Oral anticoagulation
Medical > Therapy > Basic treatments
Oral anticoagulation
Coagulopathies are associated with an increased incidence of thromboembolic events, which may lead to chronic thromboembolic pulmonary hypertension. Oral anticoagulation is the first-line treatment in these patients. However, also patients with primary pulmonary hypertension may develop extensive central thrombi, which are not visible in ventilation-perfusion lung scan(Moser et al., 1995). A long-term retrospective follow-up study in 120 patients with primary pulmonary hypertension, diagnosed by strict clinical criteria using stepwise multivariate analysis, showed that anticoagulant therapy was a important factor for prognosis (Fuster et al., 1984).
In a case of thromboembolic type of primary pulmonary hypertension proved by lung biopsy, a 2 1/2-year anticoagulant therapy led to a significant improvement of pulmonary hemodynamics (Cohen et al., 1986). In a retrospective study in 104 patients with aminorex-induced pulmonary hypertension, treatment with warfarin was associated with an improvement in pulmonary hemodynamics and in the 5- and 10-year survival rate by 25 % and 19 %, respectively (Frank et al., 1993). The mean survival time (years) was longer in the patients who started anticoagulant therapy soon after diagnosis than in those who started one year later. In primary pulmonary hypertension, combined treatment with warfarin and a calcium channel blocker was associated with the highest survival rate (Rich et al., 1992). Additionally, anticoagulant therapy improved survival significantly both in patients who responded and those who did not respond to calcium channel blocker therapy.
In conclusion, all these results suggest that anticoagulant therapy is crucial in pulmonary hypertension. It should be given to patients as soon as diagnose is made and independently of vasoreactivity of pulmonary vessels.
References:
Aromatorio, G. J., Uretsky, B. F. and Reddy, P. S. (1985) Hypotension and sinus arrest with nifedipine in pulmonary hypertension. Chest, 87, 265-267.
Bärtsch, P., Maggiorini, M., Ritter, M., et al. (1991) Prevention of high altitude pulmonary edema by nifedipine. N Engl J Med, 325, 1284-1289.
Batra, A. K., Segall, P. H. and Ahmed, T. (1985) Pulmonary edema with nifedipine in primary pulmonary hypertension. Respiration, 47, 161-163.
Chaouat, A., Kessler, R. and Weitzenblum, E. (1996) Pulmonary oedema and pleural effusion in two patients with primary pulmonary hypertension treated with calcium channel blockers. Heart, 75, 383.
Cohen, M., Edwards, W. D. and Fuster, V. (1986) Regression in thromboembolic type of primary pulmonary hypertension during 2 1/2 years of antithrombotic therapy. J Am Coll Cardiol, 7, 172-175.
Farber, H. W., Karlinsky, J. B. and Faling, L. J. (1983) Fatal outcome following nifedipine for pulmonary hypertension. Chest, 83, 708-709.
Frank, H., Gurtner, H. P., Kneussl, M., et al. (1993) Aminorex-induced, plexogenic pulmonary arteriopathy: 25 years later! Z Kardiol, 82, 568-572.
Fuster, V., Steele, P. M., Edwards, W. D., et al. (1984) Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation, 70, 580-587.
Hackett, P. H., Roach, R. C., Hartig, G. S., et al. (1992) The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: A comparison. Int J Sports Med, 13 (Suppl 1), S68-S71.
Hoeper, M. M., Olschewski, H., Ghofrani, H. A., et al. (2000) A comparison of the acute hemodynamic effects of inhaled nitric oxide and aerosolized iloprost in primary pulmonary hypertension. German PPH study group. J Am Coll Cardiol, 35, 176-182.
Hohenhaus, E., Niroomand, F., Görre, S., et al. (1995) Nifedipine dos not prevent acute mountain sickness. Am J Respir Crit Care Med, 150, 857-860.
Morgan, J. M., McCormack, D. G., Griffiths, M. J., et al. (1991) Adenosine as a vasodilator in primary pulmonary hypertension. Circulation, 84, 1145-1149.
Moser, K. M., Fedullo, P. F., Finkbeiner, W. E., et al. (1995) Do patients with primary pulmonary hypertension develop extensive central thrombi? Circulation, 91, 741-745.
Oelz, O., Maggiorini, M., Ritter, M., et al. (1989) Nifedipine for high altitude pulmonary oedema. Lancet, 2 (8674), 1241-1244.
Olschewski, H., Walmrath, D., Schermuly, R., et al. (1996) Aerosolized prostacyclin and iloprost in severe pulmonary hypertension. Ann Intern Med, 124, 820-824.
Packer, M., Medina, N. and Yushak, M. (1984) Adverse hemodynamic and clinical effects of calcium channel blockade in pulmonary hypertension secondary to obliterative pulmonary vascular disease. J Am Coll Cardiol, 4, 890-901.
Partanen, J., Nieminen, M. S. and Luomanmaki, K. (1993) Death in a patient with primary pulmonary hypertension after 20 mg of nifedipine. N Engl J Med, 329, 812; discussion 812-813.
Prigogine, T., Waterlot, Y., Gottignies, P., et al. (1991) Acute nonhemodynamic pulmonary edema with nifedipine in primary pulmonary hypertension. Chest, 100, 563-564.
Rich, S. and Brundage, B. H. (1987) High-dose calcium channel-blocking therapy for primary pulmonary hypertension: evidence for long-term reduction in pulmonary arterial pressure and regression of right ventricular hypertrophy. Circulation, 76, 135-141.
Rich, S., Ganz, R. and Levy, P. S. (1983) Comparative actions of hydralazine, nifedipine and amrinone in primary pulmonary hypertension. Am J Cardiol, 52, 1104-1107.
Rich, S. and Kaufmann, E. (1991) High dose titration of calcium channel blocking agents for primary pulmonary hypertension: guidelines for short-term drug testing. J Am Coll Cardiol, 18, 1323-1327.
Rich, S., Kaufmann, E. and Levy, P. S. (1992) The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med, 327, 76-81.
Rubin, L. J., Groves, B. M., Reeves, J. T., et al. (1982) Prostacyclin-induced acute pulmonary vasodilation in primary pulmonary hypertension. Circulation, 66, 334-338.
Rubin, L. J., Nicod, P., Hillis, L. D., et al. (1983) Treatment of primary pulmonary hypertension with nifedipine. A hemodynamic and scintigraphic evaluation. Ann Intern Med, 99, 433-438.
Sitbon, O., Humbert, M., Jagot, J. L., et al. (1998) Inhaled nitric oxide as a screening agent for safely identifying responders to oral calcium-channel blockers in primary pulmonary hypertension. Eur Respir J, 12, 265-270.
Weir, E. K., Rubin, L. J., Ayres, S. M., et al. (1989) The acute administration of vasodilators in primary pulmonary hypertension. Experience from the National Institutes of Health Registry on Primary Pulmonary Hypertension. Am Rev Respir Dis, 140, 1623-1630.
Back to > Medical > Therapy > Basic treatments
Oral anticoagulation
Coagulopathies are associated with an increased incidence of thromboembolic events, which may lead to chronic thromboembolic pulmonary hypertension. Oral anticoagulation is the first-line treatment in these patients. However, also patients with primary pulmonary hypertension may develop extensive central thrombi, which are not visible in ventilation-perfusion lung scan(Moser et al., 1995). A long-term retrospective follow-up study in 120 patients with primary pulmonary hypertension, diagnosed by strict clinical criteria using stepwise multivariate analysis, showed that anticoagulant therapy was a important factor for prognosis (Fuster et al., 1984).
In a case of thromboembolic type of primary pulmonary hypertension proved by lung biopsy, a 2 1/2-year anticoagulant therapy led to a significant improvement of pulmonary hemodynamics (Cohen et al., 1986). In a retrospective study in 104 patients with aminorex-induced pulmonary hypertension, treatment with warfarin was associated with an improvement in pulmonary hemodynamics and in the 5- and 10-year survival rate by 25 % and 19 %, respectively (Frank et al., 1993). The mean survival time (years) was longer in the patients who started anticoagulant therapy soon after diagnosis than in those who started one year later. In primary pulmonary hypertension, combined treatment with warfarin and a calcium channel blocker was associated with the highest survival rate (Rich et al., 1992). Additionally, anticoagulant therapy improved survival significantly both in patients who responded and those who did not respond to calcium channel blocker therapy.
In conclusion, all these results suggest that anticoagulant therapy is crucial in pulmonary hypertension. It should be given to patients as soon as diagnose is made and independently of vasoreactivity of pulmonary vessels.
References:
Aromatorio, G. J., Uretsky, B. F. and Reddy, P. S. (1985) Hypotension and sinus arrest with nifedipine in pulmonary hypertension. Chest, 87, 265-267.
Bärtsch, P., Maggiorini, M., Ritter, M., et al. (1991) Prevention of high altitude pulmonary edema by nifedipine. N Engl J Med, 325, 1284-1289.
Batra, A. K., Segall, P. H. and Ahmed, T. (1985) Pulmonary edema with nifedipine in primary pulmonary hypertension. Respiration, 47, 161-163.
Chaouat, A., Kessler, R. and Weitzenblum, E. (1996) Pulmonary oedema and pleural effusion in two patients with primary pulmonary hypertension treated with calcium channel blockers. Heart, 75, 383.
Cohen, M., Edwards, W. D. and Fuster, V. (1986) Regression in thromboembolic type of primary pulmonary hypertension during 2 1/2 years of antithrombotic therapy. J Am Coll Cardiol, 7, 172-175.
Farber, H. W., Karlinsky, J. B. and Faling, L. J. (1983) Fatal outcome following nifedipine for pulmonary hypertension. Chest, 83, 708-709.
Frank, H., Gurtner, H. P., Kneussl, M., et al. (1993) Aminorex-induced, plexogenic pulmonary arteriopathy: 25 years later! Z Kardiol, 82, 568-572.
Fuster, V., Steele, P. M., Edwards, W. D., et al. (1984) Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation, 70, 580-587.
Hackett, P. H., Roach, R. C., Hartig, G. S., et al. (1992) The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: A comparison. Int J Sports Med, 13 (Suppl 1), S68-S71.
Hoeper, M. M., Olschewski, H., Ghofrani, H. A., et al. (2000) A comparison of the acute hemodynamic effects of inhaled nitric oxide and aerosolized iloprost in primary pulmonary hypertension. German PPH study group. J Am Coll Cardiol, 35, 176-182.
Hohenhaus, E., Niroomand, F., Görre, S., et al. (1995) Nifedipine dos not prevent acute mountain sickness. Am J Respir Crit Care Med, 150, 857-860.
Morgan, J. M., McCormack, D. G., Griffiths, M. J., et al. (1991) Adenosine as a vasodilator in primary pulmonary hypertension. Circulation, 84, 1145-1149.
Moser, K. M., Fedullo, P. F., Finkbeiner, W. E., et al. (1995) Do patients with primary pulmonary hypertension develop extensive central thrombi? Circulation, 91, 741-745.
Oelz, O., Maggiorini, M., Ritter, M., et al. (1989) Nifedipine for high altitude pulmonary oedema. Lancet, 2 (8674), 1241-1244.
Olschewski, H., Walmrath, D., Schermuly, R., et al. (1996) Aerosolized prostacyclin and iloprost in severe pulmonary hypertension. Ann Intern Med, 124, 820-824.
Packer, M., Medina, N. and Yushak, M. (1984) Adverse hemodynamic and clinical effects of calcium channel blockade in pulmonary hypertension secondary to obliterative pulmonary vascular disease. J Am Coll Cardiol, 4, 890-901.
Partanen, J., Nieminen, M. S. and Luomanmaki, K. (1993) Death in a patient with primary pulmonary hypertension after 20 mg of nifedipine. N Engl J Med, 329, 812; discussion 812-813.
Prigogine, T., Waterlot, Y., Gottignies, P., et al. (1991) Acute nonhemodynamic pulmonary edema with nifedipine in primary pulmonary hypertension. Chest, 100, 563-564.
Rich, S. and Brundage, B. H. (1987) High-dose calcium channel-blocking therapy for primary pulmonary hypertension: evidence for long-term reduction in pulmonary arterial pressure and regression of right ventricular hypertrophy. Circulation, 76, 135-141.
Rich, S., Ganz, R. and Levy, P. S. (1983) Comparative actions of hydralazine, nifedipine and amrinone in primary pulmonary hypertension. Am J Cardiol, 52, 1104-1107.
Rich, S. and Kaufmann, E. (1991) High dose titration of calcium channel blocking agents for primary pulmonary hypertension: guidelines for short-term drug testing. J Am Coll Cardiol, 18, 1323-1327.
Rich, S., Kaufmann, E. and Levy, P. S. (1992) The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med, 327, 76-81.
Rubin, L. J., Groves, B. M., Reeves, J. T., et al. (1982) Prostacyclin-induced acute pulmonary vasodilation in primary pulmonary hypertension. Circulation, 66, 334-338.
Rubin, L. J., Nicod, P., Hillis, L. D., et al. (1983) Treatment of primary pulmonary hypertension with nifedipine. A hemodynamic and scintigraphic evaluation. Ann Intern Med, 99, 433-438.
Sitbon, O., Humbert, M., Jagot, J. L., et al. (1998) Inhaled nitric oxide as a screening agent for safely identifying responders to oral calcium-channel blockers in primary pulmonary hypertension. Eur Respir J, 12, 265-270.
Weir, E. K., Rubin, L. J., Ayres, S. M., et al. (1989) The acute administration of vasodilators in primary pulmonary hypertension. Experience from the National Institutes of Health Registry on Primary Pulmonary Hypertension. Am Rev Respir Dis, 140, 1623-1630.
Back to > Medical > Therapy > Basic treatments
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SSPH Research Prize 2012
Deadline for submission: April 30, 2012
Further information
Symposium "pulmonal-arterielle Hypertension im Kindesalter"
Donnerstag, 10. Mai 2012, 16.00-18.00, Bern
Further information:
5th International Congress of the Swiss Society of Pulmonary Hypertension (SSPH)
28.-29. September 2012, Thun, Congress Hotel Seepark Thun
Informationen: www.imk.ch/sgph2012
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