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2.
Heart Fail Rev ; 2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31317296

RESUMO

Heart failure is a multifaceted syndrome addressing for a high rate of death among the general population. The common approach to this disease has been always based on the evaluation of the left ventricular ejection fraction by two-dimensional echocardiography with Simpson's method. Mounting evidences have demonstrated the pitfalls of this method and have suggested that the management of heart failure requires a deep knowledge of the pathophysiological insights of the disease and cannot rely only on the evaluation of the left ventricular ejection fraction. Several advanced imaging technologies overwhelm the evaluation of ejection fraction and could provide a better understanding of the myocardial abnormalities underlying heart failure. Considering the limitation of left ventricular ejection fraction and the systemic involvement of heart failure, classifications of heart failure based on ejection fraction should be substituted with a comprehensive "staging" of multiorgan damage, not only considering the heart but also the lungs, kidneys, and liver, such as the HLM staging system. Such a holistic approach based on the HLM staging system and multimodality imaging can provide a global assessment of patient features allowing for targeted therapies and better heart failure management.

3.
J Cardiovasc Med (Hagerstown) ; 20(10): 701-708, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31343448

RESUMO

BACKGROUND: The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. METHODS AND RESULTS: Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ±â€Š241 vs. 1273 ±â€Š359 mm, P = 0.02 and 125 ±â€Š11 vs. 117 ±â€Š16%, P = 0.02), a smaller left atrial volume (54.1 ±â€Š26 vs. 71.5 ±â€Š20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ±â€Š11 vs. 49 ±â€Š12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ±â€Š17 vs. 141 ±â€Š23%, P = 0.014). CONCLUSION: Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure.

5.
J Diabetes Res ; 2019: 9489826, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31089475

RESUMO

Ischemic heart disease (IHD) has several risk factors, among which diabetes mellitus represents one of the most important. In diabetic patients, the pathophysiology of myocardial ischemia remains unclear yet: some have atherosclerotic plaque which obstructs coronary blood flow, others show myocardial ischemia due to coronary microvascular dysfunction in the absence of plaques in epicardial vessels. In the cross-talk between myocardial metabolism and coronary blood flow (CBF), ion channels have a main role, and, in diabetic patients, they are involved in the pathophysiology of IHD. The exposition to the different cardiovascular risk factors and the ischemic condition determine an imbalance of the redox state, defined as oxidative stress, which shows itself with oxidant accumulation and antioxidant deficiency. In particular, several products of myocardial metabolism, belonging to oxidative stress, may influence ion channel function, altering their capacity to modulate CBF, in response to myocardial metabolism, and predisposing to myocardial ischemia. For this reason, considering the role of oxidative and ion channels in the pathophysiology of myocardial ischemia, it is allowed to consider new therapeutic perspectives in the treatment of IHD.

6.
Echocardiography ; 36(5): 992-995, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30873637

RESUMO

A 20-year-old Congolese woman presented with presyncope, dyspnea, and anasarca. Past medical history was unremarkable. Echocardiography revealed a rare combination of giant right atrium (RA), a dilated and hypertrophied right ventricle, subvalvular pulmonary stenosis (subPS), severe tricuspid regurgitation (TR), pericardial effusion and what appeared to be a spontaneously closed ventricular septal defect (VSD). Cardiac Magnetic Resonance and Cardiac Computed Tomography confirmed the findings excluding the presence of intra-cardiac and extra-cardiac shunt and other associated congenital anomalies. The patient underwent subPS resection, right atrioplasty, and tricuspid annuloplasty. Multimodality approach facilitated the detection of the abnormalities and provided clarity when determining the optimal surgical strategy.

7.
G Ital Cardiol (Rome) ; 20(1): 32-40, 2019 Jan.
Artigo em Italiano | MEDLINE | ID: mdl-30638213

RESUMO

Leadless pacemaker therapy now represents a reality in the field of cardiac pacing. It was developed with the aim of reducing post-procedural complications due to endocavitary leads and with the intention to propose itself as a valid alternative in patients who have contraindications to conventional pacing. Leadless pacemakers to date allow right ventricular stimulation and are implanted through a percutaneous venous femoral access. Currently, the system available is the MicraTM Transcatheter Pacing System. On November 2017, the worldwide implants of the NanostimTM Leadless Pacemaker System were halted. These devices have shown promising results in the various clinical trials with complications mostly due to the implant procedure. In order to avoid these complications, a correct learning curve of the operators has resulted very important. Recently, a new system, the WiSE-CRT, has been introduced as a leadless alternative to cardiac resynchronization therapy. While the results of randomized trials and long-term follow-up studies are still pending, in this paper we will review the main clinical data that have been published to date, comparing them to the traditional devices for transvenous endocardial stimulation.

8.
Eur Radiol ; 29(5): 2369-2377, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30552479

RESUMO

OBJECTIVES: To investigate the prognostic role of early post-infarction cardiac magnetic resonance (CMR) on long-term risk stratification of ST segment elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF). METHODS: Seventy-seven STEMI patients treated by primary percutaneous coronary intervention (PCI) and LVEF > 50% at CMR were included. The median time between STEMI and CMR was 5 days (IQR 2-8). LV volumes and function, area at risk (on T2 weighted images), infarcted myocardium (on late enhanced images), intramyocardial hemorrhage, and early and late microvascular obstruction (MVO) were detected and measured. CMR tissue determinants were correlated with the incidence of major adverse cardiovascular events (MACEs) over a 5-year follow-up. RESULTS: During median follow-up of 4 years (range 3 to 5 years), eight (10%) patients experienced MACE, yielding an annualized event rate of 2.1%. All CMR tissue markers were not significantly different between MACE and no-MACE patients, except for the presence of late MVO (50% vs. 16%, respectively; p = 0.044) and its extent (2.30 ± 1.64 g vs. 0.18 ± 0.12 g, respectively; p = 0.000). From receiver-operating characteristic (ROC) curve (area under the curve 0.89; 95% confidence interval, 0.75-1.0; p = 0.000), late MVO extent > 0.385 g was a strong independent predictor of MACE at long-term follow-up (sensitivity = 87%, specificity = 90%; hazard ratio = 2.24; 95% confidence interval, 1.51-3.33; p = 0.000). CONCLUSIONS: Late MVO extent after primary PCI on CMR seems to be a strong predictor of MACE at 5-year follow-up in patients with LVEF > 50%. Noticeably, late MVO extent > 0.385 g provided relevant prognostic insights leading to improved long-term risk stratification. KEY POINTS: • Tissue markers provided by cardiac magnetic resonance aid in prognostic stratification after myocardial infarction • The occurrence of late microvascular obstruction after acute myocardial infarction increases risk of major adverse events at 5-year follow-up. • The greater microvascular obstruction extent on late gadolinium enhanced images is related to an increased risk of adverse events in patients with myocardial infarction and preserved left ventricular function.


Assuntos
Circulação Coronária/fisiologia , Estenose Coronária/diagnóstico , Microcirculação/fisiologia , Complicações Pós-Operatórias , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Estenose Coronária/epidemiologia , Estenose Coronária/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Incidência , Itália/epidemiologia , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Taxa de Sobrevida/tendências , Fatores de Tempo
9.
J Heart Lung Transplant ; 38(3): 306-314, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30581051

RESUMO

BACKGROUND: The added value of cardiopulmonary exercise testing (CPET) in the follow-up of patients with stable pulmonary arterial hypertension (PAH) remains undefined. METHODS: Idiopathic, heritable, and drug-induced PAH patients free from clinical worsening (CW) after 1 year of treatment were enrolled in derivation (n = 80) and validation (n = 80) cohorts at an interval of 6 years and followed for 3 years. Prognostic models were constructed and validated in low-risk patients in World Health Organization (WHO) Functional Class I or II with cardiac index (CI) ≥2.5 liters/min/m2 and right atrial pressure (RAP) <8 mm Hg. Discrimination and calibration were assessed. RESULTS: Forty-one derivation cohort patients had CW (51.2%) during 722 ± 349 days. Changes (∆) in WHO classification and CI and absolute value of RAP were independent predictors of CW. With addition of CPET variables, peak oxygen uptake (VO2 peak) and ∆CI independently improved the power of the prognostic model. Receiver operating characteristic (ROC)-derived cut-off values for ∆CI and VO2 peak were 0.40 liter/min/m2 and 15.7 ml/kg/min (≥60% predicted value), respectively. Twenty-nine validation cohort patients had CW (36.2%) during 710 ± 282 days. Different combinations of cut-off values of VO2 peak and ∆CI defined 4 groups. The event-free survival rates at 1, 2, and 3 years were 100%, 100%, and 100%, respectively, for the high ∆CI with high VO2 peak combination; 100%, 88%, and 71% for low ∆CI/high VO2 peak; 80%, 54%, and 40% for high ∆CI/low VO2 peak; and 72%, 54%, and 33% for low ∆CI/low VO2 peak. CONCLUSIONS: The combinations of baseline VO2 peak and change in CI during follow-up is important in prognostication of low-risk patients with idiopathic, heritable, and drug-induced PAH.

10.
J Cardiovasc Med (Hagerstown) ; 20(2): 66-73, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30540644

RESUMO

AIMS: Real-world data on treatment persistence, safety and effectiveness of non-Vitamin K antagonist oral anticoagulants (NOACs) play an important role in the assessment of risks and benefits of these drugs. Our aim was to evaluate persistence on treatment, incidence of major bleeding and incidence of a composite endpoint of major events, including all-cause death, myocardial infarction, stroke and systemic thromboembolism, during treatment with apixaban in a cohort of patients with nonvalvular atrial fibrillation (NVAF). METHODS: In this multicentre retrospective observational study, we retrieved data from medical records of five Italian hospitals on patients with a diagnosis of NVAF who initiated apixaban between 1 January 2014 and 31 March 2016 and had a first subsequent visit at the same hospital. RESULTS: We studied 766 patients with mean age of 74.2 (standard deviation 11.1) years and median CHADS2 and CHA2DS2VASc scores of 2.0 and 4.0, respectively. Over a median follow-up period of 339 days, persistence on treatment was 83.5% [95% confidence interval (95% CI) 75.5-89.1%]. The rate of major bleeding (per 100 person-years) was 1.15 (95% CI 0.39-1.90 per 100 person-years), while the cumulative incidence was 4.4% (95% CI 1.6-12.0). The rate of major events was 1.97 (95% CI 1.08-2.86) per 100 patient-years, with a cumulative incidence over the entire follow-up period of 7.7% (95% CI 4.6-12.8). CONCLUSION: In real-life conditions, NVAF patients treated with apixaban show rates of treatment discontinuation and major bleedings, which are comparable to those found in the ARISTOTLE pivotal study, thus supporting its external validity.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Esquema de Medicação , Substituição de Medicamentos , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
11.
Artigo em Inglês | MEDLINE | ID: mdl-30412229

RESUMO

Aims: The aim of this study was to describe incidence and determinants of left ventricular reverse remodelling (r-LVR) at 6 months follow-up after MitraClip implantation in patients with secondary severe mitral regurgitation (MR) and reduced left ventricular ejection fraction (LVEF). Methods and results: Forty-five patients, undergoing MitralClip implantation with low ejection fraction and high surgical risk were enrolled in this study. Three of them died before the scheduled 6 months follow-up period and one patient had cardiac surgery due to MitraClip detachment. All patients underwent transthoracic 2D and 3D echocardiography before and 6 months after the procedure. A significant MR severity reduction and an improvement in New York Heart Association (NYHA) class were detected in all patients. The study population was divided in two groups according to the presence of r-LVR (51%, n = 23 patients) or not (non-rLVR group, 18 patients). Non-significant differences in MR aetiology and number of clips implanted were found. Left ventricular reverse remodelling patients showed significant lower values of logistic EuroSCORE and STS score, left ventricular end-diastolic volume index (LVEDV/i), right ventricular end systolic area, and pulmonary artery systolic pressure (PASp) at baseline evaluation. At multivariable analysis, baseline PASp value resulted to be the only independent predictor of r-LVR [odds ratio 95% confidence interval 0.94 (0.89-0.99), P = 0.021]. In r-LVR patients, a significant improvement in LVEF and global longitudinal strain and a reduction in left atrial volume index were detected after 6 months, whereas in non-rLVR subgroup a significant increase in both LVEDV/i and left ventricular end-systolic volume index was observed at follow-up. Conclusion: Even if a reduction of MR was detected in all patients after MitralClip implant, our findings suggest that end-stage patients presenting with higher left ventricular volumes, logistic scores, and PASp may not benefit from the procedure at longer follow-up in terms of left ventricular function.

12.
ESC Heart Fail ; 2018 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-30378288

RESUMO

Hospitalization for acute heart failure (HF) is associated with a substantial morbidity burden and with associated healthcare costs and an increased mortality risk. However, few if any major medical innovations have been witnessed in this area in recent times. Levosimendan is a first-in-class calcium sensitizer and potassium channel opener indicated for the management of acute HF. Experience in several clinical studies has indicated that administration of intravenous levosimendan in intermittent cycles may reduce hospitalization and mortality rates in patients with advanced HF; however, none of those trials were designed or powered to give conclusive insights into that possibility. This paper describes the rationale and protocol of LeoDOR (levosimendan infusions for patients with advanced chronic heart failure), a randomized, double-blind, placebo-controlled, international, multicentre trial that will explore the efficacy and safety of intermittent levosimendan therapy, in addition to optimized standard therapy, in patients following hospitalization for acute HF. Salient features of LeoDOR include the use of two treatment regimens, in order to evaluate the effects of different schedules and doses of levosimendan during a 12 week treatment phase, and the use of a global rank primary endpoint, in which all patients are ranked across three hierarchical groups ranging from time to death or urgent heart transplantation or implantation of a ventricular assist device to time to rehospitalization and, lastly, time-averaged proportional change in N-terminal pro-brain natriuretic peptide. Secondary endpoints include changes in HF symptoms and functional status at 14 weeks.

13.
Expert Rev Respir Med ; 12(10): 809-815, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30142003

RESUMO

INTRODUCTION: Pulmonary arterial hypertension (PAH) is a progressive, life-threatening, and incurable disease. Its prognosis is based on right ventricular (RV) function. Therefore, adequate assessment of RV function is mandatory. Areas covered: This article presents the case of a patient with PAH in which the traditional diagnostic approach did not provide a complete assessment of RV function. The authors show how the analysis of other parameters yielded additional information that improved the management of this patient. Expert commentary: Despite current treatments, PAH often worsens due to progressive RV dysfunction. Appropriate assessment of RV function may facilitate the early identification of patients at risk of RV function impairment. More aggressive treatment of PAH might delay progression of the disease. Traditional risk stratification, which is based on New York Heart Association/World Health Organization (NYHA/WHO) functional class evaluation, the 6-minute walk test, and right heart catheterization, proves insufficient in many PAH patients, as it does not provide complete information about RV function. Thus, further parameters are required. Analysis of RV function, in addition to echocardiography and cardiopulmonary exercise testing, may add relevant prognostic information and improve therapy.

14.
Atherosclerosis ; 274: 218-226, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29803160

RESUMO

BACKGROUND AND AIMS: The risk of recurrence of myocardial infarction (MI) in HIV patients presenting with acute coronary syndrome (ACS) is well known, but there is limited evidence about potential differences in coronary plaques compared to non-HIV patients. METHODS: In this multicenter case-control study, HIV patients presenting with ACS, with intravascular-ultrasound (IVUS) data, enrolled between February 2015 and June 2017, and undergoing highly active antiretroviral therapy (HAART), were retrospectively compared to non-HIV patients presenting with ACS, before and after propensity score with matching, randomly selected from included centers. Primary end-point was the prevalence of multivessel disease. Secondary end-points were the prevalence of abnormal features at IVUS, the incidence of major-acute-cardiovascular-events (MACE), a composite end point of cardiovascular death, MI, target lesion revascularization (TLR), stent thrombosis (ST), non-cardiac death and target vessel revascularization (TVR). For each end-point, a subgroup analysis was conducted in HIV patients with CD4 cell count <200/mm3. RESULTS: Before propensity score, 66 HIV patients and 120 non-HIV patients were selected, resulting in 20 and 40 after propensity score. Patients with multivessel disease were 11 and 17, respectively (p = 0.56). IVUS showed a lower plaque burden (71% vs. 75%, p < 0.001) and a higher prevalence of hyperechoic non-calcified plaques (100% vs. 35%, p < 0.05) in HIV patients; a higher prevalence of hypoechoic plaques (7% vs. 0%, p < 0.05), a higher incidence of MACE (17.4% vs. 9.1% vs. l'8.0%, p < 0.05), MI recurrence (17.2% vs. 0.0% vs. 2.3%, p < 0.05), and ST (6.7% vs. 0.3% vs. 03%, p < 0.05) in HIV patients with CD4 < 200/mm3. CONCLUSIONS: Our study may provide a part of the pathophysiological basis of the differences in coronary arteries between HIV-positive and HIV-negative patients, suggesting that the former present with peculiar morphological features at IVUS, even after adjustment for clinical variables. Furthermore, we confirmed that an advanced HIV infection is associated with a high risk of non-calcific plaques and with a worse prognosis, including cardiovascular events and ACS recurrence.

15.
Int J Mol Sci ; 19(3)2018 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-29534462

RESUMO

Diabetes mellitus is one the strongest risk factors for cardiovascular disease and, in particular, for ischemic heart disease (IHD). The pathophysiology of myocardial ischemia in diabetic patients is complex and not fully understood: some diabetic patients have mainly coronary stenosis obstructing blood flow to the myocardium; others present with coronary microvascular disease with an absence of plaques in the epicardial vessels. Ion channels acting in the cross-talk between the myocardial energy state and coronary blood flow may play a role in the pathophysiology of IHD in diabetic patients. In particular, some genetic variants for ATP-dependent potassium channels seem to be involved in the determinism of IHD.


Assuntos
Diabetes Mellitus/metabolismo , Canais Iônicos/metabolismo , Isquemia Miocárdica/metabolismo , Animais , Circulação Coronária , Diabetes Mellitus/fisiopatologia , Humanos , Isquemia Miocárdica/fisiopatologia
16.
J Nucl Cardiol ; 2018 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-29594915

RESUMO

BACKGROUND: Despite therapeutic improvement, the prognosis of chronic heart failure (CHF) remains unfavorable partly due to arrhythmia and sudden cardiac death (SCD). This prospective study evaluated myocardial 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy as a predictor of arrhythmic events (AE) in CHF patients. METHODS: 170 CHF patients referred for implantable cardioverter-defibrillator (ICD) implantation for both primary and secondary prevention were enrolled. All patients underwent planar and SPECT imaging. Early and late heart-to-mediastinum (H/M) ratio, 123I-mIBG washout (WO), early and late summed SPECT scores were calculated The primary endpoint was an AE: sustained ventricular tachycardia, resuscitated cardiac arrest, appropriate ICD therapy or SCD. The secondary endpoint was appropriate ICD therapy. RESULTS: During a median follow-up of 23.3 months, 69 patients experienced an AE. Early summed score (ESS) was the only independent predictor of AE [HR 1.023 (1.003-1.043)]. Focussing on only patients with an ICD for primary prevention, ESS was the only independent predictor of AE [HR 1.028 (1.007-1.050)]. 123I-mIBG-derived parameters failed to be independent predictors of appropriate ICD therapy. However there was a "bell-shaped" relation between 123I-mIBG scintigraphy-derived parameters and AE and appropriate ICD therapy, i.e., those with intermediate 123I-mIBG abnormalities tended to be at higher risk of events. CONCLUSION: Although SPECT 123I-mIBG scintigraphy was associated with AE in CHF patients with ICD implantation for primary and secondary prevention, no association was found between 123I-mIBG scintigraphy-derived parameters and appropriate ICD therapy.

17.
Eur Heart J Suppl ; 19(Suppl C): C22-C28, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29249907

RESUMO

Pathological interplay between the heart and kidneys-also known as cardio-renal syndrome (CRS)-is frequently encountered in heart failure and is linked to worse prognosis and quality of life. Drug therapies for this complex situation may include nitroprusside or the recombinant B-type natriuretic peptide nesiritide for patients with acute CRS with normal or high blood pressure, and inotropes or inodilators for patients with acute CRS with low blood pressure. Clinical data for a renal-protective action of levosimendan are suggestive, and meta-analysis data obtained in a range of low-output states are consistent with a levosimendan-induced benefit. Evidence of favourable organ-specific effects of levosimendan, including pre-glomerular vasodilation and increased renal artery diameter and renal blood flow, were collected both in preclinical and clinical studies. Larger randomized controlled trials are however needed to confirm the renal effects of levosimendan in various clinical settings.

18.
G Ital Cardiol (Rome) ; 18(12): 854-861, 2017 Dec.
Artigo em Italiano | MEDLINE | ID: mdl-29189829

RESUMO

The introduction of specific drugs for the treatment of pulmonary arterial hypertension over the last 20 years has led to an improvement of clinical and hemodynamic conditions and prognosis of affected patients. The use of combination therapy has made it possible to act simultaneously on several biological pathways involved in the etiopathogenesis of the disease. However, although the diagnosis and management have radically changed in recent years, the disease remains progressive and often fatal. The purpose of this paper is to review and discuss the results of the main clinical trials and the future perspectives of combination strategies for the treatment of pulmonary arterial hypertension.

19.
Artigo em Inglês | MEDLINE | ID: mdl-29107544

RESUMO

BACKGROUND: Right ventricular (RV) failure is a major determinant of symptoms and shortened survival in pulmonary arterial hypertension (PAH). This study assessed the prognostic relevance of increased right heart (RH) dimensions determined by echocardiography and RH reverse remodeling (RHRR) with targeted therapies in idiopathic PAH (IPAH). METHODS: The study prospectively monitored 102 therapy-naïve IPAH patients for the presence of clinical worsening. Baseline evaluation included RH catheterization and echocardiography. RHRR at the 1-year follow-up was defined by a decrease in RV end-diastolic area, right atrial area, and the left ventricular systolic eccentricity index. RESULTS: At the 1-year follow-up, 18 of 102 patients (17.6%) presented with RHRR. A decrease in pulmonary vascular resistance was the only independent determinant of RHRR. The 94 surviving patients were monitored for 995 ± 529 days. RHRR was an independent prognostic factor and significantly improved the power of the prognostic model based on traditional clinical and hemodynamic parameters. The respective event-free survival rates at 1, 3, and 5 years were 94%, 94%, and 94% in patients with RHRR and 75%, 55%, and 24% in those without RHRR (p = 0.0001). Interestingly, RHRR was able to further stratify patients' risk assessment through the Registry to Evaluate Early And Long-term PAH Disease Management risk score. CONCLUSIONS: RHRR after 1 year of treatment is an independent predictor of prognosis in IPAH. The likelihood of RHRR is proportional to decreased pulmonary vascular resistance.

20.
Sci Rep ; 7(1): 11188, 2017 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-28894182

RESUMO

We present a study on the prediction of rogue waves during the 1-hour sea state of Hurricane Joaquin when the Merchant Vessel El Faro sank east of the Bahamas on October 1, 2015. High-resolution hindcast of hurricane-generated sea states and wave simulations are combined with novel probabilistic models to quantify the likelihood of rogue wave conditions. The data suggests that the El Faro vessel was drifting at an average speed of approximately 2.5 m/s prior to its sinking. As a result, we estimated that the probability that El Faro encounters a rogue wave whose crest height exceeds 14 meters while drifting over a time interval of 10 (50) minutes is ~1/400 (1/130). The largest simulated wave is generated by the constructive interference of elementary spectral components (linear dispersive focusing) enhanced by bound nonlinearities. Not surprisingly then, its characteristics are quite similar to those displayed by the Andrea, Draupner and Killard rogue waves.

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