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New insights into chronic thromboembolic pulmonary hypertension
Novas perspetivas sobre hipertensão pulmonar tromboembólica crónica
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Uma revisão sistemática e meta-análise" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3220 "Ancho" => 2917 "Tamanyo" => 483493 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Flowchart of study selection using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram to illustrate the study selection process.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jaime Pinho, Miguel Carvalho, Mariana Paiva, Nuno Teixeira-Tavares, Cristina Costa-Santos, Carla Sousa" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Jaime" "apellidos" => "Pinho" ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Carvalho" ] 2 => array:2 [ "nombre" => "Mariana" "apellidos" => "Paiva" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Teixeira-Tavares" ] 4 => array:2 [ "nombre" => "Cristina" "apellidos" => "Costa-Santos" ] 5 => array:2 [ "nombre" => "Carla" "apellidos" => "Sousa" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123003530?idApp=UINPBA00004E" "url" => "/08702551/0000004200000012/v3_202312120610/S0870255123003530/v3_202312120610/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S087025512300392X" "issn" => "08702551" "doi" => "10.1016/j.repc.2023.06.007" "estado" => "S300" "fechaPublicacion" => "2023-12-01" "aid" => "2243" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2023;42:947-58" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Prevalence and predictors of chronic thromboembolic pulmonary hypertension following severe forms of acute pulmonary embolism" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "947" "paginaFinal" => "958" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Prevalência e preditores de hipertensão pulmonar tromboembólica crónica após formas severas de embolia pulmonar aguda" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3416 "Ancho" => 3175 "Tamanyo" => 482803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study flowchart. * Risk stratification at admission following the current ESC guidelines, although PESI score was not considered for this categorization: low risk (absence of right ventricular [RV] dysfunction and troponin elevation); intermediate-low risk (RV dysfunction on transthoracic echocardiogram [TTE] or computed tomography pulmonary angiography [CTPA]; or elevated troponin levels); intermediate-high risk PE (RV dysfunction on TTE or CTPA and elevated troponin levels); high-risk (cardiac arrest: need for cardiopulmonary resuscitation; obstructive shock: hypotension (systolic blood pressure [BP] <90 mmHg) or vasopressors required to achieve BP >90 mmHg despite adequate filling status) and end-organ hypoperfusion (altered mental status; cold, clammy skin; oliguria/anuria; increased serum lactate); persistent hypotension (systolic BP <90 mmHg or systolic BP drop >40 mmHg, lasting longer than 15 min and not caused by new-onset arrhythmia, hypovolemia, or sepsis). CTEPH: chronic thromboembolic pulmonary hypertension; PE: pulmonary embolism; RHC: right heart catheterization.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joana Pargana, Rita Calé, Mariana Martinho, João Santos, Cândida Lourenço, José Alberto Castro Pereira, Patrícia Araújo, João Morgado, Ernesto Pereira, Tiago Judas, Sofia Alegria, Filipa Ferreira, Francisca Delerue, Hélder Pereira" "autores" => array:14 [ 0 => array:2 [ "nombre" => "Joana" "apellidos" => "Pargana" ] 1 => array:2 [ "nombre" => "Rita" "apellidos" => "Calé" ] 2 => array:2 [ "nombre" => "Mariana" "apellidos" => "Martinho" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Cândida" "apellidos" => "Lourenço" ] 5 => array:2 [ "nombre" => "José Alberto" "apellidos" => "Castro Pereira" ] 6 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Araújo" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "Morgado" ] 8 => array:2 [ "nombre" => "Ernesto" "apellidos" => "Pereira" ] 9 => array:2 [ "nombre" => "Tiago" "apellidos" => "Judas" ] 10 => array:2 [ "nombre" => "Sofia" "apellidos" => "Alegria" ] 11 => array:2 [ "nombre" => "Filipa" "apellidos" => "Ferreira" ] 12 => array:2 [ "nombre" => "Francisca" "apellidos" => "Delerue" ] 13 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025512300392X?idApp=UINPBA00004E" "url" => "/08702551/0000004200000012/v3_202312120610/S087025512300392X/v3_202312120610/en/main.assets" ] "asociados" => array:1 [ 0 => array:18 [ "pii" => "S087025512300392X" "issn" => "08702551" "doi" => "10.1016/j.repc.2023.06.007" "estado" => "S300" "fechaPublicacion" => "2023-12-01" "aid" => "2243" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2023;42:947-58" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Prevalence and predictors of chronic thromboembolic pulmonary hypertension following severe forms of acute pulmonary embolism" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "947" "paginaFinal" => "958" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Prevalência e preditores de hipertensão pulmonar tromboembólica crónica após formas severas de embolia pulmonar aguda" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3416 "Ancho" => 3175 "Tamanyo" => 482803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study flowchart. * Risk stratification at admission following the current ESC guidelines, although PESI score was not considered for this categorization: low risk (absence of right ventricular [RV] dysfunction and troponin elevation); intermediate-low risk (RV dysfunction on transthoracic echocardiogram [TTE] or computed tomography pulmonary angiography [CTPA]; or elevated troponin levels); intermediate-high risk PE (RV dysfunction on TTE or CTPA and elevated troponin levels); high-risk (cardiac arrest: need for cardiopulmonary resuscitation; obstructive shock: hypotension (systolic blood pressure [BP] <90 mmHg) or vasopressors required to achieve BP >90 mmHg despite adequate filling status) and end-organ hypoperfusion (altered mental status; cold, clammy skin; oliguria/anuria; increased serum lactate); persistent hypotension (systolic BP <90 mmHg or systolic BP drop >40 mmHg, lasting longer than 15 min and not caused by new-onset arrhythmia, hypovolemia, or sepsis). CTEPH: chronic thromboembolic pulmonary hypertension; PE: pulmonary embolism; RHC: right heart catheterization.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joana Pargana, Rita Calé, Mariana Martinho, João Santos, Cândida Lourenço, José Alberto Castro Pereira, Patrícia Araújo, João Morgado, Ernesto Pereira, Tiago Judas, Sofia Alegria, Filipa Ferreira, Francisca Delerue, Hélder Pereira" "autores" => array:14 [ 0 => array:2 [ "nombre" => "Joana" "apellidos" => "Pargana" ] 1 => array:2 [ "nombre" => "Rita" "apellidos" => "Calé" ] 2 => array:2 [ "nombre" => "Mariana" "apellidos" => "Martinho" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Cândida" "apellidos" => "Lourenço" ] 5 => array:2 [ "nombre" => "José Alberto" "apellidos" => "Castro Pereira" ] 6 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Araújo" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "Morgado" ] 8 => array:2 [ "nombre" => "Ernesto" "apellidos" => "Pereira" ] 9 => array:2 [ "nombre" => "Tiago" "apellidos" => "Judas" ] 10 => array:2 [ "nombre" => "Sofia" "apellidos" => "Alegria" ] 11 => array:2 [ "nombre" => "Filipa" "apellidos" => "Ferreira" ] 12 => array:2 [ "nombre" => "Francisca" "apellidos" => "Delerue" ] 13 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025512300392X?idApp=UINPBA00004E" "url" => "/08702551/0000004200000012/v3_202312120610/S087025512300392X/v3_202312120610/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "New insights into chronic thromboembolic pulmonary hypertension" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "959" "paginaFinal" => "960" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "João Brito" "autores" => array:1 [ 0 => array:4 [ "nombre" => "João" "apellidos" => "Brito" "email" => array:1 [ 0 => "jdbrito@netcabo.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cardiovascular Intervention Unit, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Interventional Cardiology Center, Hospital da Luz, Lisbon, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Novas perspetivas sobre hipertensão pulmonar tromboembólica crónica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening condition that occurs as a late complication of acute pulmonary embolism (PE). It is currently accepted that both central pulmonary vascular occlusion caused by unresolved fibrotic clots, and the development of secondary small vessel vasculopathy due to pulmonary vascular remodeling, play a role in the development of the disease.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> The treatment of choice for CTEPH is pulmonary endarterectomy, but this is not suitable for all patients. Other treatment strategies include balloon pulmonary angioplasty and pulmonary hypertension (PH) drugs targeting endothelial cell dysfunction.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The exact incidence of CTEPH is unknown, but in studies that used active surveillance after PE, estimates ranged between 0.1% and 8.8% within two years of a diagnosis of PE.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> This wide range across studies may be explained by differences in patient selection and, importantly, by the inconsistent use of right heart catheterization (RHC) for definitive diagnosis. Nevertheless, its incidence is considered low, and as such the current European guidelines for the diagnosis and treatment of PE recommend against routine screening for CTEPH after an acute PE episode.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The recommended strategy focuses on patients with persistent symptoms or functional limitations three to six months after PE as well as on those with conditions known to predispose to the development of CTEPH. However, clinical symptoms and signs are often hard to identify at early stages, which makes early diagnosis truly challenging, and even in expert centers the median time between symptom onset and diagnosis has been found to exceed one year.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Improvement in the diagnosis and treatment of this condition depends mainly on a high level of suspicion, and knowledge of CTEPH incidence and prevalence at a local level, as well as its predictors, are essential to achieve such improvement.</p><p id="par0015" class="elsevierStylePara elsevierViewall">These factors underline the relevance of the study by Pargana et al. presented in this issue of the <span class="elsevierStyleItalic">Journal</span>, which aimed to assess the prevalence and predictors of CTEPH two years after a symptomatic high- or intermediate-high risk PE in a national referral center for PH.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> The main finding of this retrospective single-center cohort study was an overall prevalence of suspected CTEPH by clinical assessment, Doppler echocardiography and V/Q lung scan of 6.2%, and of confirmed CTEPH by RHC of 3.1%. The presence of varicose veins and pulmonary artery systolic pressure higher than 60 mmHg at admission for the index event were identified as early predictors of CTEPH. Despite the limitation of a small sample, which resulted in only four patients with definite CTEPH, clearly undermining assessment of the predictors, the study has the merit of addressing this important topic, which is indeed understudied in Portugal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently, this group specializing in PE analyzed the current clinical recommendations for the use of percutaneous catheter-directed therapy (CDT) and proposed a standardized approach for severe forms of acute PE, highlighting the role of pulmonary embolism response teams in this setting.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Empirically, the treatment of acute PE should have a critical impact on CTEPH development, although the effect of systemic thrombolysis or CDT on this condition remains questionable. Fortunately, there are promising ongoing randomized trials that may help to answer these questions: the PEITHO-3 study will assess the efficacy and safety of reduced dose thrombolysis in intermediate-high-risk PE,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> while HI-PEITHO is comparing CDT with parenteral anticoagulation in the same PE risk category.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> It should be noted that both will have confirmed CTEPH at follow-up as a secondary outcome. Meanwhile, all efforts should be made to optimize early detection and appropriate treatment of CTEPH, in order to improve functional capacity after acute PE and ultimately the patient's quality of life.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic major-vessel thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.M. 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| Ano/Mês | Html | Total | |
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