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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">When pulmonary arterial hypertension &#40;PAH&#41; or group 1 pulmonary hypertension &#40;PH&#41; was defined in the last third of the 20th century&#44; it was described as a rare and severe disease that&#44; in its more prevalent form&#44; was thought to be idiopathic and affect mainly young women&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> It was also considered that&#44; when PH and any pulmonary disease &#8211; mainly emphysema and fibrosis &#8211; coincided in the same patient&#44; PH could be explained by those conditions and its approach as a separate clinical entity was not recommended&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PAH in-depth study began in the 80s&#46; At that time&#44; considering that PAH was a rare and severe disease&#44; clinicians took a pragmatic approach based on the description of carefully selected patients with well-defined etiologies and clearly pathologic hemodynamic diagnostic criteria in order to provide a precise picture of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> In addition&#44; the decision to use highly selective criteria to define PAH patients led to the approval of the first PAH effective drugs&#46; So&#44; looking back&#44; we can say that this initial approach was effective&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since then&#44; knowledge on PH has evolved dramatically&#46; Focusing specifically on PAH&#44; and based on the evidence provided by several national registries created on the early 2000s&#44; now we know that PAH also presents in the elder and in patients with comorbidities as an independent condition that adversely affects prognosis&#46; Indeed&#44; a specific and more conservative&#44; therapeutic approach has been proposed for this group of PAH patients presenting with comorbidities&#44; as it has been demonstrated that they benefit from pulmonary vasodilators too&#44; but might not tolerate the intensive approach proposed for patients without comorbidities&#44; better represented in clinical trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">With this background&#44; and focusing on PH associated with respiratory diseases &#40;group 3 PH&#41;&#44; clinical classification clearly distinguishes it from PAH &#40;group 1PH&#41;&#46; Nonetheless&#44; this distinction is becoming increasingly blurred as knowledge about PH increases and its epidemiology is redefined&#46; For instance&#44; a new PAH phenotype&#44; the <span class="elsevierStyleItalic">pulmonary phenotype</span>&#44; has been described&#46; The characteristic patient would be a man over 65 years old&#44; with smoking history and diffusing capacity for carbon monoxide &#60;45&#37;&#44; who has normal spirometry and no relevant abnormalities in the lung on chest computed tomography&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> This PAH phenotype has specific prognostic features and different response to vasodilator therapy&#44; which are similar to those expected in group 3 PH rather than PAH&#46; Although these patients are strictly classified as group 1 PH&#44; they may benefit from a more conservative approach&#44; similar to that used in the management of group 3 PH&#44; where most attempts to demonstrate the effectiveness of pulmonary vasodilators have failed and only inhaled vasodilators currently show some benefit in patients with interstitial lung diseases &#40;ILD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Thus&#44; PH guidelines propose treating patients with severe group 3 PH defined as pulmonary vascular resistances &#62;5 Wood Units &#40;WU&#41;&#44; and this may be a reasonable approach for this other group of patients too&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4&#44;8&#44;9</span></a> At the same time&#44; we also have the other side of the story&#58; patients who present with mild parenchymal lung disease and disproportionately significant PH&#46; These shared clinical aspects between different PH groups challenges the clinical classification and&#44; subsequently&#44; the management of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> To add more confusion regarding the management of these patients&#44; the recent update of the PH hemodynamic definition lowers the thresholds for diagnosis&#44; forcing us to contemplate PH at earlier stages&#44; when clinical presentation might even be absent&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> This &#8220;grey area&#8221; we find ourselves in&#44; highlights that we are only beginning to understand how PH behaves when it coexists with lung disease&#46; This increasingly challenging clinical scenario is reinforced by recent findings from novel imaging and multi-omic techniques&#44; which support the complexity of PH pathophysiology and suggest that we are moving along a continuum where PH and respiratory comorbidities coexist&#44; resulting in different PH behaviors in patients who&#44; <span class="elsevierStyleItalic">a priori</span>&#44; share the same underlying lung disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; PH is a relevant&#44; prevalent and serious complication of the main respiratory diseases&#46; Although this scenario shares some clinical features with PAH&#44; at the same time&#44; carries a wide range of variability that is not possible to fit in the current clinical classification and also hampers the understanding of how relevant vascular involvement is in most cases&#46; The beneficial effects of pulmonary vasodilators in patients with ILD associated PH have only recently been identified&#44; opening the door to changing the behavior of the disease&#46; In this scenario&#44; we need new tools to better understand the different traits of PH associated with respiratory diseases and be able to predict its subsequent clinical behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> While basic research is focused on the understanding of the molecular mechanisms of arterial remodeling at the most sophisticated level &#40;-omics&#44; big data&#44; machine learning&#44; network medicine&#44; and functional genetics&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> at the clinical level we are exploring the different faces of the disease improving the tools we already have &#40;cardiopulmonary exercise test&#44; hemodynamics&#44; echocardiography and magnetic resonance&#41; and combining them with interesting results&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pulmonologists must feel compelled to protocol and systematize the study of PH associated with respiratory diseases&#44; in close collaboration with other PH related specialists&#46; We must be aware of our patients&#8217; risk of developing PH&#44; and trigger a complete evaluation when suspected with the aim of phenotyping our patients or&#44; in the absence of this possibility at present&#44; at least study this complication in depth and increase our knowledge&#46; Clinical protocols are needed to guide us in the screening of PH in our respiratory patients and how to implement a stepwise investigation of this complication&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">If we focus on thoroughly studying these patients and collect our data in cohort registries&#44; this could provide valuable insights to identify traits with potential for treatment that could alter disease behavior&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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Editorial
New Phenotypes of Pulmonary Hypertension Associated With Respiratory Diseases: Towards Traits to Treat
Manuel López Meseguera,b,
Corresponding author
manuel.lopez@vallhebron.cat

Corresponding author.
, Berta Sáez Giméneza,c
a Unidad de Trasplante Pulmonar y Patología Vascular Pulmonar, Hospital Vall d’Hebron, Barcelona, Spain
b CIBER de Enfermedades Respiratorias (CIBRES), Spain
c Departament de Immunologia, Biologia Cel·lular i Fisiología Mèdica, Universitat Autònoma de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">When pulmonary arterial hypertension &#40;PAH&#41; or group 1 pulmonary hypertension &#40;PH&#41; was defined in the last third of the 20th century&#44; it was described as a rare and severe disease that&#44; in its more prevalent form&#44; was thought to be idiopathic and affect mainly young women&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> It was also considered that&#44; when PH and any pulmonary disease &#8211; mainly emphysema and fibrosis &#8211; coincided in the same patient&#44; PH could be explained by those conditions and its approach as a separate clinical entity was not recommended&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PAH in-depth study began in the 80s&#46; At that time&#44; considering that PAH was a rare and severe disease&#44; clinicians took a pragmatic approach based on the description of carefully selected patients with well-defined etiologies and clearly pathologic hemodynamic diagnostic criteria in order to provide a precise picture of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> In addition&#44; the decision to use highly selective criteria to define PAH patients led to the approval of the first PAH effective drugs&#46; So&#44; looking back&#44; we can say that this initial approach was effective&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since then&#44; knowledge on PH has evolved dramatically&#46; Focusing specifically on PAH&#44; and based on the evidence provided by several national registries created on the early 2000s&#44; now we know that PAH also presents in the elder and in patients with comorbidities as an independent condition that adversely affects prognosis&#46; Indeed&#44; a specific and more conservative&#44; therapeutic approach has been proposed for this group of PAH patients presenting with comorbidities&#44; as it has been demonstrated that they benefit from pulmonary vasodilators too&#44; but might not tolerate the intensive approach proposed for patients without comorbidities&#44; better represented in clinical trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">With this background&#44; and focusing on PH associated with respiratory diseases &#40;group 3 PH&#41;&#44; clinical classification clearly distinguishes it from PAH &#40;group 1PH&#41;&#46; Nonetheless&#44; this distinction is becoming increasingly blurred as knowledge about PH increases and its epidemiology is redefined&#46; For instance&#44; a new PAH phenotype&#44; the <span class="elsevierStyleItalic">pulmonary phenotype</span>&#44; has been described&#46; The characteristic patient would be a man over 65 years old&#44; with smoking history and diffusing capacity for carbon monoxide &#60;45&#37;&#44; who has normal spirometry and no relevant abnormalities in the lung on chest computed tomography&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> This PAH phenotype has specific prognostic features and different response to vasodilator therapy&#44; which are similar to those expected in group 3 PH rather than PAH&#46; Although these patients are strictly classified as group 1 PH&#44; they may benefit from a more conservative approach&#44; similar to that used in the management of group 3 PH&#44; where most attempts to demonstrate the effectiveness of pulmonary vasodilators have failed and only inhaled vasodilators currently show some benefit in patients with interstitial lung diseases &#40;ILD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Thus&#44; PH guidelines propose treating patients with severe group 3 PH defined as pulmonary vascular resistances &#62;5 Wood Units &#40;WU&#41;&#44; and this may be a reasonable approach for this other group of patients too&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4&#44;8&#44;9</span></a> At the same time&#44; we also have the other side of the story&#58; patients who present with mild parenchymal lung disease and disproportionately significant PH&#46; These shared clinical aspects between different PH groups challenges the clinical classification and&#44; subsequently&#44; the management of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> To add more confusion regarding the management of these patients&#44; the recent update of the PH hemodynamic definition lowers the thresholds for diagnosis&#44; forcing us to contemplate PH at earlier stages&#44; when clinical presentation might even be absent&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> This &#8220;grey area&#8221; we find ourselves in&#44; highlights that we are only beginning to understand how PH behaves when it coexists with lung disease&#46; This increasingly challenging clinical scenario is reinforced by recent findings from novel imaging and multi-omic techniques&#44; which support the complexity of PH pathophysiology and suggest that we are moving along a continuum where PH and respiratory comorbidities coexist&#44; resulting in different PH behaviors in patients who&#44; <span class="elsevierStyleItalic">a priori</span>&#44; share the same underlying lung disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; PH is a relevant&#44; prevalent and serious complication of the main respiratory diseases&#46; Although this scenario shares some clinical features with PAH&#44; at the same time&#44; carries a wide range of variability that is not possible to fit in the current clinical classification and also hampers the understanding of how relevant vascular involvement is in most cases&#46; The beneficial effects of pulmonary vasodilators in patients with ILD associated PH have only recently been identified&#44; opening the door to changing the behavior of the disease&#46; In this scenario&#44; we need new tools to better understand the different traits of PH associated with respiratory diseases and be able to predict its subsequent clinical behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> While basic research is focused on the understanding of the molecular mechanisms of arterial remodeling at the most sophisticated level &#40;-omics&#44; big data&#44; machine learning&#44; network medicine&#44; and functional genetics&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> at the clinical level we are exploring the different faces of the disease improving the tools we already have &#40;cardiopulmonary exercise test&#44; hemodynamics&#44; echocardiography and magnetic resonance&#41; and combining them with interesting results&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pulmonologists must feel compelled to protocol and systematize the study of PH associated with respiratory diseases&#44; in close collaboration with other PH related specialists&#46; We must be aware of our patients&#8217; risk of developing PH&#44; and trigger a complete evaluation when suspected with the aim of phenotyping our patients or&#44; in the absence of this possibility at present&#44; at least study this complication in depth and increase our knowledge&#46; Clinical protocols are needed to guide us in the screening of PH in our respiratory patients and how to implement a stepwise investigation of this complication&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">If we focus on thoroughly studying these patients and collect our data in cohort registries&#44; this could provide valuable insights to identify traits with potential for treatment that could alter disease behavior&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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Original language: English
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