Mimickers of chronic thromboembolic pulmonary hypertension on imaging tests: a review
Upcoming Trial To Test Diabetes Drug For Right Heart Failure In PAH
An upcoming clinical trial will test whether empagliflozin, a drug widely approved to treat diabetes and heart failure, might be able to improve heart health in people with pulmonary arterial hypertension (PAH).
The trial will be led by scientists at Cleveland Clinic, with study sites planned at two other U.S. Medical centers.
The National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) has awarded two grants, totaling more than $6 million, to help fund the research, the nonprofit medical center said in a Cleveland Clinic press release.
"If this trial shows empagliflozin is effective, I expect significant improvements in PAH patients' symptoms, quality of life and, critically, the function of their right heart," said Gustavo Heresi, MD, a pulmonologist and researcher at Cleveland Clinic who will be helping to lead the trial.
Unlike available PAH therapies that target lungs, diabetes drug acts on heartPAH is characterized by unusually high pressure in the blood vessels of the lungs. This pressure puts strain on the right side of the heart, which is responsible for pumping blood to the lungs to pick up oxygen. The left side of the heart then pumps the oxygen-rich blood out to the body.
Over time, people with PAH typically develop right heart failure, in which the right side of the heart cannot adequately perform its job. This can contribute to symptoms like shortness of breath, and it's a major cause of death in PAH.
While several treatments for PAH are available, all of them target the lungs; there are no current PAH therapy options that act on the heart.
We chose to investigate empagliflozin because of its proven success as a treatment for managing left heart failure and its ability to modulate key metabolic pathways dysregulated in heart failure.
Empagliflozin, a drug sold under the brand name Jardiance among others, is approved as a treatment for type 2 diabetes and chronic heart failure. It acts to reduce blood sugar by increasing the amount of sugar excreted into the urine. The medication also has other effects on metabolism and heart health that aren't fully understood.
"We chose to investigate empagliflozin because of its proven success as a treatment for managing left heart failure and its ability to modulate key metabolic pathways dysregulated in heart failure," Heresi said.
The newly funded clinical trial will enroll people with PAH who have right heart failure and are already taking available PAH drugs that target the lungs. Participants will be randomly assigned to take empagliflozin or a placebo for about six months, at which point their right heart health will be assessed via an MRI scan.
In addition to Cleveland Clinic, the upcoming study will take place at Vanderbilt University Medical Center in Tennessee and the Johns Hopkins Medical Center in Maryland. Cleveland Clinic did not specify when the trial is expected to begin.
Signs That Chronic Heart Failure Is Getting Worse
By Maya Guglin, MD, as told to Mary Jo DiLonardo
Your heart's job is to pump blood around your body to supply all your organs with the oxygen they need to work well. When your heart doesn't pump as strong and as efficiently as it's supposed to, you have heart failure.
As your heart struggles to pump blood, fluid levels build up in your body. This excessive fluid causes almost all symptoms of heart failure.
Typically, people with heart failure complain of shortness of breath and fatigue. They might also gain some weight.
Shortness of BreathThere are two pumping chambers in the heart: the left and right ventricles. The left side of the heart collects oxygen-rich blood from the lungs. So, if the left ventricle is more affected by heart failure, the fluid builds up in the lungs, and the main symptom is shortness of breath.
At first it happens only when you try to do something really physically challenging like running. But as the disease progresses, it becomes difficult to walk up the steps. Then it becomes harder to walk fast, then harder to walk at all. You have to stop often and catch your breath.
CoughEventually, you start waking up at night because your lungs fill with "unpumped" fluid. You have to sit up, then the gravity pulls the fluid down, and your lungs can breathe again.
At this stage, you may even have wheezing like in asthma and you may even start coughing. The cough follows the same pattern as shortness of breath: It's worse when you are lying down and better when you sit up.
But if it gets this far, it's time to go to the emergency room or call an ambulance. This is serious.
Fluid and SwellingThe right side of your heart collects the blood from your whole body. If your right ventricle fails, extra fluid accumulates in your liver, kidneys, gut, and legs.
At first, you might notice that your ankles and feet swell by the end of the day. It's not unusual at all for this to happen to people who spend a lot of time on their feet, so this symptom is easily overlooked.
Next, the swelling can continue to creep up your body and move into the shins, thighs, and pelvis. If you put your fingertip on your leg and press lightly, the pit where your fingertip was stays and slowly goes away over the next minute. The medical term for that is "pitting edema."
Eventually blisters may form, skin may break, and the clear fluid inside can start to seep out. When the tissues are in that condition, it's easy to catch an infection called cellulitis, and legs become purple and angry.
Don't let that happen! See a doctor before it gets that bad.
It's more common to have the left ventricular failure first. For example, a large heart attack almost always involves the left ventricle. But if you allow the fluid accumulation in the lungs to persist, this will spread to the rest of the body.
It's important to be aware that heart failure is not the only condition that causes feet and legs to swell. Dilated veins called varices can cause very similar symptoms. That's why you should always let your doctor know about any symptoms you're having. Let the specialists sort this out.
Stomach Pain and Weight GainSometimes you might eat just a little, yet suddenly feel very full. But even though you are barely eating, you notice that you're somehow gaining weight. That's also from all the fluid that you're collecting in your body.
When the liver gets swollen from it (your doctor may call it "distended"), it may cause stomach pain on the upper right side. Some people think they might have an inflamed gallbladder. It's actually an enlarged liver.
Fatigue and Activity ChangesThe easiest way to know that heart failure is getting worse is you're able to do less and less.
People start pacing themselves. They stop doing hobbies that involve any physical activity. They used to go fishing, but not anymore. They used to play 18 holes -- now they are down to nine. They avoid stairs whenever they can.
They choose to only walk short distances, and they do it very slowly. They don't use the bedroom upstairs and instead sleep on the couch in the living room. Then they decide to sleep in a recliner. Then they can't sleep at all.
If you notice that the disease makes you change your habits, it's time to visit a doctor. They will almost always be able to help.
There are medications that can treat heart failure, including diuretics -- or water pills -- that work the fastest. There are also plenty of other treatments that can help.
Heart failure is a chronic condition and doesn't go away. But you can always work with your doctor to treat the symptoms and in some cases even improve the course of your disease.
The Spectrum Of Pulmonary Disease: Dr Parth Rali Highlights CHEST 2024 Agenda
Parth Rali, MD, Temple University Hospital, is looking forward to approaching pulmonary vascular diseases as a spectrum, especially when assessing pulmonary embolism and pulmonary hypertension, at CHEST 2024.
There are multiple topics to be excited about participating in at CHEST 2024, according to Parth Rali, MD, FCCP, associate professor of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, director of Fellowship Wellness and Social Media, Pulmonary and Critical Care Fellowship, and director of the Pulmonary Embolism Response Team (PERT) Program, Temple University Hospital.
Rali is also an integral part of Temple Lung Center's newly launched Pulmonary Vascular Disease Program, which provides comprehensive, expedited care for high-risk pulmonary hypertension and embolism cases, including mechanical support and lung transplant evaluations while extending outpatient services across multiple locations. With 11 active clinical trials and a strong focus on clinical research, the program serves as a leading resource for both complex patient care and advancing pulmonary vascular disease treatment.
In this interview, he highlights how the meeting's sessions focus on the spectrum of pulmonary vascular diseases, including pulmonary embolism and pulmonary hypertension, and emphasizes how this approach aligns with the practice at Temple University Hospital, viewing these conditions as interconnected rather than separate entities.
This transcript has been lightly edited for clarity.
Transcript
Are there any data, sessions, or trending topics that you're looking forward to at CHEST 2024?
Absolutely; I mean, CHEST is kind of our go-to conference for a lot of physicians like myself who are interested in pulmonary vascular disease. And what I mean by that is that people oftentimes group different diseases like pulmonary embolism and pulmonary hypertension and try to have specialization or expertise in one versus the other.
I think more and more we are realizing that both fall under the umbrella of pulmonary vascular disease. It's important because that's how we approach our patients locally at Temple Lung Center. And I think that's exactly how CHEST views pulmonary disease: as a spectrum. It starts with pulmonary embolism, which is more on acute RV [right ventricular] failure, and then you have advanced pulmonary hypertension [and] different vascular diseases that can get involved in the patients with lung center and lung diseases. And there are a lot of sessions happening on the spectrum. So, I think I'm super excited for those looking at the full spectrum of the journey of different sessions that will be covering this essential topic of pulmonary vascular disease in general.
One of the other things I'm excited about is that at Temple Lung Center we believe in training the next generation. I mean, that's what we do at an academic center; we want that. Yes, I'm good, or I may be doing great, but how do I reproduce [that knowledge]? How do we create a task force of pulmonology intensivists who will go out into the community and take the leap forward? And I think that's something that we take very seriously here at Temple Lung Center in our fellowship training program.
Nothing makes me happier when my fellows go out to the conferences, work on the research data, and present that data. So, one of our fellows, Dr. [Krunal] Patel, will be attending the conference. Actually, we have 3 of our fellows were invited to attend a fellows course, which is always by invitation and selection—3 fellows have the opportunity to attend CHEST's fellows courses, where I'll also be teaching about pulmonary artery waveforms and pulmonary vascular disease states. But they'll be attending that course, and one of my fellows will be taking a scientific approach and has an oral presentation for his scientific abstract, where he has looked into the timing of a large board mechanical thrombectomy in patients with pulmonary embolism because sometimes we know that patient needs to be treated, but sometimes we don't know when we should treat that patient. Should we treat that patient right away? Should we treat that patient a few hours later? Is there any benefit? There's no guidance on that.
It's the tip of the iceberg that we are scratching, but I think as we have more options and we have more teams involved, we also need to figure out when we should be doing those interventions: who can wait and who cannot wait? So, he's looking into some further details about benefits versus risks of doing intervention early versus waiting a few hours, and is there a difference? I'm excited to see what he has to present, but that's something that we have been working on for the last 6 months, that we will be presenting just this year.
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