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ABSTRACT |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
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The six-minute walk test is a submaximal exercise test that can be performed even by a patient with
heart failure not tolerating maximal exercise testing. To elucidate the clinical significance and prognostic value of the six-minute walk test in patients with primary pulmonary hypertension (PPH), we
sought (1) to assess the relation between distance walked during the six-minute walk test and exercise capacity determined by maximal cardiopulmonary exercise testing, and (2) to investigate the
prognostic value of the six-minute walk test in comparison with other noninvasive parameters. The
six-minute walk test was performed in 43 patients with PPH, together with echocardiography, right
heart catheterization, and measurement of plasma epinephrine and norepinephrine. Symptom-limited cardiopulmonary exercise testing was performed in a subsample of patients (n = 27). Distance
walked in 6 min was significantly shorter in patients with PPH than in age- and sex-matched healthy subjects (297 ± 188 versus 655 ± 91 m, p < 0.001). The distance significantly decreased in proportion to the severity of New York Heart Association functional class. The distance walked correlated modestly with baseline cardiac output (r = 0.48, p < 0.05) and total pulmonary resistance (r = 
0.49, p < 0.05), but not significantly with mean pulmonary arterial pressure. In contrast, the distance walked correlated strongly with peak 
O2 (r = 0.70, p < 0.001), oxygen pulse (r = 0.57, p < 0.01), and E-VCO2 slope (r = 0.66, p < 0.001) determined by cardiopulmonary exercise testing.
During a mean follow-up period of 21 ± 16 mo, 12 patients died of cardiopulmonary causes. Among
noninvasive parameters including clinical, echocardiographic, and neurohumoral parameters, only
the distance walked in 6 min was independently related to mortality in PPH by multivariate analysis.
Patients walking < 332 m had a significantly lower survival rate than those walking farther, assessed
by Kaplan-Meier survival curves (log-rank test, p < 0.01). These results suggest that the six-minute
walk test, a submaximal exercise test, reflects exercise capacity determined by maximal cardiopulmonary exercise testing in patients with PPH, and it is the distance walked in 6 min that has a strong, independent association with mortality. Miyamoto S, Nagaya N, Satoh T, Kyotani S, Sakamaki F,
Fujita M, Nakanishi N, Miyatake K. Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension: comparison with cardiopulmonary exercise testing.
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INTRODUCTION |
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TOP
ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
REFERENCES
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Primary pulmonary hypertension (PPH) is a rare, but life-threatening disease characterized by progressive pulmonary
hypertension (1). Most patients with PPH have severe exertional limitation owing to cardiopulmonary factors from an
early phase of this disease, which ultimately leads to right ventricular (RV) failure and death. Indeed, D'Alonzo and coworkers have demonstarted a decrease in peak exercise oxygen consumption (peak O2) and an increase in the regression slope
relating minute ventilation to carbon dioxide output (E-VCO2
slope) in patients with PPH, using cardiopulmonary exercise
testing (2). Rhodes and coworkers have shown that the ability
of cardiopulmonary exercise testing to identify PPH patients
at high risk for cardiac catheterization is superior to that of
other noninvasive variables (3). Interestingly, peak O2 and
E-VCO2 slope obtained from cardiopulmonary exercise testing have been shown to be related to mortality in patients with
chronic heart failure (4, 5). These results raise the possibility
that exercise testing can be used as a prognostic indicator in
patients with PPH. However, maximal stress testing may be
difficult in some patients with severe PPH (3).
The six-minute walk test is a submaximal exercise test that can
be performed by a patient not tolerating maximal exercise tests
(6). The test is very simple, requires inexpensive equipment, and
is reproducible. In addition, it is considered safe because patients
are self-limited during exercise. Recently, the distance walked in
6 min has been shown to correlate significantly with peak O2
and E-VCO2 slope in patients with advanced heart failure, and
thereby serves as a prognostic indicator in this disease (7, 8). In
patients with PPH, the six-minute walk test has been used as a
relative parameter to assess changes in functional capacity during
vasodilator therapy (9, 10). However, few data exist regarding
clinical significance and prognostic value of the six-minute walk
test in patients with PPH.
In the present study, we sought (1) to assess the relation between the distance walked during the six-minute walk test and exercise capacity determined by cardiopulmonary exercise testing in patients with PPH and (2) to investigate the prognostic value of the six-minute walk test in comparison with clinical parameters, echocardiographic findings, and plasma catecholamine levels, which had been reported to be related to mortality in patients with PPH (3, 11, 12).
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METHODS |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
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Study Subjects
This study included 43 patients with PPH (13 men and 30 women; mean age, 37 yr; range, 14 to 67 yr) who were referred to our institute between December 1994 and January 1999. PPH was defined as pulmonary hypertension unexplained by any secondary cause, based on the criteria of the National Institutes of Health registry on PPH (1). Six patients were classified as New York Heart Association (NYHA) functional class II, 29 patients as class III, and eight patients as class IV. Thirty-eight patients (88%) received prostacyclin therapy: intravenous prostacyclin (n = 13) (9, 10, 13) or an oral prostacyclin analogue (n = 25) (14, 15). The remaining five patients did not receive prostacyclin therapy because four patients could not tolerate it due to hypotension resulting from uncompensated right heart failure and one patient developed hypoxia during prostacyclin therapy. All subjects gave informed consent.
Hemodynamic Studies
Diagnostic right heart catheterization was performed in all patients while they were in a stable condition during hospitalization. Baseline hemodynamic variables including mean pulmonary arterial pressure, mean right atrial pressure, pulmonary capillary wedge pressure, and mean systemic arterial pressure were measured in all patients. Cardiac output was measured by Fick's method (16). Total pulmonary resistance was calculated by dividing mean pulmonary arterial pressure by cardiac output.
Six-minute Walk Test
The six-minute walk test was performed in all patients with PPH and 16 age- and sex-matched healthy volunteers according to a standardized
protocol (6, 17). They walked along an enclosed, level, measured corridor. Technicians escorted and encouraged subjects with the standardized statements, "You are doing well" or "Keep up the good work," but
were asked not to use other phrases. Subjects were instructed to walk at
their own pace but to cover as much ground as possible in 6 min. They
tolerated the six-minute walk test without any adverse effects. Patients
with PPH were divided into two groups according to the median value
of the distance walked in 6 min: long distance group (
332 m, n = 21 and short distance group (< 332 m, n = 22).
Cardiopulmonary Exercise Testing
Symptom-limited cardiopulmonary exercise testing was performed in 27 patients with PPH and 16 age- and sex-matched healthy volunteers. The remaining 16 patients with PPH were excluded from the protocol because they could not tolerate the maximal exercise test. Patients first pedaled at 55 rpm without any added load for 1 min. The work rate was then increased by 15 watts/min up until their symptom-limited maximum. Heart rate was monitored with standard electrocardiographic leads, and blood pressure was measured at the brachial artery with a sphygmomanometer. Breath-by-breath gas analysis was performed using an AE280 (Minato Medical Science, Osaka, Japan) connected to a personal computer running analyzing software (18).
The anaerobic threshold (AT) was chosen as the O2 at which the
E/O2 increased while the E/CO2 decreased or remained constant.
Peak O2 was defined as the value of averaged data during the final 15 s
of exercise. The oxygen pulse was calculated by dividing O2 by heart
rate, an index of stroke volume during exercise. The E-VCO2 slope
was determined as the linear regression slope of E and VCO2 from
the start of exercise until the RC point (the time up until which ventilation is stimulated by CO2 output and end-tidal CO2 tension begins
to decrease) (19).
Blood Sampling and Assay for Neurohormones
Blood samples were drawn from a peripheral vein at diagnostic catheterization while the patient was in a stable hemodynamic state and not receiving vasodilator drugs. Blood was immediately transferred into a chilled glass tube containing disodium ethylenediaminetetraacetic acid (EDTA) (1 mg/ml), and plasma epinephrine and norepinephrine were measured as reported previously (20).
Echocardiographic Assessment
Echocardiography was performed with a Toshiba SSH-120A (Tokyo, Japan). Parasternal short-axis views were obtained at the papillary muscle level of the left ventricle (LV) using a 3.5-MHz sector transducer. The longest (L) and the shortest (S) diameters of the LV cavity were measured at the point of maximal deformity in early diastole. The LV deformity index was calculated as L/S (21). Pericardial effusions were also evaluated in the parasternal short-axis views in early diastole and graded as absent, small (separation less than 1 cm), or large (separation more than 1 cm).
Survival Estimates
Survival was estimated from the date of initial diagnosis to February 28, 1999, or the death of the patient. No patient received lung or heart-lung transplantation during the follow-up period. No patient died of noncardiopulmonary causes. The follow-up rate was 100%.
Statistical Analysis
All data were expressed as mean values ± SD. Comparisons between two groups were made by Fisher exact test or unpaired Student's t test. Comparisons of parameters among the four groups were made using one-way analysis of variance, followed by Scheffe's multiple comparison test. Correlation coefficients between distance walked in 6 min and other variables were determined by linear regression analysis. To determine whether the six-minute walk test has independent prognostic significance, the following eight variables were entered into a multivariate Cox proportional hazards regression analysis: age, sex, plasma norepinephrine, heart rate, arterial oxygen saturation, presence of pericardial effusion, LV deformity index, and the distance walked in 6 min. Survival curves according to the median value (332 m) of the distance walked in 6 min were derived using the Kaplan-Meier method and were compared using log-rank test. A p value < 0.05 was considered statistically significant.
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RESULTS |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
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Patient Characteristics
Demographic, hemodynamic, and neurohumoral data of the patients grouped according to the median value (332 m) of the distance walked in 6 min are summarized in Table 1. There were no significant differences in demographics between the long distance group and the short distance group. Cardiac output and mixed venous oxygen saturation were significantly lower in the short distance group than in the long distance group. Total pulmonary resistance and mean right atrial pressure were significantly higher in the short distance group than in the long distance group. Neither plasma epinephrine nor norepinephrine level significantly differed between the two groups. There was no significant difference in medication use between the two groups.
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Relations between Six-minute Walk Test and Clinical, Hemodynamic, and Neurohumoral Parameters
Distance walked in 6 min was significantly lower in patients with PPH than in healthy subjects (297 ± 188 versus 655 ± 91 m, p < 0.001). The distance significantly decreased in proportion to the severity of NYHA functional class (Figure 1). The distance walked in 6 min did not significantly correlate with mean pulmonary arterial pressure at baseline (Figure 2). In contrast, the distance walked was modestly, but significantly, correlated with cardiac output and total pulmonary resistance at baseline values. The distance walked in 6 min was not significantly correlated with plasma epinephrine or norepinephrine at baseline values.
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p < 0.05 versus NYHA functional class II;
p < 0.05 versus NYHA functional class III.
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Relations between the Six-minute Walk Test and Maximal Cardiopulmonary Exercise Testing
AT, peak O2, and oxygen pulse were markedly lower in patients with PPH than in healthy subjects (AT, 8.0 ± 2.1 versus
17.9 ± 4.5 ml/kg/min; peak O2, 13.4 ± 4.3 versus 36.4 ± 7.8 ml/kg/min; oxygen pulse, 0.09 ± 0.03 versus 0.21 ± 0.06 ml/kg,
p < 0.001, respectively). The E-VCO2 slope was significantly
higher in patients with PPH than in healthy subjects (42.5 ± 8.6 versus 24.5 ± 2.4, p < 0.001). Distance walked in 6 min
showed strong positive correlations with peak O2 and oxygen
pulse determined by maximal cardiopulmonary exercise testing (Figure 3). The distance walked showed a strong negative
correlation with E-VCO2 slope. The distance walked was modestly, but significantly, correlated with AT.
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Six-minute Walk Test and Mortality in PPH
During a mean follow-up period of 21 ± 16 mo, 12 patients died of cardiopulmonary causes: seven patients died of progressive RV failure and five patients died suddenly. Among noninvasive variables, i.e., distance walked in 6 min, age, sex, plasma norepinephrine, heart rate, arterial oxygen saturation, presence of pericardial effusion, and LV deformity index, only the distance walked was independently related to mortality in PPH by multivariate Cox proportional hazards analysis (Table 2).
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The Kaplan-Meier survival curves grouped according to the median value of the distance walked in 6 min demonstrated that patients walking < 332 m had a significantly lower survival rate than those walking farther (log-rank test, p < 0.01, Figure 4).
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DISCUSSION |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
REFERENCES
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In this study, we demonstrated that distance walked during
the six-minute walk test significantly decreased in proportion to the severity of NYHA functional class in patients with PPH, and that distance walked in 6 min was significantly correlated with baseline cardiac output, total pulmonary resistance, and mean right atrial pressure. We also demonstrated that the distance walked in 6 min was strongly correlated with peak O2,
oxygen pulse, and E-VCO2 slope determined by maximal exercise testing. Finally, we demonstrated that, among noninvasive variables, the distance walked in 6 min was independently
related to mortality in PPH, and that patients walking < 332 m
had a significantly lower survival rate than those walking farther as assessed by the Kaplan-Meier survival curves.
Six-minute Walk Test and Maximal Cardiopulmonary Exercise Testing
Maximal cardiopulmonary exercise testing has been shown to
be a useful noninvasive tool to assess physiological changes associated with exercise (3, 22). Peak O2 has been used as a
marker for exercise capacity in a variety of cardiopulmonary
diseases because it is determined by the maximal cardiac output during exercise, the potential for O2 extraction by the exercising muscle, and the ventilatory capacity (23). Earlier
studies have shown that peak O2 was markedly decreased in
patients with PPH, indicating an impaired cardiac reserve during exercise in this disease (2, 3). Unfortunately, however, cardiopulmonary exercise testing could not be performed in the
most severe forms of PPH in this study, consistent with an earlier study (3). In contrast, the six-minute walk test, a submaximal exercise test, could be performed in all patients with PPH.
Thus, this submaximal test may be applicable for evaluation of
exercise capacity in patients with PPH. In fact, the six-minute
walk test has been used as a relative parameter to assess
changes in functional capacity during vasodilator therapy (9,
10). However, little information is available regarding clinical
significance of the six-minute walk test in patients with PPH.
In the present study, we first demonstrated that distance
walked in 6 min decreased in proportion to the decrease in
peak O2 and oxygen pulse determined by maximal cardiopulmonary exercise testing. On the other hand, the distance
walked correlated modestly with baseline hemodynamic parameters. Considering that oxygen pulse is representative of
changes in stroke volume during exercise (24), these results
suggest that the distance walked during the six-minute walk
test may reflect insufficient oxygen delivery to the body during exercise at least due to an inadequate increase in stroke
volume during exercise. Unlike our study, Guyatt and coworkers failed to define a close association of the six-minute walk test with the results of maximal exercise testing in all patients with heart failure (25). Like our study, however, Cahalin and coworkers concluded that the six-minute walk test was
useful in predicting peak O2 in patients with severe heart failure who were referred for heart transplantation (7). The discrepancy may be explained in part by the difference in the severity of heart failure. The PPH patients in our study had
severely limited daily activity (mean NYHA functional class,
3.0 ± 0.6). These results raise the possibility that there is a
close association between submaximal exercise and maximal
exercise in patients with severely reduced functional capacity.
Thus, distance walked during the six-minute walk test may be
related to exercise capacity determined by maximal exercise
testing in patients with PPH.
In the present study, distance walked in 6 min was negatively correlated with E-VCO2 slope in patients with PPH.
This steeper slope is considered to be associated with increased physiologic dead space resulting from an impaired increase in pulmonary perfusion during exercise (5, 26). Thus,
the six-minute walk test may also reflect pulmonary circulation reserve during exercise.
Six-minute Walk Test and Mortality in PPH
Previous studies have shown that mortality in PPH correlates with RV hemodynamic variables obtained invasively, such as mean pulmonary arterial pressure, cardiac output, and mean right atrial pressure (27, 28). However, a simple, noninvasive, and repeatedly available assessment of the mortality would be more desirable. Interestingly, distance walked during the six-minute walk test has been shown to have a strong, independent association with short-term mortality in patients with severe left-sided heart failure (7, 8). However, whether the six-minute walk test can predict mortality in PPH has remained unknown. Earlier studies have shown that pericardial effusion determined by echocardiography is associated with severe pulmonary hypertension and high right atrial pressure, and therefore may serve as a prognostic indicator (11). Sympathetic nervous system activation, indicated by a high plasma noreprinephrine level, has recently been shown to be associated with mortality in patients with PPH (12). Thus, in the present study, these parameters were included in multivariate Cox proportional hazards regression analysis. Among these noninvasive variables, however, only the distance walked in 6 min was the best predictor of mortality. It is interesting to speculate that a decreased cardiac reserve during exercise indicated by a short distance walked in 6 min may be associated with poor outcome in patients with PPH. Furthermore, the Kaplan-Meier survival curves according to the median value of distance walked demonstrated that patients walking < 332 m had a significantly lower survival rate than those walking farther. Thus, distance walked during the six-minute walk may serve as a prognostic indicator of PPH, which may complement invasive standard prognostic markers, such as RV hemodynamic variables.
Study Limitations
First, patients with the most severe forms of PPH were excluded from the cardiopulmonary exercise study. However, the conclusions drawn from the data would not have been different even if these patients had been included, because they had markedly poor exercise capacity (distance walked in 6 min = 170 ± 168 m).
Second, it appears to be important to show the relation of
peak O2 to survival. In the present study, however, this kind of analysis was impossible to perform, because the prognosis
of patients completing maximal cardiopulmonary exercise
testing was so good.
Third, subsequent therapy, which included vasodilators and anticoagulant agents, was not controlled in this study. Nevertheless, 38 patients (88%) received prostacyclin therapy: intravenous prostacyclin or an oral prostacyclin analogue, both of which have beneficial effects on survival in PPH (9, 10, 13). In addition, there was no significant difference regarding the medication use in the long distance group and the short distance group. Furthermore, this high rate of medication use in the present study may explain, at least in part, that plasma catecholamine levels were not an independent predictor of mortality by multivariate analysis.
Finally, our results may apply to the only patients receiving medical therapy, and it may be uncertain that the six-minute walk test would be as good a prognostic indicator in untreated patients.
Conclusions
The six-minute walk test, a submaximal exercise test, reflects exercise capacity determined by maximal cardiopulmonary exercise testing in patients with PPH, and it is the distance walked in 6 min that has a strong, independent association with mortality.
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Footnotes |
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Correspondence and requests for reprints should be addressed to Noritoshi Nagaya, M.D., Division of Cardiology, Department of Medicine, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
(Received in original form June 3, 1999 and in revised form July 30, 1999).
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References |
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ABSTRACT
INTRODUCTION
METHODS
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DISCUSSION
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M. M. Hoeper, R. J. Oudiz, A. Peacock, V. F. Tapson, S. G. Haworth, A. E. Frost, and A. Torbicki End points and clinical trial designs in pulmonary arterial hypertension: Clinical and regulatory perspectives J. Am. Coll. Cardiol., June 16, 2004; 43(12_Suppl_S): 48S - 55S. [Abstract] [Full Text] [PDF]
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W. Klepetko, E. Mayer, J. Sandoval, E. P. Trulock, J.-L. Vachiery, P. Dartevelle, J. Pepke-Zaba, S. W. Jamieson, I. Lang, and P. Corris Interventional and surgical modalities of treatment for pulmonary arterial hypertension J. Am. Coll. Cardiol., June 16, 2004; 43(12_Suppl_S): 73S - 80S. [Abstract] [Full Text] [PDF]
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A. Peacock, R. Naeije, N. Galie, and J.T. Reeves End points in pulmonary arterial hypertension: the way forward Eur. Respir. J., June 1, 2004; 23(6): 947 - 953. [Abstract] [Full Text] [PDF]
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S. Huez, S. Brimioulle, R. Naeije, and J.-L. Vachiery Feasibility of Routine Pulmonary Arterial Impedance Measurements in Pulmonary Hypertension Chest, June 1, 2004; 125(6): 2121 - 2128. [Abstract] [Full Text] [PDF]
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G. Deboeck, G. Niset, M. Lamotte, J-L. Vachiery, and R. Naeije Exercise testing in pulmonary arterial hypertension and in chronic heart failure Eur. Respir. J., May 1, 2004; 23(5): 747 - 751. [Abstract] [Full Text] [PDF]
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 P. Wauthy, A. Pagnamenta, F. Vassalli, R. Naeije, and S. Brimioulle Right ventricular adaptation to pulmonary hypertension: an interspecies comparison Am J Physiol Heart Circ Physiol, April 1, 2004; 286(4): H1441 - H1447. [Abstract] [Full Text] [PDF]
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B. R. Celli, C. G. Cote, J. M. Marin, C. Casanova, M. Montes de Oca, R. A. Mendez, V. Pinto Plata, and H. J. Cabral The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease N. Engl. J. Med., March 4, 2004; 350(10): 1005 - 1012. [Abstract] [Full Text] [PDF]
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H. H. Leuchte, M. Holzapfel, R. A. Baumgartner, I. Ding, C. Neurohr, M. Vogeser, T. Kolbe, M. Schwaiblmair, and J. Behr Clinical significance of brain natriuretic peptide in primary pulmonary hypertension J. Am. Coll. Cardiol., March 3, 2004; 43(5): 764 - 770. [Abstract] [Full Text] [PDF]
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M. R. Wilkins Selective or Nonselective Endothelin Receptor Blockade in Pulmonary Arterial Hypertension Am. J. Respir. Crit. Care Med., February 15, 2004; 169(4): 433 - 434. [Full Text] [PDF]
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R. J. Barst, D. Langleben, A. Frost, E. M. Horn, R. Oudiz, S. Shapiro, V. McLaughlin, N. Hill, V. F. Tapson, I. M. Robbins, et al. Sitaxsentan Therapy for Pulmonary Arterial Hypertension Am. J. Respir. Crit. Care Med., February 15, 2004; 169(4): 441 - 447. [Abstract] [Full Text] [PDF]
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N. Nagaya, S. Kyotani, M. Uematsu, K. Ueno, H. Oya, N. Nakanishi, M. Shirai, H. Mori, K. Miyatake, and K. Kangawa Effects of Adrenomedullin Inhalation on Hemodynamics and Exercise Capacity in Patients With Idiopathic Pulmonary Arterial Hypertension Circulation, January 27, 2004; 109(3): 351 - 356. [Abstract] [Full Text] [PDF]
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V.M. Pinto-Plata, C. Cote, H. Cabral, J. Taylor, and B.R. Celli The 6-min walk distance: change over time and value as a predictor of survival in severe COPD Eur. Respir. J., January 1, 2004; 23(1): 28 - 33. [Abstract] [Full Text] [PDF]
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K. B. Highland, C. Strange, J. Mazur, and K. N. Simpson Treatment of Pulmonary Arterial Hypertension: A Preliminary Decision Analysis Chest, December 1, 2003; 124(6): 2087 - 2092. [Abstract] [Full Text] [PDF]
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A.R. Glanville and M. Estenne Indications, patient selection and timing of referral for lung transplantation Eur. Respir. J., November 1, 2003; 22(5): 845 - 852. [Abstract] [Full Text] [PDF]
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R J Allcock, J J O'Sullivan, and P A Corris Atrial septostomy for pulmonary arterial hypertension Heart, November 1, 2003; 89(11): 1344 - 1347. [Full Text] [PDF]
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 {blacktriangledown}Bosentan for pulmonary arterial hypertension DTB, September 1, 2003; 41(9): 70 - 72. [Abstract] [Full Text] [PDF]
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A. Torbicki, M. Kurzyna, P. Kuca, A. Fijalkowska, J. Sikora, M. Florczyk, P. Pruszczyk, J. Burakowski, and L. Wawrzynska Detectable Serum Cardiac Troponin T as a Marker of Poor Prognosis Among Patients With Chronic Precapillary Pulmonary Hypertension Circulation, August 19, 2003; 108(7): 844 - 848. [Abstract] [Full Text] [PDF]
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M.M. Hoeper, N. Taha, A. Bekjarova, R. Gatzke, and E. Spiekerkoetter Bosentan treatment in patients with primary pulmonary hypertension receiving nonparenteral prostanoids Eur. Respir. J., August 1, 2003; 22(2): 330 - 334. [Abstract] [Full Text] [PDF]
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F. Sciurba, G. J. Criner, S. M. Lee, Z. Mohsenifar, D. Shade, W. Slivka, and R. A. Wise Six-Minute Walk Distance in Chronic Obstructive Pulmonary Disease: Reproducibility and Effect of Walking Course Layout and Length Am. J. Respir. Crit. Care Med., June 1, 2003; 167(11): 1522 - 1527. [Abstract] [Full Text] [PDF]
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J.A. Barbera, V.I. Peinado, and S. Santos Pulmonary hypertension in chronic obstructive pulmonary disease Eur. Respir. J., May 1, 2003; 21(5): 892 - 905. [Abstract] [Full Text] [PDF]
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N. Galie, A. L. Hinderliter, A. Torbicki, T. Fourme, G. Simonneau, T. Pulido, N. Espinola-Zavaleta, G. Rocchi, A. Manes, R. Frantz, et al. Effects of the oral endothelin-receptorantagonist bosentan on echocardiographicand doppler measures in patients with pulmonary arterial hypertension J. Am. Coll. Cardiol., April 16, 2003; 41(8): 1380 - 1386. [Abstract] [Full Text] [PDF]
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R. Budhiraja and P. M. Hassoun Portopulmonary Hypertension: A Tale of Two Circulations Chest, February 1, 2003; 123(2): 562 - 576. [Abstract] [Full Text] [PDF]
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