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Impacto da terapêutica vasodilatadora pulmonar na remodelagem reversa do ventrículo direito em doentes com hipertensão arterial pulmonar
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Introdução: Apesar de múltiplos avanços nas últimas décadas relativamente à compreensão e tratamento da Hipertensão Arterial Pulmonar (HAP), esta entidade apresenta ainda uma elevada morbilidade e mortalidade. A falência ventricular direita é o principal condicionante prognóstico, que ocorre devido a uma remodelagem ventricular inicialmente adaptativa e, posteriormente, mal adaptativa. Curiosamente, nos casos de normalização da pós-carga como ocorre no transplante pulmonar bilateral, tem sido documentada a reversibilidade destes fenómenos. No entanto, relativamente à terapêutica vasodilatadora pulmonar, as respostas parecem ser parciais e inconsistentes entre classes farmacológicas. Não obstante, em ambos os casos, a remodelagem reversa do ventrículo direito (VD) apresenta implicações prognósticas.
Objetivo: Avaliar o impacto da terapêutica vasodilatadora pulmonar em doentes com HAP na remodelagem reversa do VD e a sua associação com variáveis prognósticas.
Métodos: Estudo observacional retrospetivo incluindo doentes em seguimento num centro de referência para a HAP, desde 2008. Foram analisados parâmetros clínicos, funcionais, laboratoriais, ecocardiográficos e hemodinâmicos previamente à implementação de terapêutica e cerca de 12 meses depois da mesma.
Resultados: Em 37 doentes com HAP, entre 32% a 43% dos indivíduos mostraram reversão de pelo menos um dos principais marcadores anatómicos de remodelagem reversa. Observaram-se correlações importantes entre a variação de parâmetros funcionais e morfológicos do ventrículo direito com a variação de marcadores prognósticos. Globalmente, os indivíduos com remodelagem reversa evidenciaram melhorias superiores nas variáveis prognósticas, salientando-se a diminuição da Resistência Vascular Periférica e da Classe Funcional a 12 meses nos doentes com diminuição do índice de excentricidade. A mortalidade foi inferior nos indivíduos com remodelagem reversa, sendo estatisticamente significativa nos doentes com melhoria da função VD definida pela FAC e TAPSE. Conclusão: A remodelagem reversa do coração direito foi objetivada numa percentagem considerável dos indivíduos e associou-se a variáveis com valor prognóstico e menor mortalidade
Background: Despite multiple advances in recent decades regarding the understanding and treatment of Pulmonary Arterial Hypertension (PAH), this entity still has high morbidity and mortality. Right ventricular failure is the main prognostic determinant, which occurs due to an initially adaptive and later maladaptive ventricular remodeling. Interestingly, in cases of afterload normalization, as in bilateral lung transplantation, the reversibility of these phenomena has been documented. However, regarding pulmonary vasodilator therapy, responses appear to be partial and inconsistent across pharmacological classes. Nevertheless, in both cases, reverse right ventricle (RV) remodeling has prognostic implications. Objective: To assess the impact of pulmonary vasodilator therapy in patients with PAH on reverse RV remodeling and it’s association with prognosis. Methodology: Retrospective observational study including patients followed at a referral center for Pulmonary Hypertension since 2008. Clinical, functional, laboratory, echocardiographic and hemodynamic parameters were analyzed before the implementation of therapy and approximately 12 months after. Results: In 37 patients with PAH, between 32% and 43% of subjects showed reversal of at least one of the major anatomical markers of reverse remodeling. Important correlations were observed between the variation of functional and morphological parameters of the RV and the variation of prognostic markers. Overall, individuals with reverse remodeling showed greater improvements of prognostic variables, with emphasis on the decrease in Pulmonary Vascular Resistance and Functional Class at 12 months in patients with decreased Eccentricity Index. Lower mortality was observed in individuals with reverse remodeling, which was statistically significant in patients with improved RV function evaluated by FAC and TAPSE. Conclusion: Reverse remodeling of the right heart was observed in a considerable percentage of individuals and was associated with prognostic variables and lower mortality.
Background: Despite multiple advances in recent decades regarding the understanding and treatment of Pulmonary Arterial Hypertension (PAH), this entity still has high morbidity and mortality. Right ventricular failure is the main prognostic determinant, which occurs due to an initially adaptive and later maladaptive ventricular remodeling. Interestingly, in cases of afterload normalization, as in bilateral lung transplantation, the reversibility of these phenomena has been documented. However, regarding pulmonary vasodilator therapy, responses appear to be partial and inconsistent across pharmacological classes. Nevertheless, in both cases, reverse right ventricle (RV) remodeling has prognostic implications. Objective: To assess the impact of pulmonary vasodilator therapy in patients with PAH on reverse RV remodeling and it’s association with prognosis. Methodology: Retrospective observational study including patients followed at a referral center for Pulmonary Hypertension since 2008. Clinical, functional, laboratory, echocardiographic and hemodynamic parameters were analyzed before the implementation of therapy and approximately 12 months after. Results: In 37 patients with PAH, between 32% and 43% of subjects showed reversal of at least one of the major anatomical markers of reverse remodeling. Important correlations were observed between the variation of functional and morphological parameters of the RV and the variation of prognostic markers. Overall, individuals with reverse remodeling showed greater improvements of prognostic variables, with emphasis on the decrease in Pulmonary Vascular Resistance and Functional Class at 12 months in patients with decreased Eccentricity Index. Lower mortality was observed in individuals with reverse remodeling, which was statistically significant in patients with improved RV function evaluated by FAC and TAPSE. Conclusion: Reverse remodeling of the right heart was observed in a considerable percentage of individuals and was associated with prognostic variables and lower mortality.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022
Palavras-chave
Hipertensão arterial pulmonar Ventrículo direito Terapêutica vasodilatadora Remodelagem reversa Prognóstico Cardiologia