Detectable Serum Cardiac Troponin T as a Marker of Poor Prognosis Among Patients With Chronic Precapillary Pulmonary Hypertension (original) (raw)
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The Value of Cardiac Troponins in Diagnosis and Differential Diagnosis of Pulmonary Embolism
Journal of Pulmonary & Respiratory Medicine, 2013
Aim: Pulmonary Embolism (PE) is a major cause of deaths in hospitals. Early diagnosis and emergent treatment decrease mortality rate. Cardiac troponins are thought to be useful in early diagnosis and especially in predicting PE prognosis. The aims of this study are 1) to investigate the diagnostic importance of cardiac troponins in PE and 2) to evaluate the relationship between disease severity, right ventricular dilatation and high levels of cardiac troponins. This study also aims to determine the role of cardiac troponins in differential diagnosis of PE from other pulmonary diseases that may also cause hypoxemia. Methods: A total number of 117 patients, 59 of whom, diagnosed with PE (group I) and 58 with asthma attack and community acquired pneumonia (group II) were enrolled in the study. Cardiac troponin T (cTnT) and I (cTnI) levels were measured twice in all patients during inclusion and within 12 hours. Clinical and laboratory findings were recorded. Results: cTnT and cTnI were positive in 8 (13.6%) and 48 (81.3%) patients in group I and in 1 (1.7%) and 47 (81.3%) patients in group II (1.72%), respectively (p=0.03 and 1.7). Mean cTnI levels were 3.92 ± 2.65 ng/ml in group I and 3.30 ± 2.93 ng/ml in group II (p>0.05). In existence of hpoxemia (PaO 2 ≤ 55mmHg), there was no correlation between groups and cTnT and cTnI levels. Cardiac troponin levels were more positive in patients who had echocardiographic pathology due to pulmonary embolism. cTnT and cTnI elevation was not found to be related with the clinical severity of PE, however massive PE cases had high troponin levels. The sensitivity, specificity, PPV and NPV of cTnI (cut-off value 2.935 ng/ml) and cTnT positivity (>0.01 ng/ml) were found as 66.1%, 60.3%, 62.9%, 63.6%, and 13.6%, 98.3%, 88.9%, and 52.8%, respectively. Troponin I was a differential factor for patients with pulmonary embolism when it was compared with controls, although it was no very sensitive. Mortality rate was 7.4% and high levels of cTnI positivity (≥3 ng/ml) were detected in these cases in present study. Conclusion: Cardiac troponins might be a role in differential diagnosis for PE, but we should be kept in mind that they could be elevated in pneumonia and asthma attack. Another result of this study suggests that cardiac troponins might be useful parameter for detection of right ventricular dysfunction, prediction of mortality and massive disease in PE patients.
Definitions and Diagnosis of Pulmonary Hypertension
Journal of the American College of Cardiology, 2013
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure !25 mm Hg at rest, measured during right heart catheterization. There is still insufficient evidence to add an exercise criterion to this definition. The term pulmonary arterial hypertension (PAH) describes a subpopulation of patients with PH characterized hemodynamically by the presence of pre-capillary PH including an end-expiratory pulmonary artery wedge pressure (PAWP) 15 mm Hg and a pulmonary vascular resistance >3 Wood units. Right heart catheterization remains essential for a diagnosis of PH or PAH. This procedure requires further standardization, including uniformity of the pressure transducer zero level at the midthoracic line, which is at the level of the left atrium. One of the most common problems in the diagnostic workup of patients with PH is the distinction between PAH and PH due to left heart failure with preserved ejection fraction (HFpEF). A normal PAWP does not rule out the presence of HFpEF. Volume or exercise challenge during right heart catheterization may be useful to unmask the presence of left heart disease, but both tools require further evaluation before their use in general practice can be recommended. Early diagnosis of PAH remains difficult, and screening programs in asymptomatic patients are feasible only in high-risk populations, particularly in patients with systemic sclerosis, for whom recent data suggest that a combination of clinical assessment and pulmonary function testing including diffusion capacity for carbon monoxide, biomarkers, and echocardiography has a higher predictive value than echocardiography alone. (J Am Coll Cardiol 2013;62: D42-50) ª 2013 by the American College of Cardiology Foundation Diagnosis and assessment of patients with pulmonary arterial hypertension (PAH) have been major topics at all previous world meetings on pulmonary hypertension (PH), with the last update coming from the 4th World Symposium on Pulmonary Hypertension (WSPH) held in 2008 in Dana Point, California (1). The recommendations from that conference were incorporated into the most recent international guidelines (2-4). During the 5th WSPH in 2013 in From the
Left ventricular dysfunction in patients with suspected pulmonary arterial hypertension
Jornal Brasileiro de Pneumologia, 2014
Objective: To evaluate the role of right heart catheterization in the diagnosis of pulmonary arterial hypertension (PAH). Methods: We evaluated clinical, functional, and hemodynamic data from all patients who underwent right heart catheterization because of diagnostic suspicion of PAH-in the absence of severe left ventricular dysfunction (LVD), significant changes in pulmonary function tests, and ventilation/perfusion lung scintigraphy findings consistent with chronic pulmonary thromboembolism-between 2008 and 2013 at our facility. Results: During the study period, 384 patients underwent diagnostic cardiac catheterization at our facility. Pulmonary hypertension (PH) was confirmed in 302 patients (78.6%). The mean age of those patients was 48.7 years. The patients without PH showed better hemodynamic profiles and lower levels of B-type natriuretic peptide. Nevertheless, 13.8% of the patients without PH were categorized as New York Heart Association functional class III or IV. Of the 218 patients who met the inclusion criteria, 40 (18.3%) and 178 (81.7%) were diagnosed with PH associated with LVD (PH-LVD) and with PAH, respectively. The patients in the HP-LVD group were significantly older than were those in the PAH group (p < 0.0001). Conclusions: The proportional difference between the PAH and PH-LVD groups was quite significant, considering the absence of echocardiographic signs suggestive of severe LVD during the pre-catheterization investigation. Our results highlight the fundamental role of cardiac catheterization in the diagnosis of PAH, especially in older patients, in whom the prevalence of LVD that has gone undiagnosed by non-invasive tests is particularly relevant.
Kardiologia Polska, 2015
Right heart catheterisation (RHC) is the 'gold standard' for haemodynamic assessment of the pulmonary circulation. For the diagnosis of pulmonary hypertension (PH), the guidelines of the European Society of Cardiology require a mean pulmonary arterial pressure ≥ 25 mm Hg to be confirmed by direct haemodynamic measurement. Additionally, RHC provides a lot of valuable information about the differential diagnosis and severity of PH, and also helps determine the patient's prognosis. Acute vasoreactivity testing performed in patients with pulmonary arterial hypertension is intended to identify the group of patients who should be treated with calcium channel blockers. Patients referred for heart transplantation require advanced pulmonary vascular disease to be ruled out either on resting examination or during vasoreactivity testing. RHC is a component of such interventional procedures as balloon atrial septostomy, closure of intracardiac shunts in congenital heart and great vessel defects, valvuloplasty for pulmonary valve stenosis, and pulmonary angioplasty. Pulmonary angiography is an examination recommended when selecting patients for pulmonary endarterectomy or balloon pulmonary angioplasty in thromboembolic PH. Due to the dynamic growth in the number of patients diagnosed with and treated for PH in Poland, the Boards of the Polish Cardiac Society's Working Group on Pulmonary Circulation and Association of Cardiovascular Interventions have undertaken a joint project to develop recommendations to standardise guidelines for RHC procedure, acute vasoreactivity testing and pulmonary angiography at cardiac wards and haemodynamic laboratories in Poland. This document has been prepared by experts delegated by the Working Group on Pulmonary Circulation and the Association of Cardiovascular Interventions, and subsequently approved by the Boards of both organs of the Polish Cardiac Society.
Diagnosis and Assessment of Pulmonary Arterial Hypertension
Journal of the American College of Cardiology, 2009
The diagnosis and assessment of pulmonary arterial hypertension is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. The definition of pulmonary hypertension has been simplified, and is now based on currently available evidence. There has been substantial progress in advancing the imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. The importance of accurate assessment of right ventricular function in following up the clinical course and response to therapy is more fully appreciated. As new therapies are developed for pulmonary arterial hypertension, screening, prompt diagnosis, and accurate assessment of disease severity become increasingly important. A clear definition of pulmonary hypertension and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to deriving maximal benefit from our expanding therapeutic armamentarium.
Pulmonary Arterial Hypertension: Evaluation of the Newly Diagnosed Patient
Seminars in Respiratory and Critical Care Medicine, 2005
With a quickly growing range of therapeutic options precise prognostic stratification became particularly important for clinical decision making in patients with pulmonary arterial hypertension (PAH). Assessment of disease-specific functional class remains the simplest method and is a fairly reliable way of assessing severity of PAH, and current guidelines recommend a therapeutic algorithm based on functional class evaluation. Six-minute walk is the most widely used test assessing exercise tolerance both in clinical practice and in clinical trials testing new therapies in PAH. Right heart catheterization with a vasoreactivity test is mandatory to identify a subgroup that has good long-term prognosis when treated with calcium channel blockers alone. Echocardiographic variables of documented prognostic value in PAH are not those directly correlated with pulmonary arterial pressure (PAP). Instead, the presence of pericardial effusion, enlarged right atrium, and elevated Doppler index of right ventricular performance have been the most consistently reported signs of poor prognosis. Low or decreasing brain natriuretic peptide (BNP) suggests a good outcome whereas troponin T leak persisting despite therapy is a poor prognostic sign. Biomarkers seem particularly useful for noninvasive follow-up of patients with PAH, and due to simplicity and low costs may successfully compete with echocardiography.