AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2641-0419/476
Specialist in Internal Medicine, Subspecialist in Pulmonology and Intensive Care Medicine Private Hospitals. Tehran. Iran.
*Corresponding Author: Farahnaz Fallahian, (2025), Hemodynamic Assessment of Newly Detected Pulmonary Hypertension, J Clinical Cardiology and Cardiovascular Interventions, 8(7); DOI: 10.31579/2641-0419/476
Citation: Farahnaz Fallahian, (2025), Assessment of Newly Detected Pulmonary Hypertension Cases, J Clinical Cardiology and Cardiovascular Interventions, 8(7); DOI: 10.31579/2641-0419/476
Copyright: © 2025, Farahnaz Fallahian. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 05 May 2025 | Accepted: 14 May 2025 | Published: 19 May 2025
Keywords: pulmonary hypertension; definition; hemodynamic indices
Pulmonary hypertension (PH) is a heterogenous disease. Left heart disease and chronic lung disease are the most common etiologies. Comorbidities, aging population, different pulmonary arterial hypertension phenotypes, and occult groups that show PH with exercise challenge, new molecular mechanisms for pathogenesis, and use of hemodynamic indices had changed the definition and treatment modalities.
Diagnostic algorithm, clinical evaluation, considering exact phenotype, comorbidities, shared decision-making before therapy, patient–clinician discussion, indices measuring right ventricle (RV)-pulmonary artery (PA) system and factors that have roles in the RV and the PA circulation will help to detect hemodynamic status and treatment response. Reconsidering the hemodynamic parameters thresholds that define PH and cardiopulmonary interactions is warranted for early detection and management strategies.
Pulmonary hypertension is a syndrome characterized by marked remodeling of the pulmonary vasculature and a progressive rise in the pulmonary vascular load, leading to hypertrophy and remodeling of the right ventricle. Death results from right ventricular failure if pulmonary hypertension is left untreated (1). Pulmonary hypertension (PH) is a pathophysiological manifestation of a heterogeneous group of diseases characterized by abnormally elevated pulmonary arterial pressures diagnosed on right heart catheterization (2).
PH leads to progressively worsening exertional dyspnea and right heart failure in untreated patients. Each patient presenting with a suspicion for PH must be thoroughly investigated to characterize their phenotype and identify the correct underlying pathophysiological mechanisms related to their specific diagnosis. Only then can patients be appropriately managed. Recent changes in the understanding of PH have justified an update to the hemodynamic definition and classification of PH (2). In this manuscript, diagnostic definitions and hemodynamic parameters in newly detected PH cases is reviewed.
A review of literature was performed in 2024-2025 to summarize scientific reports on pulmonary hypertension. Articles indexed in the PubMed and Medline, and Web of Science by using medical subject headings (MeSH) were searched by using the following key words: new detected pulmonary hypertension, definition and types, right ventricle and hemodynamic indices. Full text of relevant title and also their relevant references were extracted.
Definition of pulmonary hypertension
Pulmonary hypertension (PH) is a hemodynamic condition that is characterized by the elevation of mean pulmonary arterial pressure (mPAP) above the upper limit of normal (3).
In the 2022 ESC/ERS guidelines, major updates were made to the hemodynamic definition reducing the thresholds of PH to an mPAP > 20 mmHg and the PVR threshold to >2 WU to define pre-capillary PH, while the PAWP cut-off of ≤15 mmHg was maintained to distinguish pre-capillary from post-capillary PH (4). Additionally, exercise induced PH was reintroduced into the hemodynamic classification. Exercise pulmonary hypertension has been reintroduced into the hemodynamic definitions and is defined by an mPAP/cardiac output slope of >3 mmHg/L/min between rest and exercise (4).
Consequently, the current ESC/ERS guidelines recommend a PAWP threshold ≤ 15 mmHg is recommended by for the differentiation between pre-capillary and post-capillary PH, while acknowledging the presence of a grey area between 13 and 15 mmHg (4,5). This highlights the crucial role of accurately phenotyping patients during the diagnostic evaluation (5).
Based on a large number of invasive hemodynamic measurements in healthy subjects in the supine position, the upper limit of normal mPAP is 20 mmHg (5-7). Pre-capillary PH is defined by mPAP >20 mmHg and the elevation of pulmonary vascular resistance (PVR) above the upper limit of normal that is considered to be 2 Wood Units (WU) (5,6,8), and by a pulmonary arterial wedge pressure (PAWP) ⩽15 mmHg. This form of PH is characteristic of hemodynamic conditions and diseases with pulmonary arterial involvement and no significant left heart disease (3). Post-capillary PH is defined by mPAP >20 mmHg and PAWP >15 mmHg and is strongly suggestive of left heart disease. The value of the PVR further distinguishes between isolated post-capillary PH (ipcPH, PVR ⩽2 WU) and combined post- and pre-capillary PH (cpcPH, mPAP >20 mmHg, PAWP >15 mmHg, PVR >2 WU). Exercise PH is a hemodynamic condition describing a normal mPAP at rest with an abnormal increase of mPAP during exercise and is defined as a mPAP/cardiac output (CO) slope >3 mmHg/L/min between rest and exercise (3).
The mPAP/CO slope defines exercise PH. For assessment, linear regression based on multipoint measurements is possible but cumbersome, and a more practical method is assessing the mPAP/CO relationship based on measurements at rest and peak exercise (9). Exercise PH is defined as mPAP/CO slope >3 mmHg/L/min (4,5,10). From the differential-diagnostic point of view, recognizing post-capillary causes of exercise PH is of significant relevance. The PAWP/CO slope >2 mmHg/L/min between rest and exercise (11), and an increase of the absolute value of PAWP>25 mmHg are considered markers of post-capillary exercise PH (12).
Among subjects with exercise intolerance and suspected early‐stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management (13). In a cohort of subjects with exercise intolerance and suspected early‐stage PH, showed rest gas exchange parameters (minute ventilation to carbon dioxide production ratio (VE/VCO2) and end‐tidal carbon dioxide (ETCO2) can identify patients who are likely to have PVD (13). Such patients may benefit from a prompt invasive hemodynamic evaluation and PH vasodilator therapy (13).
The main changes in the new classification of PAH1 include: (a) the identification of two subgroups of idiopathic PAH according to acute vasoreactivity test response, (b) the list of genes associated with heritable forms of PAH, (c) an update of the drugs and toxins that can induce PAH, and (d) the inclusion of pulmonary veno-occlusive disease (PVOD) within group (2).
Elevated PVR remains associated with a significant increase in the hazard for 30-day mortality after cardiac transplantation, even in the setting of lower pulmonary artery pressures (14).
PAH patients with comorbidities are increasingly seen in clinical practice and have been found in several studies to have a higher rate of adverse events with therapy (15,16) and possibly a less robust treatment response. Potential contributors include differences in PAH phenotype as well as the occurrence of occult group 2 PH, where patients meet typical hemodynamic criteria for pre-capillary PH at rest, but manifest group 2 hemodynamics with provocative maneuvers such as exercise or fluid challenge, resulting in misclassification (15).
Clinical manifestations
Clinical findings in patients with pulmonary hypertension are: Dyspnea (during stress or at rest), cyanosis, fatigue, dizziness, syncope, thoracic pain, palpitations, orthopnea, cough, croakiness, abdominal tension, peripheral edema, ascites, and hepatomegaly (17).
The most frequent symptoms in patients with PH are dyspnea on exertion, fatigue and rapid exhaustion. Bendopnea (dyspnea when bending forward), weight gain due to fluid retention or syncope during physical exertion may occur. Particular attention should be paid to risk factors in the patient’s history that are associated with PH (e.g. connective tissue disease, portal hypertension, HIV, congenital cardiac disorders, thromboembolic disease, left heart diseases, lung diseases and illicit drug use) (3). A thorough physical examination of the patient may reveal an accentuated second heart sound and, in more advanced cases, a systolic murmur due to tricuspid regurgitation, or a diastolic murmur due to pulmonary valve insufficiency (Graham Steell murmur). Signs of right heart failure such as peripheral edema, distended and pulsating jugular veins, hepatic heave or ascites are suggestive of severe right heart failure (3).
Hemodynamic indices in pulmonary hypertension
Here some of the hemodynamic indices of pulmonary hypertension calculated by cardiac output monitoring devices and direct and indirect measurements during right heart catheterization is mentioned in (Table 1):
| Name | Description |
| Cardiac index (CI) | is reflective of the global function of the RV (in patients with normal systolic and diastolic left ventricular function) and forms an integral component to assess the functionality of the cardiopulmonary unit. As PH worsens, the CI decreases, due to failure of the RV in the setting of a higher afterload. CI is a well-known predictor of outcomes in PH and the European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines assigned CI thresholds of ≥2.5 L/min/m², 2–2.4 L/min/m², and <2>10%) of dying at 1-year (18,19).
|
| Cardiac output (CO) | (per Fick) formula is: [125 × body surface area (BSA)]/ [Hb × 1.36 × (SaO2-SvO2)], normal range: 4.0-8.0 L/min (20). Cardiac index (CI) formula is: CO/BSA, normal range: 2.5-4.0 L /min/m² (20). |
| Stroke volume (SV) | Stroke volume (SV) may be more accurate than CI in estimating RV function as it removes the compensatory heart rate (HR) response when CO is inappropriate to meet the body demands (SV = CO/HR) (18). Stroke volume (SV) formula is: CO/HR × 1000, normal range: 60-100 ml/beat (20). |
| Stroke volume index (SVI) | Stroke volume index (SVI) could allow for a more precise evaluation of the RV function in patients with PAH (18). Some investigators have proposed using SVI rather than CI as a treatment target in PAH since a decrease in SVI was independently associated with death or lung transplantation (a drop of 10 mL/m2 in SVI led to a 28% increase) at the first follow-up right heart catheterization after initiation of PAH therapies (21). Stroke volume index (SVI) formula is: CI/HR × 1000, with normal range: 33-47 ml (m²*beat) (20). |
| Cardiac power output | Cardiac power output formula is: (MAP × CO)/451, normal range: > 0.6 (20). |
| Cardiac power output index (CPOi) | Cardiac power output index (CPOi) = cardiac index x (MAP-CVP)/451. Lower CPOi associated with worse outcomes (22). Performs better with the inclusion of CVP, especially if CVP > 8 mm Hg. In cardiogenic shock (CS) or Impella support, cutoffs > 0.28-0.30 W/m² (22). |
| Left ventricular stroke work (LVSW) | Left ventricular stroke work (LVSW) = (MAP-PAWP) x SV x 0.0136. Limited data in CS (22). |
Left/right filling pressures (CVP/PAWP) | Left/right filling pressures = CVP/PAWP, Higher ratio associated with poorer outcomes CVP/PAWP > 0.63 post-LVAD (left ventricular assist device), > 0.86 acute myocardial infarction (22). |
| Right ventricular stroke work (RVSW) | Right ventricular stroke work (RVSW) Varies with PVR. The formula is (mean PA – CVP) x SV x 0.0136: lower levels associated with poorer outcomes, < 15> |
| Right ventricular systolic work index (RVSWI) | RVSWI is used to quantify the amount of work required by the RV for ejecting blood in each cardiac cycle when adjusted for BSA. RVSWI is calculated as (mPAP − mRAP) × SVI × 0.0136 (18). Parameter measured for Right ventricular work and used in PH for Survival prognosis in PAH and CTEPH (18). |
| Diastolic pulmonary gradient (DPG) | Diastolic pulmonary gradient (DPG) formula is: PADP-PCWP, normal range: < 7> Diastolic pulmonary gradient (DPG)= dPAP-PAWP. Parameter measured is pulmonary vascular constriction/remodeling (18). Used for differentiate CpcPH and IpcPH in patients with PH-LHD (18). Diastolic pressure gradient (DPG) formula is: PA diastolic pressure – PAWP: Abnormal if > 5-7 mm Hg, suggests pulmonary vascular disease, But usually > 7 mm Hg in pressure-overloaded right heart failure (22). Diastolic pulmonary gradient (DPG): DPG is calculated by subtracting PAWP from the diastolic pulmonary artery pressure (dPAP) (18). A DPG of ≥7 mmHg showed the best combination of sensitivity and specificity to be an independent predictor of survival in patients with PH-LHD (18,23). |
| Trans-pulmonary pressure gradient (TPG) | Trans-pulmonary pressure gradient (TPG) formula is: MPAP-PCWP, normal range: < 13> 15 mm Hg in pressure-overloaded right heart failure (22). The TPG is calculated by subtracting the PAWP from the mPAP and higher values reflect pulmonary vascular constriction and/or remodeling (18). A TPG cutoff of >12 or ≤12 mmHg was used to distinguish IpcPH from CpcPH (23,24). As with mPAP, TPG is influenced by the same hemodynamic factors, including flow, resistance, and left heart filling pressures (18,25). Due to these limitations, TPG was removed, in favor of PVR (TPG/CO), as a tool to establish the different hemodynamic types of PH-LHD (18,26,19). In patients with PH due to valvular heart disease, a higher TPG also predicted worse outcomes. Patients with high TPG (>12 mmHg) who underwent restrictive mitral annuloplasty for severe mitral regurgitation had worse outcomes (all-cause mortality and readmission for heart failure) (18,27). Similarly, patients with markers of precapillary PH (including an elevated TPG and PVR) had worse survival after transcatheter aortic valve replacement (18,28). |
Pulmonary vascular resistance (PVR) | Pulmonary vascular resistance (PVR) = Transpulmonary gradient/ cardiac output: Abnormal ≥ 2WU, But usually > 5WU in pressure-overloaded right heart failure (22). Pulmonary vascular resistance (PVR) formula is: (mPAP-PCWP)/CO (20). PVR is a static hemodynamic index based on Poiseuille’s law and is calculated as (mPAP − PAWP)/CO. A meta-regression analysis of 21 trials showed that changes in PVR were independently predictive of adverse clinical events, particularly total mortality (18,29). While a PVR of ≥3 WU is currently used to define precapillary PH, this threshold is not based on evidence regarding the upper limit of normal which is <2>2.2 WU was associated with all-cause mortality in patients undergoing right heart catheterization; and a PVR between 2.2 and 3 WU may represent early pulmonary vascular disease (18,30,8,31). |
| Pulmonary vascular resistance index (PVRI) | Pulmonary vascular resistance index (PVRI) formula is: 80 × (MPAP-PCWP)/CI, range: 255-285 dynes·sec/ cm⁵/m² (20). Pulmonary vascular resistance index (PVRI): It is calculated as follows: PVRI = (mPAP − PAWP)/CI or PVRI = PVR × BSA (18). |
| Systemic vascular resistance (SVR) | Systemic vascular resistance (SVR) formula is: 80 × (MAP-RAP)/CO, normal range: 800-1200 dynes·sec/ cm⁵ (20) |
| Systemic vascular resistance index (SVRI) | (SVRI) formula is: 80 × (MAP-RAP)/CI, normal range: 1970-2390 dynes·sec/ cm⁵/m² (20). |
Central venous pressure (CVP) | Represents right atrial pressure, and interprets right-sided filling pressures of the heart. CVP>15 mmHg indicates overloaded right-sided pressures (45). |
| Left/right filling pressures (CVP/PAWP) | Higher ratio associated with poorer outcomes CVP/PAWP > 0.63 (post-LVAD), > 0.86 (acute MI) |
Pulmonary artery pulsatility index (PAPI) | (PAPI) formula is: (PASP-PADP)/RAP, normal range is: > 0.9 (20). (PAPI) formula is: PA pulse pressure/CVP. Lower PAPI associated with worse prognosis, but cutoff varies with PVR (22,32): < 1> PAPi is an indirect measure of RV function and is defined as the ratio of PAPP to RAP [PAPi = (sPAP − dPAP)/RAP] (18). PAPi reflects the adaptive response of the RV to increased afterload (RV to pulmonary artery coupling) with implications for prognosis and survival (18,33,34). Also, it is mentioned for vasopressors and inotropes wean in cardiogenic shock, if CPO is above >0.6 and PAPI >0.9 (56). |
| Proportional pulmonary pulse pressure (PPP) | Proportional pulmonary pulse pressure (PPP) = PA pulse pressure/mean PA pressure, Lower in right heart failure. If > 0.60 post-VA ECMO is associated with better hemodynamic response (22). |
| Pulmonary artery capacitance | Pulmonary artery capacitance formula is Stroke volume/ PA pulse pressure. Lower capacitance is associated with poorer outcomes. < 0> |
| Aortic pulsatility index (API) | Aortic pulsatility index (API) formula is: (SBP-DBP)/PAWP with variable cutoffs (≥1.45103 to ≥2.9104) (22). Lower API associated with worse prognosis, mostly in patients with heart failure (22). |
| Pulmonary arterial compliance (PAC) | Pulmonary arterial compliance (PAC): Unlike the static index PVR, PAC measures arterial distensibility and therefore provides information about the pulsatile load on the RV (18). A simplified approximation of PAC uses the ratio of SV and pulmonary artery pulse pressure (PAPP). The formula is PAC = SV/(sPAP − dPAP). Parameter measured is pulmonary artery distensibility, RV afterload (dynamic) (18). |
| Pulmonary effective arterial elastance (Ea) | Pulmonary effective arterial elastance (Ea): Ea and PAC were more strongly associated with RV dysfunction and were consistently better predictors of mortality than TPG and PVR in patients with PH-LHD (18). |
RAP/PAWP | RAP/PAWP is another index that can serve to evaluate RV failure (18). As long as RV function is maintained, RAP remains lower than PAWP. When the RV starts failing, the RAP increases “out of proportion” to the PAWP, thus raising the RAP/PAWP ratio. Fluid overload and/or other organ dysfunction (left ventricular, kidney, and/or liver failure) would be expected to raise the RAP, but the RAP/PAWP ratio should remain <1> A RAP/PAWP value of ≥1 provided the best combination of sensitivity and specificity (36). RAP/PAWP ratio is higher in precapillary PH and CpcPH as compared to IpcPH. A ratio of ≥1 was associated with smaller left atrial volume, decreased tricuspid annular plane systolic excursion (TAPSE), and a higher RV/left ventricle size ratio (37). In addition, RAP/PAWP ratio may help to identify patients at high risk of developing right ventricular failure and mortality after the implantation of a left ventricular assist device (18,38). RAP/PAWP ratio increased immediately following left ventricular assist device (LVAD) implantation, then decreased for a short period followed by a gradual increase in the long-term that may represent the change in the RV function over time (18,39). |
Pressure-volume loops (PV loops) | The gold standard assessment of RV function is done by determining pressure-volume loops that allow a meticulous evaluation of the RV-pulmonary artery coupling (18). This procedure assesses how efficient the RV function is transferred as energy to the pulmonary vascular load (40,41). It is described by the ratio of end systolic elastance (Ees) over Ea (Ees/Ea). Ees is a measure of ventricular contractility that can be estimated by the ratio of end systolic pressure (ESP) to end systolic volume (ESV) (Ees = ESP/ESV). Pulmonary vascular load is estimated by the Ea derived from ESP divided by SV (Ea = ESP/SV) (18). |
| Cardiac output and oxygen delivery | There is general agreement that improving global oxygen delivery (DO2) is the main therapeutic objective; by extension, increasing cardiac output the therapeutic target in CS (22). Increasing DO2 to 3 times that of oxygen consumption (VO2) in CS has been proposed (43), as pathological supply dependence develops below a DO2:VO2 ratio of about 2(44), (this critical point of supply dependence may be higher in the presence of microcirculatory abnormalities). Therefore, the critical level of DO2 is ≥300 ml/min/m2 in the critically ill patient to achieve DO2:VO2 ratio of 2–3(22). |
| Mixed venous saturation (SvO2) | normal range is 60 – 80 %, Oximetry analysis of a blood sample taken from the pulmonary artery (distal lumen) (45). Central venous saturation < 60> |
| Intracardiac shunt (IS) | PA oxygen saturation greater than 75% may indicate the presence of a left-to-right IS, so it is recommended to measure the superior and inferior vena cava, RA (middle, high and low), RV and PA (45). Increased oxygen saturation ≥ 7% may be indicative of a left-to right atrial shunt, whereas ≥ 5% may indicate a shunt at the level of the RV or the PA. The direct Fick method is the preferred means of CO measurement when a left-to-right IS is suspected (45,46). |
| PA pressure-volume loops (PV loops) | The formula is End systolic elastance/Ea. Parameter measured is RV-arterial coupling (18). It is used for early diagnosis of PAH and CTEPH and evaluation of RV-PA coupling (18). |
Table 1: Parameters in hemodynamic monitoring
In a retrospective cohort study of 4343 patients undergoing routine RHC for clinical indication. Patients with mPAP values of 18 mm Hg or less, 19 to 24 mm Hg, and at least 25 mm Hg were classified as reference, borderline PH, and PH, respectively. Among whom the prevalence of PH and borderline PH was 62% and 18%, respectively (47). Borderline PH is common in patients undergoing RHC and is associated with significant comorbidities, progression to overt PH, and decreased survival. Small increases in mPAP, even at values currently considered normal, are independently associated with increased mortality (47). Prospective studies are warranted to determine whether early intervention or closer monitoring improves clinical outcomes in these patients. Future studies may consider evaluating the efficacy of closer interval monitoring or early therapeutic interventions, particularly in patients with left heart disease (47).
In analysis of the VA-CART (Veterans Affairs- Clinical Assessment, Reporting, and Tracking (CART) program, which links cardiopulmonary hemodynamic and outcome data from all 76 VA catheterization centers), national hemodynamic database demonstrates that borderline PH, defined as mPAP of 19 to 24 mmHg, is a common and independent risk factor for adverse clinical outcomes in a large cohort of patients with underlying cardiopulmonary disease, particularly left heart dysfunction or parenchymal lung disease, who are referred for invasive hemodynamic testing(48). Overall, these data illustrate the continuum of PH risk on mortality and hospitalization and support future prospective studies that investigate the significance of borderline PH in other patient populations, as well as the consequences of treatment on clinical end points in this cohort of at-risk patients (48).
Although the new mPAP >20mmHg and PVR >2.0 WU criteria for PH are positioned to identify at-risk patients earlier in the disease arc, most patients with PH are diagnosed late and at a time point when hemodynamics are severely abnormal (49). It is possible, that abnormally high cardiac output states, such as liver failure or large arterio-venous fistula, may result in mPAP >20mmHg and PVR lessthan 2 WU. Lowered thresholds aim to identify patients early in the disease course, which is important because delay to diagnosis of PH is common and linked to elevated morbidity and shortened lifespan (49). This clinical primer highlights key changes in diagnosis and approach to PH management, focusing on concepts that are likely to be encountered frequently in general practice. Specifically, this includes hemodynamic assessment of at-risk patients, pharmacotherapeutic management of pulmonary arterial hypertension, approach to PH in patients with heart failure with preserved ejection fraction, and newly established indications for early referral to PH centers to prompt co-management of patients with pulmonary vascular disease experts (49). Pathologic data confirmed the findings of adverse vascular remodeling in patients with lower PVR beginning approximately at 1.8–2 WU (4,50).
Patients with exercise PH are characterized by a normal mPAP at rest, but an abnormal increase of mPAP during exercise. The clinical relevance of current hemodynamic criteria of PH has been supported by recent studies. They represent the cornerstone for diagnosis of different forms of PH, but they should always be interpreted within the individual patient’s clinical context. For diagnosis of PH, we propose a stepwise approach, starting with simple, noninvasive tools, and with the main aim of discerning those patients who need to be referred to a PH center and should undergo invasive hemodynamic assessment (3).
The mPAP/CO slope was investigated for prognostic relevance similarly to the mPAP and PVR thresholds (4,51-54). The largest study was performed in a group of patients evaluated for unexplained dyspnea (4,53). The authors found that an mPAP/CO threshold of 3 mmHg/L/min for exercise PH was associated with a worse cardiovascular (CV) event-free survival regardless of whether there was resting PH. Further, both pre- and post-capillary contributions to the abnormal mPAP/CO slope were independently associated with increased hazard of CV hospitalization or death (4). In systemic sclerosis patients without manifest PH, exercise PH is a known predictor of disease progression and poor outcomes but further investigation found that an mPAP/CO slope > 3.5 mmHg/L/min identifies those with increased mortality at 10 years despite normal resting hemodynamics (4,54,55).
Most patients who undergo diagnostic evaluation for PH present with symptoms of dyspnea, exercise intolerance and/or clinical signs of right heart failure. The authors suggest a stepwise diagnostic approach for these patients, starting with simple, noninvasive tools and followed by more complex diagnostic methods, including the assessment for common cardiac and pulmonary conditions (3). Future advances in the management of PAH will focus on right ventricular function and involve deep phenotyping and the development of a personalized medicine approach (57).
Different pulmonary arterial hypertension phenotypes, occult groups that show PH with exercise challenge, and new pathogenesis molecular mechanisms had changed the definition and treatment modalities. Focused research on hemodynamic parameters would impact on better management of at-risk patients. Considering clinical evaluation, comorbidities, diagnostic algorithm, patient–clinician discussion, shared decision-making before therapy, indices measuring different aspects of the RV-PA system will help to early detection and better hemodynamic management strategies.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
