| Pulmonary hypertension(PH)can occur under a variety of clinical conditions.It is characterized by various pathophysiological changes of distal pulmonary arteries,leading to progressive increase of pulmonary vascular resistance(PVR)and right ventricle(RV)afterload,which can lead to right heart failure(RHF)and even death.As far as we know,Pulmonary hypertension can be classified into 5 groups:Pulmonary Arterial Hypertension(PAH),Pulmonary Hypertension due to left heart disease(PH-LHD),PH caused by hypoxia and/or pulmonary diseases,and chronic thromboembolic pulmonary hypertension(CTEPH),the last group of PH is the pathological cause of PH is unknown.For the diagnosis and treatment of PH patients,the Priority is to find the cause of the disease.The next step is to make an effective treatment plan.These treatment plans will make sure patients will receive quality medical care and be recovered soonly.Although the treatment of pulmonary arterial hypertension(PAH)is developing fast,still the 5-year survival rate of first group PAH is only between 47%to 55%.Regardless of the cause of PH,all PH will be associated with reduced exercise tolerance and increased morbidity and mortality.The most important step in the diagnosis of PH is to distinguish between pulmonary arterial hypertension(PAH)and left heart disease-associated pulmonary hypertension(PH-LHD).Right Heart Catheterization(RHC)examination is the gold standard to the diagnosis of PH-LHD.Because RHC is an invasive procedure,it has not been used commonly in medical examinations.Echocardiography can display the heart structure in real time,which is simple,safe,economical and repeatable,making it the most commonly used imaging method for non-invasive evaluation of pulmonary artery pressure and right heart function.Due to the lack of specificity of the initial symptoms,and people have insufficient understanding of it,the majority of PH patients have obvious delay in seeing a doctor,at least 1/5patients have spent more than 2 years from the onset of symptoms to the diagnosis,up to half of patients with idiopathic pulmonary hypertension(IPAH)have reached WHO functional class(WHO-FC)III-IV at the time of hospital diagnosis,therefore,it is imperative to explore powerful ultrasonic indicators for comprehensive assessment of pulmonary artery pressure and early p H screening.Pulmonary arterial hypertension associated with connective tissue disease(CTD-PAH)is a complicated and fatal complication of CTD.According to statistics,8-12%of patients with Systemic sclerosis(SSC)have PAH,accounting for 75%of CTD-PAH cases,1-5%of patients with systemic lupus erythematosus(SLE)have PAH,and 3-4%of patients with mixed connective tissue disease(MCTD)have PAH.PAH,the leading cause of death in SSC patients,has a worse prognosis than IPAH.After CTD-PAH patients received PAH-specific therapy,the 1-year survival rates for SLE,MCTD,and SSC patients were 94%,88%,and 82%,respectively.Therefore,it is of great significance to study the specific group of CTD-PAH.Tadalafil is a selective type 5 phosphodiesterase inhibitor(PDE-5)that has been approved for the treatment of pulmonary hypertension.This study was intended to study the clinical efficacy of tadalafil in the treatment of CTD-PAH patients,and follow-up visits were conducted to observe its long-term prognosis.Computed tomography pulmonary angiography(CTPA)is an important step in the screening process of pulmonary hypertension.contrast induced nephropathy(CIN)is an iatrogenic acute kidney injury observed after intravascular diagnosis or angiographic intervention with contrast material(CM),which will significantly increase the mortality rate of patients once it occurs.Therefore,it is a research hotspot to actively explore drugs that can reduce pulmonary artery pressure and have protective effect on renal function.Echocardiography(ECHO)is an important method for primary screening of patients with pulmonary hypertension.Sodium ferulate(SF)has the effect of lowering pulmonary artery pressure.Although SF has a beneficial effect in many diseases such as diabetic nephropathy,whether it has a positive effect on renal protection after CTPA examination in PH patients remains to be studied.Among PAH patients,the 5-year survival rate was>90%in patients with stable or improved right ventricular function;however,the survival rate of patients with decreased right ventricular function was less than 30%,which was not affected by changes in pulmonary vascular resistance.Right heart failure was the most common cause of death.Therefore,this paper planned to review the evaluation of right ventricular function in patients with pulmonary hypertension.Meanwhile,based on the previous research of our center,this series of studies will focus on echocardiography as the guidance to explore the patients with pulmonary hypertension in three parts:1.Echocardiography to optimize the differential diagnosis of pulmonary hypertension,to study the application of echocardiography and RHC examination in distinguishing PAH and PH-LHD.2.Echocardiography was used to evaluate the clinical efficacy of tadalafil on CTD-PAH,to provide more insights for the treatment of CTD-PAH.3.Echocardiography was used to screen the patients with pulmonary hypertension,and renal ultrasound was used to evaluate the effect of drugs on the renal protection after CTPA examination in this group.Part One Application of Echocardiography Combined with Right Heart Catheter in Optimizing the Differentiation of Pulmonary Art-erial Hypertension and Pulmonary Hypertension due to Left Heart DiseaseObjective:The purpose of this study was to investigate the clinical value of echocardiography(ECHO)and right heart catheterization(RHC)in differentiating pulmonary arterial hypertension(PAH,category 1)from pulmonary hypertension due to left heart disease(PH-LHD,category 2).Methods:Patients diagnosed with pulmonary hypertension(PH)were divided into two groups:PAH group and PH-LHD group.The PH-LHD group included heart failure with reduced ejection fraction(HFr EF)group and heart failure with preserved ejection fraction(HFp EF)group.The main outcomes included systolic pulmonary artery pressure(s PAP),tricuspid annular plane systolic excursion(TAPSE),stroke volume(SV),and pulmonary effective arterial elastance(Ea),TAPSE/s PAP,pulmonary artery compliance(PAC),and left ventricular eccentric index(LVEI),etc.Each parameters is compared respectively.Results:1.Patients who underwent RHC examination(PAH and HFp EF group),s PAP?d PAP?m PAP and PVR in HFp EF group were lower than those in the PAH group,while PAWP was higher than PAH group,the difference was statistically significant(P<0.05).2.ECHO-s PAP was highly correlated with RHC-s PAP,with a correlation coefficient of 0.860.3.RHC-TAPSE/s PAP(area under the ROC curve(AUC)=0.918,optimal cut-off point 0.275mm/mm Hg,sensitivity 100%,specificity 77.8%),ECHO-TAPSE/s PAP(AUC=0.887,the optimal cut-off point was0.275mm/mm Hg,the sensitivity was 95.0%,the specificity was 66.7%),and the diagnostic accuracy of HFp EF was good.4.RHC-PAC(AUC=0.916,optimal cut-off point 1.42 ml/mm Hg·m~2,sensitivity 85.0%,specificity 87.0%)showed good diagnostic accuracy for HFp EF.5.Combined with ECHO and RHC test results,Ea in the HFp EF group was lower than that in the PAH group.The area of Ea under the ROC curve of RHC-Ea was 0.073,which was used to distinguish HFp EF with low accuracy.6.The cases of LVEI>1 in PAH group was higher than that of HFr EF group,while there was no statistical difference between PAH group and HFp EF group.Summary:1.Echo-s PAP is highly correlated with RHC-s PAP;Echo-TAPSE/s PAP was highly correlated with RHC-TAPSE/s PAP.2.The TAPSE/s PAP of 0.275mm/mm Hg and RHC-PAC of 1.42ml/mm Hg·m~2 obtained from RHC and Echo are the best cut-off points for predicting PH-HFp EF.Part Two Echocardiographic Evaluation of Tadalafil in the Treatment of Connective Tissue Disease Associated Pulmonary Hyper-tensionObjective:The purpose of this study was to evaluate the clinical efficacy of Tadalafil in patients with connective tissue disease associated pulmonary arterial hypertension(CTD-PAH)using echocardiographic parameters.Methods:Patients diagnosed with CTD-PAH were randomly divided into tadalafil group and control group.The tadalafil group was given tadalafil10mg orally once a day,and the control group was given Beraprost 40ug orally three times a day,both groups were given conventional treatment.Right heart catheterization(RHC)was performed in both groups after admission,and echocardiography and 6-minute walk distance(6MWD)were reexamined at admission,3 months and half a year after medication.The main results were to compare the changes of echocardiographic parameters such as tricuspid regurgitation velocity(TRV)and s PAP,as well as the changes of 6MWD,N-terminal pro-B-type natriuretic peptide(NT-pro BNP),length of hospital stay,mortality,WHO-FC,etc.Results:In CTD-PAH patients,there was a moderate correlation betw-een ECHO-s PAP and RHC-s PAP,with a correlation coefficient of 0.544.There were no significant differences in baseline of TRV,s PAP,6MWD and NT-pro BNP levels between the two groups at admission(P>0.05).After 3months of treatment in CTD-PAH patients,s PAP levels in the tadalafil group were lower than those in the CON group,and the difference was statistically significant(P<0.05).After 6 months of treatment,LV,SV and TAPSE in tadalafil group were higher than those in control group;LVEF,s PAP and TRV was lower than the control group,and the difference was statistically significant(P<0.05).After 3 months of treatment,the improvement of NT-pro BNP and 6MWD in the tadalafil group was better than that in the CON group(P<0.05).After 6 months of treatment,6MWD in the tadalafil group was better than that in the CON group,and the difference was statistically significant(P<0.05).The level of NT-pro BNP in Tadalafil group was lower than that in CON group,but the difference was not statistically significant(P>0.05).There was no significant difference in the length of stay between the tadalafil group and the CON group(P>0.05).After 6 months of treatment,there was no significant difference in the mortality rate and readmission rate between the two groups(P>0.05).the number of WHO-FC?II patients in the tadalafil group was higher than that in the CON group(P<0.05).Summary:1.In patients with CTD-PAH,there was a moderate correlation between ECHO-s PAP and RHC-s PAP.2.Tadalafil was used in CTD-PAH patients for 6 months,and the pulmonary artery pressure was reduced,which was safe and effective in clinical application.3.After half a year of treatment for CTD-PAH patients,WHO-FC levels?II in the tadalafil group were more than those in the CON group,and the length of hospital stay and the number of re-hospitalizations were not increased,with the improvement of hemodynamic parameters and motor ability,the patients obtained a higher quality of life.Part Three Study on the Renal Protective Effect of Ultrasound Evalua-tion Sodium Ferulate on Patients with Pulmonary Hypert-ension after CTPA ExaminationObjective:The purpose of this study was to evaluate the renal protective effect of sodium ferulate(SF)on patients with pulmonary hypertension(PH)after CT pulmonary angiography(CTPA),and whether the renal resistance index(RRI)is associated with the occurrence of contrast induced nephropathy(CIN)after CTPA examination in PH patients.Methods:PH patients meeting the inclusion criteria were included and randomly divided into SF group and control group(CON).Patients in the SF group received intravenous injection of 3.0g/d SF 12h before and 72h after CTPA examination,and patients in CON group received routine treatment.All candidates underwent CTPA examination after admission.The serum creatinine(SCr),estimation of glomerular filtration rate(e GFR)and cystatin C(Cys-C)were measured at 1h before CTPA examination,24h,48h and 72h after CTPA examination,respectively,the renal function was evaluated and the incidence of contrast-induced nephropathy(CIN)was calculated,and the indicators of the two groups were compared.Renal resistance index(RRI)examination was performed 1h before,1h after and 24h after CTPA examination.RRI levels were compared between the CIN group and the non-CIN group.Results:The levels of SCr,e GFR and Cys-C were similar between SF group and CON group at admission,and the differences were not statistically significant(P>0.05).There was no significant difference in SCr level between SF group and CON group at 24h after CTPA examination(P>0.05),the SCr level at 48h and 72h after CTPA examination was lower than that in CON group(P<0.05).e GFR level of SF group was slightly higher than that of CON group at 24,48 and 72h after CTPA examination,but the difference was not statistically significant(P>0.05).The level of Cys-C in SF group at 48h and72h after CTPA examination was significantly lower than that in CON group(P<0.05).Seventy-two hours after CTPA examination,9 patients were diagnosed with CIN,and the incidence of CIN was 9.78%.The incidence of CIN in SF group was 4.08%(2/49)and 16.28%(7/43)in CON group.The incidence of CIN in SF group was significantly lower than that in CON group(P<0.05).At 1h before CTPA examination,there was no difference in RRI between the CIN group and the non-CIN group,at 1h and 24h after CTPA examination,RRI in CIN group was higher than that in non-CIN group(P<0.05).RRI in the non-CIN group returned to closer to baseline at 24h after CTPA(P>0.05).Summary:1.Intravenous SF infusion from 12h before CTPA examination to 72h after CTPA examination can reduce the incidence of CIN in patients with PH.2.There were significant differences in RRI between the CIN group and the non-CIN group,suggesting that RRI might be used as a predictor of CIN after CTPA in patients with PH.Conclusion:1.Echo-s PAP is highly correlated with RHC-s PAP;Echo-TAPSE/s PAP was highly correlated with RHC-TAPSE/s PAP.2.Echo's follow-up showed that the pulmonary artery pressure of CTD-PAH patients decreased after half a year's treatment with tadalafil,and the clinical application was safe and effective.3.Intravenous SF infusion from 12h before CTPA examination to 72h after CTPA examination can reduce the incidence of CIN in patients with PH. |
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