Sotatercept for Pulmonary Arterial Hypertension in the Inpatient Setting.

Patients with pulmonary arterial hypertension (PAH) who are admitted to the hospital pose a challenge to the multidisciplinary healthcare team due to the complexity of the pathophysiology of their disease state and PAH-specific medication considerations. Pulmonary arterial hypertension is a progressive disease that may lead to death as a result of right ventricular (RV) failure. During acute on chronic RV failure it is critical to decrease the pulmonary vascular resistance with the goal of improving RV function and prognosis; therefore, aggressive PAH-treatment based on disease risk stratification is essential. Pulmonary arterial hypertension treatment for acute on chronic RV failure can be impacted by end-organ damage, hemodynamic instability, drug interactions, and PAH medications dosage and delivery. Sotatercept, a first in class activin signaling inhibitor that works on the bone morphogenetic protein/activin pathway is on track for Food and Drug Administration approval for the treatment of PAH based on results of recent trials in where the medication led to clinical and hemodynamic improvements, even when added to traditional PAH-specific therapies. The purpose of this review is to highlight important considerations when starting or continuing sotatercept in patients admitted to the hospital with PAH.

Plasma Catecholamines in Patients Undergoing Invasive Cardiopulmonary Exercise Test for Exercise Intolerance.

BACKGROUND: Invasive cardiopulmonary exercise testing (iCPET) combines traditional cardiopulmonary exercise testing with invasive hemodynamic measurements to assess exercise intolerance, which can be caused by preload insufficiency (PI), characterized by low ventricular filling pressures and reduced cardiac output during exertion. We hypothesize that plasma catecholamine levels at rest and during exercise correlate with hemodynamic parameters in PI. METHODS: We included adult patients who underwent iCPET for exercise intolerance and had plasma catecholamines measured at rest and peak exercise. RESULTS: Among 84 patients, PI was identified in 57 (67.8%). Compared to patients without PI, those with PI were younger [median (IQR) 37 (28, 46) vs 47 (39,55) years, p=0.005] and had lower workload at peak exercise [81 (66, 96) vs 95 (83.5, 110.50) Watts, p=0.006]. Patients with PI had higher heart rates at rest and peak exercise [87 (78, 97) vs 79 (74, 87) bpm, p=0.04; and 167 (154, 183) vs 156 (136, 168) bpm, p=0.01, respectively]. In all patients, epinephrine and norepinephrine at peak exercise directly correlated with peak workload (r:0.41, p<0.001 and r:0.47, p<0.001, respectively). Resting epinephrine was higher in patients with PI [136 (60, 210) vs 77 (41, 110) pg/mL, p=0.02]. There was no significant difference in the change in catecholamines from rest to peak exercise between patients with or without PI. CONCLUSION: PI patients exhibited elevated heart rate and epinephrine at rest, indicating increased sympathetic activity. We did not find strong associations between catecholamines and cardiac filling pressures, suggesting that catecholamine levels are predominantly influenced by peak workload.

Impact of body position on hemodynamic measurements during exercise: A tale of two bikes.

The addition of exercise testing during right heart catheterization (RHC) is often required to accurately diagnose causes of exercise intolerance like early pulmonary vascular disease, occult left heart disease, and preload insufficiency. We tested the influence of body position (supine vs. seated) on hemodynamic classification both at rest and during exercise. We enrolled patients with exercise intolerance due to dyspnea who were referred for exercise RHC at the Cleveland Clinic. Patients were randomized (1:1) to exercise in seated or supine position to a goal of 60 W followed by maximal exercise in the alternate position. We analyzed 17 patients aged 60.3 ± 10.9 years, including 13 females. At rest in the sitting position, patients had significantly lower right atrial pressure (RAP), mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP) and cardiac index (CI). In every stage of exercise (20, 40, and 60 W), the RAP, mPAP, and PAWP were lower in the sitting position. Exercise in the sitting position allowed the identification of preload insufficiency in nine patients. Exercise in either position increased the identification of postcapillary pulmonary hypertension (PH). Body position significantly influences hemodynamics at rest and with exercise; however, mPAP/CO and PAWP/CO were not positionally affected. Hemodynamic measurements in the seated position allowed the detection of preload insufficiency, a condition that was predominantly identified as no PH during supine exercise.

Taquicardias con complejo QRS ancho: ¿Cómo establecer la diferencia?: parte I / Tachycardia with a wide QRS complex: part I

Las taquicardias con complejos QRS ancho revierten un valor pronóstico y terapéutico de gran importancia en la práctica clínica cotidiana. Se han descripto una cantidad importante de criterios que ayudan al diagnóstico diferencial de las mismas. Se considera oportuno describir la frecuencia de aparición, mecanismos, algoritmos, el aporte de drogas y estudios complementarios para establecer un diagnóstico apropiado

Taquicardias con complejo QRS ancho: ¿Cómo establecer la diferencia?: parte II / Tachycardia with a wide QRS complex: What's the difference?: part II

Las taquicardias con complejos QRS anchos presentan un valor pronóstico y terapéutico de gran importancia en la práctica clínica cotidiana. Se han descripto un gran número de criterios que ayudan al diagnóstico diferencial. En esta parte del artículo se analizarán los aspectos morfológicos y algoritmos usados para establecer un diagnóstico apropiado

Taquicardias con complejo QRS ancho: ¿Cómo establecer la diferencia?: parte I / Tachycardia with a wide QRS complex: part I

Las taquicardias con complejos QRS ancho revierten un valor pronóstico y terapéutico de gran importancia en la práctica clínica cotidiana. Se han descripto una cantidad importante de criterios que ayudan al diagnóstico diferencial de las mismas. Se considera oportuno describir la frecuencia de aparición, mecanismos, algoritmos, el aporte de drogas y estudios complementarios para establecer un diagnóstico apropiado (AU)

Taquicardias con complejo QRS ancho: ¿Cómo establecer la diferencia?: parte II / Tachycardia with a wide QRS complex: Whats the difference?: part II

Las taquicardias con complejos QRS anchos presentan un valor pronóstico y terapéutico de gran importancia en la práctica clínica cotidiana. Se han descripto un gran número de criterios que ayudan al diagnóstico diferencial. En esta parte del artículo se analizarán los aspectos morfológicos y algoritmos usados para establecer un diagnóstico apropiado (AU)