (a sustained decrease in mPAP and an increase in CO ≥ 20%) with at least ≥ 12 months on nifedipine without addition of other modern modalities of therapy for IPAH.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Data analysis: </span>We: 1) analyzed the clinical and hemodynamic characteristics of our patients for the whole group (n = 90) and separately for those considered to be responders (n = 34) or non-responders (n = 56); 2) evaluated the ability for LVPO, RVPO, and their ratio to identify responders; 3) compared the Task Force criteria (a decrease in mean PAP by at least 10 mmHg to an absolute of less than 40 mmHg without a decrease in CO)<span class="elsevierStyleSup">8,14,15</span> with our acute positive criteria to identify responders; 4) compared both criteria among responders; and 5) assessed the long-term response to nifedipine. </p><p class="elsevierStylePara">Data are expressed as mean ± SD, median (min,max) and frequencies (percentages) as appropriate. A Student <span class="elsevierStyleItalic">t </span>test, 1-way-ANOVA (Bonferroni's-test for multiple comparison), <span class="elsevierStyleItalic">chi square</span>, or Fisher exact test was used as appropriate. Univariate analysis based on the logistic regression model was used to examine the relation between responders or non-responders and selected demographics, medical history, and hemodynamic variables that were measured at initial RHC. Results are expressed as odds ratio with 95% CI. Upon completion of the univariate analysis, any variable whose univariate test produced a value of <span class="elsevierStyleItalic">p</span> < 0.25 was considered a candidate for the multivariate model. Inclusions in the final multivariate logistic regression model were determined by those variables associated with a significance level of <span class="elsevierStyleItalic">p</span> < 0.05 in a stepwise elimination process. After the predictor variables in the regression model had been finalized, two statistical tests were performed to assess the model performance: the Hosmer-Lemeshow statistics and the ROC curve. Analyses were performed using SPSS-13 software. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Demographic/clinical characteristics: </span>According to the NYHA/WHO classification, there were no class IIIIV responders and no class-I non-responders (<span class="elsevierStyleBold">Table 1</span>). Treatments, such as subcutaneous treprostinil (n = 12), sitaxsentan (n = 8), bosentan (n = 10), ambrisentan (n = 5) and sildenafil (n = 21), were only distributed in nonresponders. Fourteen non-responders in classes III-IV were electively sent for graded atrial septostomy.<span class="elsevierStyleSup">17</span> Mortality associated to sudden death occurred in one responder and two non-responders and to refractory RVF in seven nonresponders. </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig1.jpg" alt="Table 1. Clinical and demographic data."></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Baseline hemodynamics</span>: When we compared responders and non-responders, no differences in mPAP (<span class="elsevierStyleItalic">p</span> = 0.07), CO (<span class="elsevierStyleItalic">p</span> = 0.7), mPWP (0.87), PVR (0.08), and PVR/ SVR ratio (<span class="elsevierStyleItalic">p</span> = 0.08) were observed. Differences were observed for mRAP, LVPO, RVPO and LVPO/RVPO (<span class="elsevierStyleItalic">p</span> < 0.001; for all measurements, <span class="elsevierStyleBold">Table 2</span>). </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig2.jpg" alt="Table 2. Hemodynamic data at baseline and during acute vasodilation testing."></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Acute response to vasodilating: </span>The following changes in hemodynamic parameters were observed in the responders (34/90, 37.7%): a decrease from baseline mRAP, mPAP, and PVR values (-20%, <span class="elsevierStyleItalic">p </span>< 0.045; - 31.5%, <span class="elsevierStyleItalic">p </span>< 0.001; - 45%, <span class="elsevierStyleItalic">p</span> < 0.001, respectively), no change in mPWP (<span class="elsevierStyleItalic">p</span> = 0.901), an increase in CO (+ 36.9%, <span class="elsevierStyleItalic">p</span> < 0.001), and a decrease in PVR/SVR ratio (<span class="elsevierStyleItalic">p</span> < 0.001, Table 2). During the vasodilator trial, RVPO <span class="elsevierStyleItalic">decreased</span> (<span class="elsevierStyleItalic">p </span>< 0.001), LVPO (<span class="elsevierStyleItalic">p </span>= 0.012) <span class="elsevierStyleItalic">increased</span> and LVPO/RVPO <span class="elsevierStyleItalic">increased</span>. No differences from baseline mPAP (fall), RVPO (decrease), LVPO (increase), and LVPO/ RVPO (increase) reached during acute vasodilator testing among responders were observed when the Task Force<span class="elsevierStyleSup">8,14</span> and our criteria were compared (<span class="elsevierStyleBold">Table 3</span>). </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig3.jpg" alt="Table 3. Hemodynamic values reached during vasodilator testing in acute responders according to the task force and our criteria."></img></p><p class="elsevierStylePara">For the non-responders (56/90, 62.2%), mRAP (<span class="elsevierStyleItalic">p</span> = 0.275), mPAP (<span class="elsevierStyleItalic">p </span>= 0.222), PVR (<span class="elsevierStyleItalic">p</span> = 0.37), and mPWP (<span class="elsevierStyleItalic">p </span>= 0.81) did not change; CO increased (+ 12%, <span class="elsevierStyleItalic">p</span> < 0.001); mSAP decreased (<span class="elsevierStyleItalic">p </span>< 0.002); and the PVR/SVR ratio did not change (<span class="elsevierStyleItalic">p</span> = 0.243). During the acute vasodilator trial, RVPO <span class="elsevierStyleItalic">increased</span> (p < 0.001), LVPO (p = 0.125) and LVPO/RVPO (<span class="elsevierStyleItalic">p</span> = 0.467) <span class="elsevierStyleItalic">did not change</span>. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Hemodynamics and NYHA classes: </span>mRAP was different among classes (class I: 5.5 ± 3.4, class II: 9.9 ± 4.2, class III: 11.4 ± 3, and class IV: 18 ± 0.1 mmHg; <span class="elsevierStyleItalic">p</span> < 0.001). For mPAP, CO, PVR, RVPO, LVPO, and LVPO/RVPO no differences were documented among classes. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Long-term evaluation: </span>Was performed by a repeat RHC in 30 responders under chronic nifedipine (this cohort includes 16 patients who did not fulfill the Task Force criteria<span class="elsevierStyleSup">8,15</span> at the initial RHC) and in 42 non-responders treated with the other forms of therapy (<span class="elsevierStyleBold">Table 4</span>). Long-term nifedipine-treated responders, according to the Task Force<span class="elsevierStyleSup">8,15</span> or our criteria, did not differ in terms of treatment regimen: the mean daily doses of nifedipine were 59 ± 15 mg (range 40-80 mg, n = 14), 62 ± 14 mg (range 40-80, n = 16), <span class="elsevierStyleItalic">p</span> = 0.27; and nifedipine therapy duration (6.4 ± 3.5 <span class="elsevierStyleItalic">versus</span> 6.3 ± 2.9 years, <span class="elsevierStyleItalic">p</span> = 0.85, respectively).</p><p class="elsevierStylePara"><img src="293v81n02-90024005fig4.jpg" alt="Table 4. Long-term hemodynamic evaluation."></img></p><p class="elsevierStylePara">For responders, mRAP (<span class="elsevierStyleItalic">p</span> = 0.05) and mPAP (<span class="elsevierStyleItalic">p</span> < 0.001) remained low; CO was still <span class="elsevierStyleItalic">increased</span> (<span class="elsevierStyleItalic">p</span> < 0.002); the PVR/SVR ratio (<span class="elsevierStyleItalic">p</span> = 0.01) and RVPO (<span class="elsevierStyleItalic">p</span> < 0.04) remained <span class="elsevierStyleItalic">decreased</span> and LVPO <span class="elsevierStyleItalic">increased</span> (<span class="elsevierStyleItalic">p</span> < 0.001) after 6.4 ± 3.1 years of follow-up (<span class="elsevierStyleBold">Table 4</span>). For the LVPO/RVPO, a further increase was documented in comparison to the acute evaluation among responders (<span class="elsevierStyleItalic">p</span> < 0.001). For this group, the patients remained in I-II classes. </p><p class="elsevierStylePara">For non-responders, mPAP (<span class="elsevierStyleItalic">p</span> = 0.473), mRAP (<span class="elsevierStyleItalic">p</span> = 0.494), CO (<span class="elsevierStyleItalic">p</span> = 0.121), RVPO (<span class="elsevierStyleItalic">p</span> = 0.1), LVPO (<span class="elsevierStyleItalic">p</span> = 0.193), and LVPO/RVPO did not change. The same initial abnormal hemodynamic profile was observed after 6.1 ± 3.2 years. In this group, the patients remained in classes II-III. When we compared the hemodynamic evolution over time of the responders versus the non-responders, the responders displayed a <span class="elsevierStyleItalic">decreased</span> mRAP (<span class="elsevierStyleItalic">p </span>< 0.001), mPAP (<span class="elsevierStyleItalic">p</span> < 0.001) and RVPO (<span class="elsevierStyleItalic">p</span> < 0.01) and an<span class="elsevierStyleItalic"> increased </span>CO (<span class="elsevierStyleItalic">p</span> < 0.001), LVPO (<span class="elsevierStyleItalic">p</span> < 0.001), and LVPO/RVPO (<span class="elsevierStyleItalic">p</span> < 0.001, <span class="elsevierStyleBold">Figure 1</span>). </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig5.jpg" alt="Figure 1. LVPO/RVPO behavior for responders and non-responders at baseline (B), during acute vasodilating (AV) and at long-term (LT) RHC. Differences are noted between B, AV trial, and at LT for the responder cohort; also between responders and non-responders at B, AV, and LT RHC. Lamda-Wilkins (F = 75.87; p < 0.001). U-Man-Whitney test."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1. </span>LVPO/RVPO behavior for responders and non-responders at baseline (B), during acute vasodilating (AV) and at long-term (LT) RHC. Differences are noted between B, AV trial, and at LT for the responder cohort; also between responders and non-responders at B, AV, and LT RHC. Lamda-Wilkins (F = 75.87; <span class="elsevierStyleItalic">p </span>< 0.001). U-Man-Whitney test.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Univariate analysis: </span>Variables associated with an acute responder included: age (<span class="elsevierStyleItalic">p</span> = 0.03), estimated symptom duration (<span class="elsevierStyleItalic">p</span> = 0.02), mRAP (<span class="elsevierStyleItalic">p</span> < 0.001), mPAP (<span class="elsevierStyleItalic">p</span> < 0.001), RVPO (<span class="elsevierStyleItalic">p </span>= 0.007), and LVPO (<span class="elsevierStyleItalic">p</span> = 0.036) (<span class="elsevierStyleBold">Table 5</span>). </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig7.jpg" alt="Table 5. Univariate variables entered into the multivariate model to be an acute responder."></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Multivariate analysis: </span>Age, RVPO, and LVPO remained as independent variables (OR = 0.927, 95% CI: 0.87-0.98, <span class="elsevierStyleItalic">p</span> = 0.01; OR = 0.114, 95% CI: 0.00-0.91, <span class="elsevierStyleItalic">p</span> = 0.045; and OR = 171.5, 95% CI: 5.3-549, <span class="elsevierStyleItalic">p</span> = 0.004, respectively) for estimating the probability of being a responder. According to the logistic multivariate analysis, the following equation was derived for identifying responders among patients = 1.0196-0.0631 (age) -4.7693(RVPO), +3.8152 (LVPO), ROC: 0.76, 95% CI: 0.63-0.89; <span class="elsevierStyleItalic">p</span> = 0.001. According to the results of the Hosmer-Lemeshow test (X<span class="elsevierStyleSup">2</span>: 9.234, DF = 8, <span class="elsevierStyleItalic">p</span> = 0.323) and the area value for the ROC curve (0.76, 95% CI: 0.63-0.89, <span class="elsevierStyleItalic">p</span>= 0.001), the derived model can be used to estimate the probability of being an acute responder among IPAH patients (<span class="elsevierStyleBold">Figure 2</span>). </p><p class="elsevierStylePara"><img src="293v81n02-90024005fig6.jpg" alt="Figure 2. The probability to be an acute responder patient when the model is applied to a value of 0.5 W for LVPO. For a patient aged 30 years with RVPO of 0.4 W, the probability to be a responder is 30%."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2. </span>The probability to be an acute responder patient when the model is applied to a value of 0.5 W for LVPO. For a patient aged 30 years with RVPO of 0.4 W, the probability to be a responder is 30%.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara">A critical reason for considering an "<span class="elsevierStyleItalic">acute positive</span>" response in IPAH is to identify patients whose response at entry RHC appears to predict better long-term prognoses.<span class="elsevierStyleSup">1-5</span> However, this also has important economic consequences (low price oral vasodilators <span class="elsevierStyleItalic">vs.</span> other expensive modern therapies). Thus, a continued search for hemo-dynamic markers that define better responsive patients is required. By using the proposed criteria from the Task Force<span class="elsevierStyleSup">8,14</span> or our criteria to identify responders among IPAH patients, it is possible to achieve this important goal in this population. However, using the Task Force criteria,<span class="elsevierStyleSup">8,14</span> responders will be identified in 17.7%, whereas our criteria identify 37.7% of the total IPAH patients, and among responders the Task Force criteria<span class="elsevierStyleSup">8,14</span> would identify only 53% of them. Consequently, the question arises as to which hemodynamic criteria are the most appropriate for achieving this important goal. If analyzed as a group, the responders could reach 38.2 mmHg, although a stringent cut-off value of 40 mmHg was not always achieved in association with a >20% increase in CO. Although, we must emphasize that we also observed a decrease in >10 mmHg for mPAP in our responders.<span class="elsevierStyleSup">8,14</span> In addition, the different hemodynamic behavior of the responders and non-responders in regard to RVPO, LVPO, and LVPO/RVPO reinforces our ability to identify responders among IPAH population. In our study we demonstrated a <span class="elsevierStyleItalic">decrease</span> in RVPO associated with an <span class="elsevierStyleItalic">increase</span> in LVPO and LVPO/RVPO for responder patients.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">NYHA/WHO-classification influence on the proportion of responders: </span>In our study, the acute response rate appears higher than other reported for adult IPAH patients.<span class="elsevierStyleSup">9</span> This may be explained, in part, by differences in the proportional NYHA classes distribution of the studied populations. In the cohort studied by Sitbon<span class="elsevierStyleSup">9</span> (n = 557), only 19% (n = 70) were class I-II patients. Thus, a low proportion of classes I-II were included compared to classes III-IV patients in the Sitbon study.<span class="elsevierStyleSup">9</span> On the contrary, in our series, 78.8% (71/90) were in classes I-II at initial RHC. </p><p class="elsevierStylePara">Consequently, we should emphasize that whenever responder patients are examined in IPAH studies, we must take into consideration the total of class I-II patients who are evaluated in the acute vasodilator challenge. Thus, differences in the acute response rate not only could result from the applied criteria, but also from the number of class I-II patients tested in relation to the number of class III-IV patients tested in an acute trial. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Long-term measurements: </span>The significant differences noted between responders and non-responders for RVPO, LVPO, and LVPO/RVPO at the initial RHC were confirmed at the RHC long-term follow-up. For patients under chronic nifedipine therapy, the RVPO <span class="elsevierStyleItalic">decreased</span> further, and LVPO <span class="elsevierStyleItalic">increased</span> to 1.15 ± 0.27 W, which is close to the resting normal values.<span class="elsevierStyleSup">10</span> These data suggest a persistent predominant vasodilator effect in the pulmonary vasculature and translates a sustained good RV pumping performance. For non-responders, a persistent abnormal elevation in mPAP, decreased CO, <span class="elsevierStyleItalic">increased</span> RVPO, and a <span class="elsevierStyleItalic">low abnormal resting</span> LVPO (0.67 + 0.15 W) were documented, resulting in a sustained hemodynamic profile that eventually must worsen the cardiac pumping ability. This condition could explain why a low long-term mortality was not associated in non-responders, but was related in the responder cohort (<span class="elsevierStyleBold">Table 1</span>). The hemodynamic findings for the coupling of RV-pulmonary circulation observed at long-term RHC further underscores the validity of our criteria of "<span class="elsevierStyleItalic">acute positive response</span>" applied at the initial RHC for the IPAH patients studied. Stibon<span class="elsevierStyleSup">9</span> was able to retrospectively define more stringent criteria at baseline, which identified the responders who would have sustained long-term benefit from CCBs. We were unable to demonstrate that such criteria at baseline predict the change from responder to non-responder status in 58% (14/24) of patients; our responders remained as responders at least up to 6.4 ± 3 years under nifedipine (<span class="elsevierStyleBold">Table 4</span>).</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">The model: </span>To test the proposed model, we examined Rich's<span class="elsevierStyleSup">4</span> study. The rate of responders obtained by Rich<span class="elsevierStyleSup">4</span> after the vasodilating test was 26%. When we applied our model to estimate the proportion of responders, among IPAH patients, the derived value was close to 30%. Thus, our model to predict an acute positive response is in reasonable agreement with previous information on the proportion of responders who have been observed with a similar age, tested acutely for vasodilation with nifedipine and long-term treated with CCBs.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Overall evaluation: </span>Based on our results, we propose that the hemodynamic behavior of RVPO and LVPO should be incorporated, in addition to the proposed criteria for the definition of a "<span class="elsevierStyleItalic">positive</span>" response to vasodilators. In this regard, there are several pathophysiological reasons to include RVPO for such clinical/hemodynamic stratification. As PAH develops, the distensibility of the elastic arteries decreases.<span class="elsevierStyleSup">8,20</span> Consequently, a larger amount of RV work must be expended to distend the stiff pulmonary arteriolar vessels. As a consequence, the pulsatile arterial power generated by the RV is an important proportion (35-40%) of the total external power.<span class="elsevierStyleSup">10</span> If we include only PVR, we are missing part of the RV load; whereas by determining RVPO, we obtain an approximate calculation of the pressure work generated by the RV, which is determined by flow output and the pulmonary arterial load.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Our findings for the proposed markers support that RVF is the main resulting cause of death in these patients.<span class="elsevierStyleSup">1-3,5,8</span> In non-responders with lower likelihood of survival, the behavior of RVPO and LVPO indicates that these patients are hemodynamically characterized with a reduced reserve of the pulmonary circulation associated with decreased RV function, resulting in an inappropriate RV-pulmonary arterial coupling and an inappropriate ventricular interaction.<span class="elsevierStyleSup">1,3,5</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Limitations: </span>Are essentially associated with the fact that the information is from a single cardiovascular referral center, located at moderate altitude. Although, we should emphasize that alveolar hypoxia was ruled out (as part of our IPAH definition);<span class="elsevierStyleSup">14</span> thus, our findings could be generalized for IPAH patients. Moreover, the number of patients included for testing RVPO and LVPO can be considered large because IPAH is a rare disease.<span class="elsevierStyleSup">1,5</span> We are aware that the retrospective nature of the study potentially introduces a selection bias. However, the information collected at the first RHC for the RVPO and LVPO was reproducible for all the patients at long-term follow-up RHC. We are also aware that 1) instantaneous (pulsatile) data on pressure and flow are essential for an accurate calculation of external ventricular work and an error using mPAP in combination with CO (instead of measured flow) will underestimate the true RVPO-LVPO in our RHC studies.<span class="elsevierStyleSup">10</span> 2) perhaps we cannot compare exactly the acute response to adenosine with that obtained with iNO or epoprostenol in class III-IV IPAH patients;<span class="elsevierStyleSup">14,15 </span>and, 3) due to the small number of deaths in the studied population, a mortality prognostic value could not be derived for RVPOLVPO. Mortality prognostic value for RVPO-LVPO that in the near future should be investigated in a larger population IPAH patients. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara">RVPO is a novel hemodynamic-derived measure that gives better insight into the RV-pulmonary arterial coupling nature and, in conjunction with LVPO and LVPO/RVPO, for the overall hemodynamics in IPAH. RVPO and LVPO result in good hemodynamic tools that should be added to the existing ones to identify responders among IPAH patients. </p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleItalic">Corresponding author:</span> Eulo Lupi Herrera. <br></br> Director de la Línea de Servicio de la División Cardiovascular Centro Médico ABC. Sur 136 N° 116. Col. Las Américas, 01120, México, D.F. México. <br></br> Telephone: 52 308 000 Extension: 3762. <span class="elsevierStyleItalic"><br></br> E-mail:</span><a href="mailto:elupih@abchospital.com" class="elsevierStyleCrossRefs">elupih@abchospital.com</a>, <a href="mailto:eulolupiherrera@hotmail.com" class="elsevierStyleCrossRefs">eulolupiherrera@hotmail.com</a></p> Received on April 16, 2009; <br></br> accepted on September 28, 2010. " "pdfFichero" => "293v81n02a90024005pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec192357" "palabras" => array:1 [ 0 => "Hipertensión pulmonar idiopática; Poder del ventrículo derecho; Poder del ventrículo izquierdo; Respondedores; México" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec192356" "palabras" => array:1 [ 0 => "Idiopathic pulmonary hypertension; Right/left ventricular power output, Responders; Mexico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Introduction: Despite the prognostic importance of traditionally derived measurements, the significance of right heart catheterization (RHC) remains controversial. Thus, a continued search for hemodynamic markers that define better responsive patients is required. Since, right ventricular failure is the most fatal pathway, right (RVPO) and left (LVPO) ventricular power output are parameters that could provide input for a better understanding of the hemodynamics involved in idiopathic pulmonary artery hypertension (IPAH). Method: We retrospectively analyzed how demographics and outcome correlate with hemodynamics to identify responders among IPAH patients. Results: Ninety patients fulfilled the following criteria for inclusion in this study: (1) complete RHC at baseline; (2) an acute evaluation for vasodilators (AEFV, including a positive response, that is, an increase in CO, a decrease in both mPAP and pulmonary vascular resistance ≥ 20% from baseline, respectively); and (3) a long-term follow-up under accepted IPAH treatments. If RVPO decreased (p < 0.001) and LVPO increased (p < 0.012) during AEFV, it is considered that these findings reinforce our ability to identify responders; that is, patients that remained as responders after 6.4 ± 3 years under nifedipine treatment (37.7% of the studied IPAH population). After multivariate analysis, age, RVPO, and LVPO remained as independent variables (OR = 0.927, 95%CI: 0.87-0.98, p = 0.01; OR = 0.114, 95%CI: 0.00-0.91, p = 0.045; and OR = 171.5, 95% CI: 5.3-549, p = 0.004, respectively) when estimating the probability of being a responder. On this basis, an equation was derived to identify responders among IPAH patients, where the probability of being a responder = 1.0196-0.0631 (age) - 4.7693 (RVPO) + 3.8152 (LVPO), ROC: 0.76, 95% CI: 0.63-0.89; p = 0.001. Conclusion: based on the proposed equation, LVPO and RVPO could be used for the identification of responders among IPAH patients." ] "es" => array:1 [ "resumen" => "Introducción: A pesar de la importancia y del significado pronóstico que tienen las mediciones directas y las derivadas del cateterismo cardiaco derecho, éstas permanecen hasta el día de hoy en el terreno académico de la controversia. Por lo tanto, se requiere la continua búsqueda de marcadores hemodinámicos para estratificar a los enfermos con hipertensión arterial pulmonar idiopática. Particularmente, cuando la disfunción contráctil del ventrículo derecho es la vía final más común de esta patología. En esta circunstancia, la determinación del poder del ventrículo derecho y del ventrículo izquierdo representa parámetros que pudieran ser de utilidad para lograr un mejor entendimiento en la hemodinámica de la hipertensión arterial pulmonar idiopática. Método: De manera retrospectiva, analizamos los aspectos demográficos, los hemodinámicos y la sobrevivencia, y si éstos se vieron asociados a la posibilidad de ser enfermos respondedores entre los portadores de hipertensión arterial pulmonar idiopática. Resultados: Noventa enfermos llenaron los siguientes criterios para ser incluidos en el estudio: 1. Contar con cateterismo cardiaco derecho basal; 2. Tener valoración aguda con adenosina, en donde quedó definida una respuesta "positiva aguda" como: aumento del gasto cardíaco, disminución de la presión arterial pulmonar media y de la resistencia vascular pulmonar calculada (≥ 20% de la basal, respectivamente) y; 3. Contar con un seguimiento a largo plazo bajo la influencia de los tratamientos modernos aceptados para enfermos con hipertensión arterial pulmonar idiopática. Sí, el poder del ventrículo derecho disminuyó (p < 0.001) y el poder ventrículo izquierdo aumentó (p < 0.012) durante el reto vasodilatador agudo se consideró que éstos hallazgos reforzaban la habilidad para detectar a los sujetos respondedores con hipertensión arterial pulmonar idiopática; población de enfermos que guardó ese comportamiento hemodinámico durante 6.4 ± 3 años bajo la influencia de nifedipina (37% de la totalidad de la población con hipertensión arterial pulmonar idiopática). Después de efectuar un análisis multivariado, la edad, el poder del ventrículo derecho y del ventrículo izquierdo permanecieron como variables independientes (OR = 0.927, 95%IC: 0.87-0.98, p = 0.01; OR = 0.114, 95%IC: 0.00-0.91, p = 0.045; y OR = 171.5, 95%IC: 5.3-549, p = 0.004, respectivamente) para ser considerados "respondedores". Como resultado, se derivó una ecuación donde la probabilidad de ser respondedor = 1.0196-0.0631 (edad) - 4.7693 (poder del ventrículo derecho) + 3.8152 (poder del ventrículo izquierdo), ROC: 0.76, 95%CI: 0.63 - 0.89; p = 0.001. Conclusión: Con fundamento en los hallazgos de este estudio, la ecuación propuesta, el poder del ventrículo derecho y el ventrículo izquierdo pueden ser utilizados para identificar "respondedores" entre los enfermos con hipertensión arterial pulmonar idiopática." ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v81n02-90024005fig1.jpg" "imagenAlto" => 1083 "imagenAncho" => 2045 "imagenTamanyo" => 263789 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and demographic data." ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v81n02-90024005fig2.jpg" "imagenAlto" => 1162 "imagenAncho" => 2104 "imagenTamanyo" => 413408 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Hemodynamic data at baseline and during acute vasodilation testing." ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v81n02-90024005fig3.jpg" "imagenAlto" => 854 "imagenAncho" => 2075 "imagenTamanyo" => 248747 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Hemodynamic values reached during vasodilator testing in acute responders according to the task force and our criteria." ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v81n02-90024005fig4.jpg" "imagenAlto" => 1016 "imagenAncho" => 2058 "imagenTamanyo" => 302933 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Long-term hemodynamic evaluation." ] ] 4 => array:7 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v81n02-90024005fig5.jpg" "Alto" => 637 "Ancho" => 991 "Tamanyo" => 55228 ] ] "descripcion" => array:1 [ "en" => "90024005fig5.jpg" width="991" height="637" alt="Figure 1. LVPO/RVPO behavior for responders and non-responders at baseline (B), during acute vasodilating (AV) and at long-term (LT) RHC. Differences are noted between B, AV trial, and at LT for the responder cohort; also between responders and non-responders at B, AV, and LT RHC. Lamda-Wilkin" ] ] 5 => array:8 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v81n02-90024005fig6.jpg" "Alto" => 691 "Ancho" => 983 "Tamanyo" => 62215 ] ] "descripcion" => array:1 [ "en" => "The probability to be an acute responder patient when the model is applied to a value of 0.5 W for LVPO. For a patient aged 30 years with RVPO of 0.4 W, the probability to be a responder is 30%." ] ] 6 => array:8 [ "identificador" => "tbl5" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v81n02-90024005fig7.jpg" "imagenAlto" => 1216 "imagenAncho" => 1016 "imagenTamanyo" => 178906 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Univariate variables entered into the multivariate model to be an acute responder." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Survival in patients with primary pulmonary hypertension: Results from a national prospective registry." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D´Alonzo GE" 1 => "Barst RJ" 2 => "Ayres SM" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Ann Intern Med 1991" "volumen" => "115" "paginaInicial" => "343" "paginaFinal" => "349" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Survival in primary pulmonary hypertension: validation of a prognostic equation." 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ISSN: 14059940Original language: English
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