Evaluation of left ventricular function in patients with mitral annular disjunction using speckle tracking echocardiography.

BACKGROUND: Mitral annular disjunction (MAD) is a structural abnormality characterized by the systolic detachment of the posterior mitral annulus and the ventricular myocardium. It is usually observed coexistent with mitral valve prolapse (MVP) and associated with a mechanical dysfunction despite preserved electrical isolation function of the mitral annulus. This study aimed to evaluate left ventricular (LV) function using speckle tracking echocardiography in MVP patients with MAD. METHODS: This study was designed as a prospective, single-center study including 103 patients with MVP and 40 age- and sex-matched control subjects. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed to assess LV function and MAD presence. RESULTS: MAD (+) MVP (n = 34), MAD (-) MVP (n = 69), and control (n = 40) groups were enrolled in the study. Among the MVP patients, 34 (33%) had MAD. T-negativity in the inferior leads on electrocardiography was more frequent in the MAD (+) group than in the MAD (-) patients (4.3% vs. 20.6%, p = .014). Mitral regurgitation degree, Pickelhaube sign (17.6% vs. 1.4%, p = .005), and late gadolinium enhancement frequency (35.3% vs. 10.6%, p = .002) were significantly higher in MAD (+) patients. MAD (+) patients had significantly impaired global longitudinal strain (-23.1 ±  2.1 vs. -23.5 ± 2.3, p < .001), basal longitudinal strain (BLS) (-19.6 ±  1.5 vs. -20.5 ± 1.9, p < .001), Mid-Ventricular Longitudinal Strain (-22.2 ± 1.7 vs. -23.2 ± 2.2, p < .001) and LA strain (-24.5 ± 3.9 vs. -27.2 ± 3.6, p < .001) when compared to MAD (-) MVP patients, despite similar LV ejection fraction. All these values of MVP patients were also significantly lower than the control group. The mean MAD distance was 7.8 ± 3.2 mm in MAD (+) patients. Patients with two or more symptoms were higher in the MAD (+) group than in the MAD (-) group (4.3% vs. 44.1%, p < .001). CONCLUSION: This study demonstrated a significant decrease in longitudinal strain in MVP patients with MAD, indicating myocardial dysfunction. These findings suggest that MAD may contribute to LV dysfunction and highlight the importance of early detection in younger patients. Further research is needed to explore the functional implications and long-term outcomes of MAD.

A Breathtaking Case of Pulmonary Hypertension with Frightening Complications and Intertwining Different Etiologies.

Pulmonary hypertension (PH) is a major health problem with increasing awareness. Although most common cause of PH is left heart disease (Group 2 PH), life-threatening complications occur mostly in Group 1 (pulmonary arterial hypertension) and Group 4 (chronic thromboembolic PH) patients. Although external compression of the left main coronary artery (LMCA) due to pulmonary artery dilatation is rare, it is a life-threatening complication since it causes myocardial ischemia and sudden cardiac death. In addition, PH is more than a single clinical entity due to its complex mechanism in which more than one subgroup may develop over time in the same patient. This complex mechanism challenges us when diagnosing the patient and faces us with life-threatening complications. In this case; we report a pulmonary arterial hypertension patient applied to our clinic with progressive dyspnea and recent angina, after detection of LMCA ostial stenosis, the patient was treated with intravascular ultrasound-guided stent implantation. In the further follow-ups, the patient underwent the pulmonary endarterectomy operation due to the diagnosis of chronic thromboembolic pulmonary hypertension secondary to newly diagnosed primary antiphospholipid syndrome.

Percutaneous Treatment of Left Main Coronary Artery Compression in a Pulmonary Artery Hypertension Patient Associated with Atrial Septal Defect.

Pulmonary arterial hypertension is still a fatal disease persisting with poor prognosis, despite all the advances in treatment (new agents and new combination strategies) in recent years. Patients present with different symptoms which are not specific to the disease (dyspnea, angina, palpitation, and syncope). Angina may occur secondary to myocardial ischemia due to increased right ventricular after load (oxygen supply and demand mismatch) or external compression on the left main coronary artery. Left main coronary artery compression is associated with post-exercise sudden cardiac death in pulmonary arterial hypertension patients. It should be kept in mind in the differential diagnosis of angina in patients with pulmonary arterial hypertension and should be treated immediately. Here, we report a pulmonary arterial hypertension patient associated with secundum-type atrial septal defect presented with ostial left main coronary artery compression caused by an enlarged pulmonary artery and treated with intravascular ultrasound-guided percutaneous coronary intervention.

Evaluation of primary and accessory respiratory muscles and their influence on exercise capacity and dyspnea in pulmonary arterial hypertension.

BACKGROUND: Skeletal and respiratory muscle disfunction has been described in pulmonary arterial hypertension (PAH), however, involvement of accessory respiratory muscles and their association with symptomatology in PAH is unclear. OBJECTIVES: To assess the primary and accessory respiratory muscles and their influence on exercise tolerance and dyspnea. METHODS: 27 patients and 27 healthy controls were included. Serratus anterior (SA), pectoralis muscles (PM) and sternocleidomastoid (SCM) muscle strength were evaluated as accessory respiratory muscles, maximal inspiratory (MIP) and expiratory pressures (MEP) as primary respiratory muscles, and quadriceps as peripheral muscle. Exercise capacity was evaluated with 6-min walk test (6MWT), dyspnea with modified Medical Council Research (MMRC) and London Chest Activity of Daily Living (LCADL) scales. RESULTS: All evaluated muscles, except SCM, and 6MWT were decreased in patient group (p < 0.01). SA was the most affected muscle among primary and accessory respiratory muscles (Cohen's-d = 1.35). All evaluated muscles significantly correlated to 6MWT (r = 0.428-0.525). A multivariate model including SA, SCM and MIP was the best model for predicting 6MWT (R = 0.606; R2 = 0.368; p = 0.013) and SA strength had the most impact on the 6MWT (B = 1.242; ß = 0.340). None of the models including respiratory muscles were able to predict dyspnea, however PM and SA strength correlated to LCADL total (r = -0.493) and MMRC (r = -0.523), respectively. CONCLUSION: SCM may be excessively used in PAH since it retains its strength. Considering the relationship of accessory respiratory muscles with exercise tolerance and dyspnea, monitoring the strength of these muscles in the clinical practice may help providing better management for PAH.

Prevalence of musculoskeletal pain and its impact on quality of life and functional exercise capacity in patients with pulmonary arterial hypertension.

BACKGROUND: In pulmonary arterial hypertension (PAH), pathophysiological consequences of the disease and the drugs used to treat PAH may adversely affect musculoskeletal system. Aim of the study was to evaluate musculoskeletal pain prevalence and its impact on quality of life (QoL) and exercise capacity in PAH patients. METHODS: 61 PAH patients were evaluated with Nordic Musculoskeletal Questionnaire (NMQ) for musculoskeletal pain presence, EmPHasis-10 and Minnesota Living with Heart Failure Questionnaire (MLHFQ) for QoL, 6-min walk test (6MWT) for functional exercise capacity and International Physical Activity Questionnaire- Short Form (IPAQ-SF) for physical activity participation. RESULTS: 77% of PAH patients reported musculoskeletal pain. Pain prevalence was highest at low back (38%), followed by knees (36%), shoulders (36%) and neck (33%). Hemodynamic indicators of PAH severity were associated with pain presence in various parts of the body. Patients receiving any PAH-specific drug were more likely to experience pain compared to the patients whose drug therapy has not yet been initiated (RR = 1.6-2.0). Pain presence in neck, shoulder, low back and knees significantly correlated to worse QoL scores in both EmPHasis-10 and MLHFQ (p < 0.05). Pain presence in knees had the strongest influence on QoL, and it was the only significant correlate of 6MWT (r = -0.424) and IPAQ-SF (r = -0.264) (p < 0.05). CONCLUSIONS: Musculoskeletal pain is a common complaint in PAH patients, which significantly impairs QoL and physical functioning. Treatment strategies should include a more comprehensive assessment for musculoskeletal pain complaints of these patients and address pain presence accordingly, which may help providing a better management for PAH.

Effects of Adding Respiratory Training to Osteopathic Manipulative Treatment on Exhaled Nitric Oxide Level and Cardiopulmonary Function in Patients With Pulmonary Arterial Hypertension.

Limited research exists regarding nonpharmacologic management of pulmonary arterial hypertension (PAH), except for exercise training. The objective of this study was to investigate the effects of osteopathic manipulative treatment (OMT) alone and combined with respiratory training on fractional exhaled nitric oxide (FeNO), and cardiopulmonary function in patients with PAH. This single-blind, prospective, randomized controlled study included 54 patients with PAH who were randomly allocated to OMT, combined intervention, and control groups. The OMT group (n = 16) and combined intervention group (n = 16) received OMT and yoga respiratory training plus OMT, respectively, twice a week for 8 weeks. The control group (n = 16) received no intervention. All patients undertook an educational lecture. FeNO level, pulmonary function, 6-minute walk distance (6MWD), maximal inspiratory and expiratory pressures, and handgrip strength were assessed at baseline and 8 weeks. Combined intervention and OMT groups significantly improved all outcome measures after 8 weeks of treatment (p <0.01), except mean forced expiratory flow between 25% and 75% of forced vital capacity, which did not change in the OMT group (p >0.05). The control group showed significant deteriorations in 6MWD, inspiratory and peripheral muscle strength, and pulmonary function except peak expiratory flow at 8 weeks (p <0.05). The combined intervention group revealed significantly greater improvements of FeNO, 6MWD, respiratory and peripheral muscle strength, and pulmonary function except mean forced expiratory flow between 25% and 75% of forced vital capacity compared with the OMT group (p <0.05). All outcomes significantly improved in both intervention groups versus the control group (p <0.05). Our study demonstrated that adding respiratory training to OMT provided further benefit to FeNO level and cardiopulmonary function compared with OMT alone and that the OMT might be a useful and safe intervention for patients who cannot attend cardiac rehabilitation programs.

Clinical efficacy, safety, tolerability, and survival outcome of long-term inhaled iloprost treatment in the management of pulmonary arterial hypertension: Data from prospective multicenter observational OPTION study.

OBJECTIVE: To evaluate clinical efficacy, safety and tolerability of long-term inhaled iloprost treatment in the daily practice for the management of pulmonary arterial hypertension (PAH). METHODS: A total of 115 patients with PAH on inhaled iloprost treatment were included. New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and 6-minute walk distance (6MWD) were recorded at baseline and at 3rd to 24th month visits. Safety and tolerability of iloprost treatment were also evaluated during follow-up, as were the survival, clinical worsening, and the related risk factors. RESULTS: The treatment was associated with an increase in the percentage NYHA functional class II (from 0.0% at enrolment to 36.2% at 24th month visit) patients but no significant difference was noted in 6MWD values. Clinical worsening was observed in 63.5% patients, while survival rate was 69.6%. NT-proBNP levels were significantly higher in non-survivors than in survivors (p=0.042). Cox regression analysis revealed the association of female sex [odds ratio (OR)=0.318; 95% confidence interval (CI), 0.128-0.792; p=0.014] and scleroderma-related PAH (OR=0.347; 95% CI, 0.140-0.860; p=0.022) with significantly lower risk (3.14 fold and 2.88 fold, respectively) of mortality. CONCLUSION: Our findings indicate favorable efficacy, safety, and tolerability of long-term iloprost treatment in the management of PAH, whereas improved NYHA functional class was not accompanied with a significant change in 6MWD values. Patient age was a risk factor for clinical worsening, while female sex, scleroderma subtype, and lower NT-proBNP levels were associated with significantly lower mortality risk.

Resting heart rate and real-life treatment modalities in outpatients with left ventricular systolic dysfunction study: A multicenter, prospective, observational, and national registry.

OBJECTIVE: Heart rate (HR) reduction is associated with improved outcomes in heart failure (HF). This multicenter, prospective, observational, and national registry aimed to evaluate resting HR and the impacts of HR-related medications in real-life clinical practice in patients with HF. METHODS: The Resting HR and Real-Life Treatment Modalities in Outpatients with Left Ventricular Systolic Dysfunction (REALITY HF) study enrolled 1054 patients with HF and left ventricular ejection fraction (LVEF) of <40% from 16 centers. Clinical characteristics, HR, and medications were noted (enrollment phase). A total of 487 patients with sinus rhythm and HR of ≥70 bpm were included in a further 4-month follow-up (FU) program (V0). Changes in HR and medications were reevaluated at 1-month (V1) and 4-month (V2) FU visits. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess the quality of life (QoL) of 320 patients in a 4-month FU program. RESULTS: During enrollment, 794 patients (75.3%) were in sinus rhythm, in whom resting HR was 76.7±14 bpm, 69.1% had a resting HR of ≥70 bpm, 79.1% were receiving beta blocker (BB), and 6.1% were receiving ivabradine. Resting HR was lower in patients receiving BB (75.8±13 vs. 80.4±16 bpm; p=0.001); however, 65.8% of those still had a resting HR of ≥70 bpm. A significant association was found between elevated HR and worse New York Heart Association (NYHA) class, worse QoL, or lower LVEF. During the 4-month FU, adjustment of HR-lowering therapy was left to the physician's discretion. Resting HR significantly reduced from 83.6±12 (80) bpm at V0 to 78.6±13 (77) bpm at V1 (p=0.001) and further decreased to 73.0±11 (73) bpm at V2 (p=0.001). Patients achieving a resting HR of <70 bpm were 21.7% at V1 (p=0.001) and 39.9% at V2 (p=0.001). KCCQ significantly increased from 59.7±23 (62.7) at V0 to 73.1±18 (78.5) at V2 (p=0.001). In addition, patients with NYHA I increased from 22.2% at V0 to 29.2% at V1 and 39.4% at V2 (p=0.01). CONCLUSION: In real-life clinical practice, elevated HR is highly prevalent in HF despite widely used BB therapy and is associated with worse clinical picture. Therapeutic interventions targeting HR significantly reduce HR, and HR lowering is associated with improved clinical outcomes.

Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension?

BACKGROUND: To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT. METHODS: Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis. RESULTS: The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88. CONCLUSIONS: The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.

Ten-year outcome of chronic thromboembolic pulmonary hypertension patients in a tertiary center.

OBJECTIVE: Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension (PH). We aimed to investigate the outcome of CTEPH patients who were followed-up by a PH outpatient clinic. METHODS: We screened the medical records of 29 PH patients who were followed-up by a PH outpatient clinic between 2009 and 2018. The patients' demographics and their clinical, echocardiographic, and hemodynamic characteristics were recorded. RESULTS: Our study group consisted of 16 females (55.2%) and 13 males (44.8%). The mean age was 59.5±13.7 years and the median follow-up duration was 44 months (1-113 months). The mean initial 6-minute walking distance (6MWD) was 321.4±119.9 m. The initial median N-terminal pro brain natriuretic peptide (NT-proBNP) level was 2468 pg/mL (46.1-20.564 pg/mL). All patients were on oral anticoagulant therapy. Pulmonary endarterectomy (PEA) was performed in 17 of 29 patients (58.6%). Twelve patients (41.4%) were not operated upon due to distal disease, comorbidities, or their own preference. The operated patients were younger than the non-operated patients (55 years & 65 years, p=0.04). At the follow-up, the 6MWD in the operated patients increased (+76 m) and decreased in non-operated patients (-46 m). The survival rate at 10-year follow-up was 58.6% for the whole group. Twelve patients died during the follow-up period. While 7 of 12 not-operated patients died (58.3%), just 5 of 17 operated patients (4 perioperatively and 1 at follow-up) died (29%). Advanced-stage final functional capacity (FC) [New York Heart Association (NYHA) III-IV], inoperability, lower final 6MWD, higher final NT-proBNP, and reduced tricuspid annular plane systolic excursion (TAPSE) were associated with an increased mortality rate. Univariate Cox regression analysis showed that patients with NYHA I-II final FC showed a 166-fold decreased mortality rate. CONCLUSION: The long-term prognosis of operated patients is better than the outcome of not-operated patients. The strongest predictor associated with mortality was a worse final FC (NYHA III-IV).

The impact of the new World Symposium on Pulmonary Hypertension definition of pulmonary hypertension on the prevalence of pre-capillary pulmonary hypertension.

OBJECTIVE: Since the first World Symposium on Pulmonary Hypertension (WSPH; Geneva, 1973), pulmonary hypertension (PH) has been defined as a mean pulmonary artery pressure (mPAP) ≥25 mm Hg measured at right heart catheterization (RHC) while at rest in the supine position. At the 6th WSPH congress (Nice, 2018), a new proposal was presented defining pre-capillary PH as mPAP >20 mm Hg, with pulmonary arterial wedge pressure (PAWP) <15 mm Hg, and pulmonary vascular resistance (PVR) >3 WU. The aim of this study was to investigate the impact of the new definition of PH on the number of pre-capillary PH patients. METHODS: The results of RHC performed with various clinical indications between 2017 and 2018 were analyzed. The 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) and the 6th WSPH congress PH definitions were used to identify PH patients. RESULTS: Fifty-eight RHC procedures were performed in our hospital in a 1-year period. Most were performed with a suspicion of PH (n=52). The remainder (n=6) were performed with indications of valvular heart disease or left heart disease. There were 40 females (69%) and 18 males (31%). The mean age was 53.3±16.6 years. The RHC results revealed a mean PAP of 36.4±16.4 mm Hg, PAWP of 12.6±3.9 mm Hg, and PVR of 4.9±4.4 WU. Forty-three of 58 patients (74.1%) were classified as pre-capillary PH according to the ESC/ERS PH guideline, whereas 50 of 58 patients (86.2%) had pre-capillary PH according to the new WSPH definition. CONCLUSION: The results of this study indicated that the impact of the new definition of PH on the number of pre-capillary PH patients identified was greater than the predicted <10%.

Risk assessment and survival of patients with pulmonary hypertension: Multicenter experience in Turkey.

OBJECTIVE: Risk stratification continues to evolve in pulmonary arterial hypertension (PAH). Our aim was to further confirm the risk assessment strategy in our cohort and to determine the most reliable model. METHODS: We enrolled incident patients with idiopathic PAH (IPAH), heritable, drug-induced, congenital heart disease (CHD), connective tissue diseases (CTD) subsets, and chronic thromboembolic pulmonary hypertension (CTEPH) from January 2008 to February 2018. Data from the baseline and subsequent follow-ups within 1 year of diagnosis were included. An abbreviated risk assessment strategy was applied using the following variables: functional class (FC), 6-minute walk distance (6 MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) or BNP, right atrial (RA) area, pericardial effusion, the mean RA pressure, cardiac index, and mixed venous oxygen saturation. Three different methods were applied to categorize patients. RESULTS: A total of 189 subjects (46+-17 years, 23% male) were included. Sixty-one patients had died. The survival differed significantly between the risk groups both at diagnosis and during the follow-up. Patients with a low-risk profile had a better survival rate. An abbreviated risk assessment tool predicted mortality at early follow-up in the entire group and CHD, CTD subsets, and CTEPH, separately. An overall mortality among risk categories was significantly different according to each categorization method. The most reliable model comprised FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up. CONCLUSION: The abbreviated risk assessment tool may be valid for the PAH subsets and CTEPH. Echocardiographic variables do matter. A model comprising FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up could be useful for better prognostication.

Natriuretic Peptides in Clinical Practice.

Natriuretic peptides have long been introduced into clinical practice. These biomarkers have certainly been shown to provide useful information in the diagnosis, prognosis and risk stratification in heart failure and also may have a role in the guidance of heart failure therapy. Although, there are some limitations in using of these markers such as lack of specificity, aging, renal dysfunction or obesity, among the huge number of candidates for heart failure biomarkers, only natriuretic peptides are currently widely used in daily clinical practice in heart failure. Recent heart failure guidelines recognize natriuretic peptides as an essential tool in the new diagnostic and therapeutic algorithms. Furthermore, natriuretic peptides are not only used in the diagnosis or prognosis of heart failure, but also these biomarkers are referred to have some potential role in primary prevention, cardio-oncology, advanced heart failure, assessment of response to cardiac resynchronization therapy, pulmonary arterial hypertension, acute coronary syndromes, atrial fibrillation and valvular heart disease. In this article, natriuretic peptides have been reviewed for their updated information and new recommendations in heart failure and also potential role of these biomarkers in the management of various clinical conditions have been addressed in the form of expert opinion based on the available data in the literature.

Pulmonary hypertension experience in an expert university hospital.

OBJECTIVE: Pulmonary artery hypertension (PAH) is characterized by remodeling of the small pulmonary arteries, leading to a progressive increase in pulmonary vascular resistance and right ventricular failure. In this study, we aimed to share our 10 years of experience dealing with pulmonary hypertension (PH) and provide information in real-life settings in terms of demographics, clinical course, PH subgroup distribution, and treatment patterns in patients with PAH in a tertiary center. METHODS: In this retrospective, single-center, observational study, we screened the patients who applied to PH outpatient clinic of Istanbul University Institute of Cardiology due to the suspicion of PAH between 2008 and 2017. While group 1, 4, and 5 PH patients were included, group 2 and 3 PH patients were excluded from the study. RESULTS: Our study group comprised 162 patients (115 females, 71%). The female:male ratio was 2.4. The mean age was 52±16 years. Most (86.4%) of the patients were in group 1 PH (PAH). The rest (13.6%, n=22) of the patients were in group 4 PH (chronic thromboembolic PH). In group 1 PH, 45.7% of patients (n=64) were classified as having idiopathic PAH (IPAH) after excluding the alternative diagnosis using PH diagnostic algorithm. The remaining 54.3% of group 1 PH patients (n=76) had various diseases that caused PAH, which is called associated PAH (APAH); APAH group included PAH associated with congenital heart diseases (n=70), connective tissue disorders (scleroderma, n=4) and portal hypertension (n=2). CONCLUSION: Our data provides important information in real-life settings in terms of demographics, clinical course, PH subgroup distribution, and treatment patterns in patients with PAH in a reference tertiary center in Turkey.

Endarteritis of coarctation of the aorta diagnosed with PET-CT.

Infective endocarditis (IE) is an infectious disease that affects the endothelium of the large intrathoracic vessels, heart valves, and intra-cardiac foreign body material. A 20-year-old woman was admitted to the cardiology department with complaints of fever and palpitations. Transthoracic echocardiography revealed a bicuspid aortic valve, aortic root enlargement, and aortic coarctation. Transesophageal echocardiography revealed a bicuspid aortic valve, but there was no vegetation. Methicillin-sensitive Staphylococcus aureus was identified on a blood culture. 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) revealed increased intensive glucose uptake on the dilated aortic segment adjacent to the distal coarctation zone. Several reports have shown promising results for radio-labelled white blood cell single-photon emission computed tomography and 18F-FDG PET-CT imaging in IE. To our knowledge, this is the first described case in which PET-CT revealed endarteritis of the descending aorta in a patient without prosthetic material.

Practical approaches for the treatment of chronic heart failure: Frequently asked questions, overlooked points and controversial issues in current clinical practice.

Heart failure (HF) is a progressive disorder associated with impaired quality of life, high morbidity, mortality and frequent hospitalization and affects millions of people from all around the world. Despite further improvements in HF therapy, mortality and morbidity remains to be very high. The life-long treatment, frequent hospitalization, and sophisticated and very expensive device therapies for HF also leads a substantial economic burden on the health care system. Therefore, implementation of evidence-based guideline-recommended therapy is very important to overcome its worse clinical outcomes. However, HF therapy is a long process that has many drawbacks and sometimes HF guidelines cannot answers to every question which rises in everyday clinical practice. In this paper, commonly encountered questions, overlooked points, controversial issues, management strategies in grey zone and problems arising during follow up of a HF patient in real life clinical practice have been addressed in the form of expert opinions based on the available data in the literature.

Six-minute walk test in pulmonary arterial hypertension.

Exercise intolerance is the main characteristic of pulmonary arterial hypertension (PAH). The six-minute walk test (6MWT) and cardiopulmonary exercise test are widely used in assessing exercise capacity of PAH patients. Six-minute walk distance (6MWD) has been specified as the main clinical outcome in PAH and has been used as the primary end-point in many studies conducted for new PAH treatments. Using 6MWD as the end-point in clinical studies has many advantages. 6MWT is an inexpensive, easily applicable, and repeatable standardized test that is well-tolerated by PAH patients. Moreover, it is a valid measure of symptomatic improvement. It is correlated with variables of maximal cardiopulmonary exercise test as a measure of submaximal exercise capacity and disease severity markers such as functional class and pulmonary hemodynamics. It is widely used in clinical practice together with other invasive and non-invasive disease markers in assessing disease progression and response to treatment. In addition, it has prognostic importance and is a good prognostic marker. On the other hand, there are limitations to the use of 6MWD as the primary end-point in PAH treatment. It has decreased sensitivity in individuals with less severe disease and high 6MWD at baseline and decreased adequacy in assessing the effects of treatment in patients who are still under PAH treatment. Despite the limitations, 6MWD plays a key role in the evaluation and management of PAH patients.