Cardiovascular Complications of Sickle Cell Disease
Conditions: Sickle Cell Disease
Sponsor: University of Chicago

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Version date: 16Mar09 
Approval date: 19Mar09 
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Cardiovascular Complications of Sickle Cell Disease 
 
 
 
Principal Investigator 
-Amit R. Patel, MD, Assistant Professor of Medicine, Section of Cardiology, Department of Medicine 
(apatel2@medicine.bsd.uchicago.edu) 
 
 
Co-Investigators   
-Joe G.N. Garcia, MD, Chair and Professor of Medicine, Department of Medicine 
(jgarcia@medicine.bsd.uchicago.edu) 
-Roberto M. Lang, MD, Professor of Medicine, Section of Cardiology, Department of Medicine 
(rlang@medicine.bsd.uchicago.edu) 
-Nicole Artz, MD, Assistant Professor of Medicine, Section of Hospital Medicine, Department of Medicine 
(nartz@medicine.bsd.uchicago.edu) 
-Roberto Machado, MD, Assistant Professor of Medicine, Section of Cardiology, Department of Medicine 
(robertom@nhlbi.nih.gov) 
-Ankit A. Desai, MD, Fellow, Section of Cardiology, Department of Medicine 
(adesai1@medicine.bsd.uchicago.edu) 
 
 
 
1.  Background:   
Sickle-cell disease (SCD) is a group of inherited blood disorders characterized by red blood cells that 
assume an abnormal, rigid, sickle shape. Sickle cells contain abnormal hemoglobin, an iron-rich protein 
that carries oxygen for distribution to the body, which causes the sickle shape. Sickling decreases the 
cells' flexibility, predisposes the cells to lysis, and results in their restricted movement through blood 
vessels, depriving downstream tissues of oxygen. SCD patients are often perturbed by periodic painful 
attacks and a risk of systemic complications due to these vaso-occlusive episodes and hemolysis, the 
clinical hallmarks of SCD [1]. The polymerization of deoxy-hemoglobin, changes in red cell membrane 
structure and function, disordered cell volume control, and increased adherence to vascular endothelium 
all play an important role in the pathophysiologic events responsible for vaso-occlusive complications [2]. 
The most frequently occurring form of SCD is the homozygous form called sickle cell anemia 
(Hemoglobin SS, HbSS), followed by HbSC disease and sickle hemoglobin-beta thalassemia. In the 
United States, 6 to 10 percent of African-American newborns have the heterozygous form called sickle 
cell trait [3]. Life expectancy is substantially shortened, with most studies reporting an average of up to 50 
years for age [4].  Important cardiovascular complications of SCD include pulmonary hypertension and 
left ventricular systolic and diastolic dysfunction. 
 
Pulmonary Hypertension: Acute and chronic pulmonary complications including pulmonary hypertension 
(PH) occur frequently in patients with SCD and represent the most common cause of death during 
adulthood in these patients[5]. PH, a complex pulmonary vascular syndrome, is defined as an increase in 
blood pressure (>25mm Hg at rest and >30mm Hg with activity) in the pulmonary artery, pulmonary vein, 
or pulmonary capillaries. PH can lead to a significant increase in morbidity and mortality. Severe PH can 
manifest as either an acute or chronic presentation. Acute PH can induce a sudden increase in right 
ventricle (RV) afterload, with increased end-diastolic volume, and reduced RV ejection fraction.  Chronic 
PH, on the other hand, leads to progressive RV systolic pressure overload and dilatation, resulting in 
gradual RV dysfunction, failure, and death. PH develops in most forms of hereditary and chronic 
hemolytic anemia, including SCD, thalassemia, hereditary spherocytosis, and paroxysmal nocturnal 
hemoglobinuria suggesting that there is a clinical syndrome of hemolysis-associated pulmonary 
hypertension [6-8]. Retrospective studies from tertiary care referral centers suggest a prevalence of PH 
ranging from 30 to 40 percent [2, 9] in patients with SCD. Postmortem studies of patients with SCD often 

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show evidence of pulmonary vascular bed obliteration, smooth muscle hypertrophy, and parenchymal 
fibrosis [5].  
 
Survival is decreased among both children and adults whose SCD is complicated by PH [10]. In one 
study, the median survival was 26 months for patients with PH and SCD, whereas 70 percent of patients 
without PH were still alive at the end of the nearly 10 year study [11]. Although these studies have 
demonstrated that patients with SCD have lower pulmonary pressures (but still elevated) and higher 
cardiac output than patients with primary pulmonary hypertension (PPH), the two-year mortality rates 
approach 50 percent in both groups. Even modestly elevated pulmonary artery pressures portend a poor 
prognosis [2, 11].  
 
Etiology of PH- Most studies have looked at PH collectively in SCD and have not determined the 
prevalence of the different subtypes of PH. Thus, it is unknown whether patients who have SCD and PH 
have intrinsic pulmonary vascular disease (group 1 pulmonary arterial hypertension, PAH, as defined by 
the recent World Health Organization (WHO) classification), left heart disease (group 2 PH) from both 
systolic or diastolic failure, or parenchymal lung disease (group 3 PH), or pulmonary thromboembolic 
disease (group 4 PH). There is also significant controversy over the contribution of left ventricular 
dysfunction to increased pulmonary pressures in patients with SCD. Invasive hemodynamic 
measurements have shown a mixed picture of high pulmonary artery pressures and elevated pulmonary 
capillary wedge pressures, suggesting that LV diastolic or systolic dysfunction may contribute to the high 
pulmonary artery systolic pressures and increased risk of death [10, 11]. Diastolic dysfunction in SCD 
patients may be a consequence of relative systemic hypertension or direct myocardial damage from 
either microvascular vaso-occlusive disease or iron overload [12]. Pegelow et al. [13] have shown that the 
normal range of blood pressure is lower in healthy SCD patients compared with the general population. 
Multiple studies have shown that those SCD patients with blood pressure values higher than expected for 
their population, “relative systemic hypertension,” had an increased risk of stroke and death. There is also 
a growing body of results associating relative systemic hypertension with stroke, diastolic dysfunction, 
and increased mortality in SCD patients. Other potential mechanisms for diastolic dysfunction in patients 
with SCD include 1) small myocardial infarctions and microvascular dysfunction caused by poor 
myocardial perfusion related to red blood cell sickling and 2) iron overload which is secondary to the 
frequent blood transfusions many of these patients require.  Dr. Machado, a co-investigator in this 
proposal, has previously shown that diastolic dysfunction is an independent risk factor for mortality in 
SCD patients [12]. Therefore, a major goal of our study is to better characterize LV structure and function 
in the SCD population and to relate these measures with PH and cardiovascular mortality.  
 
As PH is a complex, multifactorial, polygenic disorder, the genetic basis for PH associated with SCD. 
Recently, mutations in the bone morphogenetic protein receptor type 2 gene (BMPR2) have been 
identified in ~50% of cases of familial Primary PH [14]. We, therefore, hypothesize that both genetic 
polymorphisms and environmental factors play a pivotal role in the pathological sequence that leads to PH 
in SCD patients. The complexity of the disease also lends itself to the use of microarray technology, which 
allows the efficient and accurate simultaneous expression measurement of thousands of genes. This 
technology has been most successfully employed in the investigation of cancer, including the 
classification of histologically-indistinct tumor types with different natural histories [15]. In this proposal we 
will utilize mid- and high throughput array technologies to detect genome–wide gene expression and 
targeted genetic polymorphism detection to enhance our understanding of the genetic basis of the 
cardiopulmonary and vascular disease which afflicts SCD patients.   
 
Diagnosis — Because of the nonspecific clinical manifestations (or absence of manifestations many 
times) of PH in SCD, noninvasive screening for PH employing two-dimensional (2-D) and Doppler trans-
thoracic echocardiography (TTE) is still the first-line for detection. Many TTE-based studies have 
attempted to better define the subphenotypes of the left and right ventricle including diastolic dysfunction, 
systolic dysfunction with wall motion abnormalities, as well as the pulmonary artery characteristics of SCD 
patients. Most of these studies have revealed a possible multi-factorial contribution to the phenotype in 
SCD patients. Other noninvasive measures that may help identify PH patients include plasma levels of 
brain natriuretic peptide (BNP). The Multicenter Study of Hydroxyurea in Sickle Cell Anemia study [9] 
found that BNP >160 pg/mL had a sensitivity, specificity, and positive predictive value of 57, 91, and 78 

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percent, respectively, in detecting PH, as defined by TTE criteria. BNP levels correlated directly with 
mortality (RR 2.87, 95% CI 1.2-6.6) and indirectly with hemoglobin levels. There are also a number of 
other plasma markers that are under investigation including arginine levels and glomerular filtration rate 
[16]. This proposal aims to screen the blood for an array of established and novel plasma markers from 
SCD patients to advantage future studies designed to characterize and detect association with the PH 
phenotype. 
 
Cardiac magnetic resonance (CMR) has also gained increasing clinical application in cardiopulmonary 
diseases.  Due to its 3-dimensional nature, CMR is considered the gold-standard for quantifying left and 
right ventricular systolic function and size.  Additionally, its high tissue contrast allows for a detailed 
characterization of myocardial tissue.  Specifically, the use of techniques such as late gadolinium 
enhancement can be used to detect the presence of tiny amounts of myocardial scar [17].  Other 
techniques, such as T2*, have been shown to correlate strongly with myocardial iron content [18].  Just as 
importantly, CMR perfusion imaging can accurately quantify myocardial blood flow and can provide 
tremendous insight into the function of the microcirculation [19, 20]. CMR’s high spatial and temporal 
resolution, its 3-dimensional approach, its ability to characterize the tissue, and its ability to evaluate the 
micro- and macro-circulation make it a comprehensive technique for the evaluation of heart disease.   
Recently, one CMR study has already shown the presence of cardiac microvascular disease in a subset 
of adult SCD patients in the absence of infarcted myocardium, myocardial iron overload, or coronary 
artery disease, increasing the evidence for the contribution of left heart disease to PH development in 
these patients [21]; unfortunately, strong conclusions could not be made because the study was 
underpowered. Thus, this proposal will leverage the advantages offered by CMR to better characterize 
and detect the PH and cardiopulmonary subphenotypes in the SCD patient population. 
 
2. Purpose of the Study:  
Aim 1: Using CMR, TTE, and a plasma screen (BNP, hemoglobin, complete blood count, complete 
metabolic profile, bilirubin, lactate dehydrogenase [22], ferritin, von Willebrand factor (vWF), plasma 
vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), P- and E-
selectin, nitric oxide (NO), erythropoietin, vascular endothelial growth factor (VEGF), pre-B-cell colony 
enhancing factor (PBEF), macrophage migration inhibitory factor (MIF), sphingosine-1 phosphate (S1P) 
metabolites levels, and arginine), we plan to comprehensively and quantitatively characterize the 
cardiopulmonary complications of SCD and gain an improved understanding of the pathophysiology of 
PH and diastolic dysfunction in patients with SCD. 
 
Aim 2: To utilize mid- and high throughput array technologies to detect genome–wide gene expression 
(microarray and microRNAs) and targeted genetic polymorphisms (selected candidate genes) in SCD 
patients linked to a quantitative noninvasive-based PH phenotype as defined by Aim 1 in SCD patients. 
These studies will enhance our understanding of the genetic basis of the cardiopulmonary and vascular 
disease which afflicts SCD patients. 
 
3.  Methods:   
I. Selection of patients 
Patients with SCD will be recruited from the sickle cell clinic at the University of Chicago Medical Center.  
172 patients will be needed to adequately power the study.  Based on prior experience 15% of patients 
will have inadequate perfusion MRI data quality; therefore, approximately 200 patients will be enrolled 
into the study. As most of these patients are already enrolled in TRIDOM (Translational Research 
Initiative in the Department of Medicine), plasma screens for the markers listed earlier will be conducted 
using the blood already available from this initiative and hence new blood draws will not be needed. For 
the patients who are not enrolled in TRIDOM yet, we will inform of them of their opportunity to participate 
in the program (but not require them to participate) while also recruiting them for this study.  In addition, 
20 control subjects (age, race, and sex distributions similar to those of the SCD patients) will be used to 
determine baseline or normal values for myocardial blood flow, LV size and function, RV size and 
function, and myocardial iron content (i.e. T2* values).  These normal ranges will be specific for the 
techniques and equipment used at The University of Chicago Medical Center.   Healthy control subjects 
will not be eligible if they have a history of coronary artery disease or renal insufficiency based on direct 

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questioning. For all subjects who do not have a blood sample available from TRIDOM, we will collect a 
blood sample from them as part of this study (about 20 ml or 4 teaspoons). 
   
 
a) Inclusion criteria 
-Patients must be 18+. 
-Patients who were diagnosed with SCD confirmed by high-pressure liquid chromatography or 
hemoglobin electrophoresis will be eligible for the study.  
-Only outpatients in stable condition will be included. 
-Patients receiving transfusions will not be excluded. 
 
b) Exclusion criteria 
-Patients with a history of vaso-occlusive crises or an episode of acute chest syndrome within the 
previous four weeks will be evaluated at a later time. 
-Patients with high degree heart block; active, hemodynamically significant, ventricular arrhythmias; 
unstable coronary syndromes; history of myocardial infarction within 1 month of the study. 
-Contraindications to gadolinium-enhanced magnetic resonance examination:   
-severe claustrophobia, 
-Pacemaker, defibrillators, cerebral aneurysm clips, or neurostimulator. 
-GFR<30 mL/min/m2 
-Pregnancy  
-Patients with sinus node dysfunction 
 
 
II. Data collection 
A prospective study will be performed. Patients will be provided a schedule for their CMR and TTE.  Each 
subject will be assessed and the patient chart will be reviewed by one of the investigators to document 
the presence of any cardiovascular signs and symptoms as well as a history of cardiovascular events, 
and all subjects will undergo a routine 12-lead surface electrocardiography. 
 
a)  A comprehensive ultrasound study will be performed on all enrolled patients to evaluate the 
cardiovascular system in patients with SCD. Cardiac measurements will be performed according to the 
guidelines of the American Society of Echocardiography [23, 24]. Diastolic function will be assessed in all 
patients using standard Doppler and tissue Doppler measurements of the mitral inflow, pulmonary veins, 
and mitral annulus. Diastolic dysfunction will be graded as normal, mild, moderate, or severe.  Pulmonary 
hypertension will be quantified using standard Doppler measurements through the tricuspid and pulmonic 
valves. Both 2D and 3D echocardiography will be used to quantify left and right ventricular systolic 
function. Color Doppler will be used to identify and quantify the presence of significant valvular disease.  
Additionally, during their echocardiography session, all patients will undergo an evaluation of their aortic 
compliance using radial tonometry.  This additional examination will take approximately 5 extra minutes.  
Briefly, a blood pressure measurement will be obtained and then a high fidelity pulse wave contour will be 
acquired by placing a pencil-like probe that is a pressure sensor over the radial artery.  The waveform will 
provide important information with regards to arterial stiffness and how it may relate to the diastolic 
dysfunction seen in many SCD patients. Clinically relevant results from the echocardiogram will be 
dictated and reported to the patient’s physician. 
 
b)  CMR will be performed on all patients. Patients will be asked to not eat or drink for 6 hours prior to the 
CMR study. Additionally, beta-blockers, rate-lowering calcium channel blockers, and nitrates will be held 
on the morning of the study. Upon arrival to the MRI unit, an 18-guage IV will be placed in the upper 
extremity. EKG leads will be attached to the patient’s chest wall and a flexible surface coil will be placed 
over the thorax. The blood pressure and heart rate will be monitored throughout the study. Steady state 
free precession imaging will be performed to quantify left and right ventricular size and function and T2* 
images will be acquired to determine whether myocardial iron overload is present. In order to assess 
microcirculatory function, first-pass perfusion CMR using Gd-DTPA will be performed under resting and 
hyperemic conditions. The subject will receive a 0.4mg bolus of intravenous regadenoson to induce 
hyperemia. Immediately afterwards, 0.01 mmol/ kg of Gd-DTPA will be infused intravenously at a rate of 

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0.5 ml/ sec followed by a 0.1mmol/ kg infusion of Gd-DTPA at a rate of 5ml/sec. Images will be acquired 
as the Gd-DTPA transits the left ventricle using a hybrid GRE-EPI pulse sequence [25]. The same 
perfusion protocol will be repeated under resting conditions.  Using time intensity curves extracted from 
the acquired images, the absolute resting myocardial blood flow, hyperemic myocardial blood flow, and 
perfusion reserve will be calculated for each of the 16 American Heart Association myocardial segments 
using a Fermi function deconvolution [26]. A perfusion reserve <1.85 will be considered abnormal. After 
the perfusion imaging is completed, late gadolinium enhancement using an inversion recovery technique 
will be used to detect the presence of myocardial scar. The presence or absence of late gadolinium 
enhancement will be determined for each of the 17 American Heart Association myocardial segments. 
The presence of any late gadolinum enhancement will be considered abnormal. Clinically relevant results 
from the cardiac MRI study will be dictated and reported to the patient’s physician. 
  
Whole genomic SNP survey- This proposal will utilize the new Affymetrix® Genome-Wide Human SNP 
Array 6.0 with 1.8 million genetic markers (including more than 906,600 single nucleotide polymorphisms 
(SNPs) and 946,000 probes for the detection of copy number variation). Given the large numbers of 
probes, the SNP Array 6.0 will enable the design of this association study to take advantage of larger 
sample sizes in the proposal, thereby significantly increasing the overall genetic power. Briefly, total 
genomic DNA (500 ng), obtained from the TRIDOM initiative, will be utilized for the amplification and 
technical protocol as recommended by the Affymetrix manufacturer. PCR conditions have already been 
optimized to preferentially amplify fragments. Affymetrix Genome-Wide Human SNP Array 6.0 contains 
validated and qualified reagents for the most critical steps in the assay. This includes the PCR primer and 
adaptors, reagents to fragment and label the PCR products and several control reagents. Details of this 
kit and protocol are all available from the Affymetrix website 
(http://www.affymetrix.com/products/arrays/specific/genome_wide_snp6/genome_wide_snp_6.affx). The 
measurements and analyses for all of the SNP, gene, and microRNA studies will be performed at the 
Functional Genomics facility here at the University of Chicago Medical Center (details of the protocols for 
DNA, RNA, and microRNA isolation and measurement protocols as well as quality control are described 
at http://fgf.uchicago.edu/). 
 
Gene and microRNA Expression Profiling- This proposal will utilize the GeneChip® Human Gene 1.0 ST 
Array by Affymetrix (details at the website) got gene expression profiling, covering 28,869 genes 
represented on the array by approximately 26 probes spread across the full length of an individual gene. 
The Human Gene 1.0 ST Array has greater than 99 percent coverage of sequences present in the 
RefSeq database. To determine microRNA differences, this proposal plans to use the mercury LNA 
microRNA array offered by Exiqon. The array provides access for examination of over 1300 human 
microRNAswith as little as 30ng total RNA (obtained from the TRIDOM initiative). Details of this 
technology are also provided at http://www.exiqon.com.  
 
Soluble protein levels of select biomarkers will be assessed via commercially available enzyme-linked 
immunoassay kits for VCAM-1, ICAM-1, E-selectin (Invitrogen Corporation), NOx (Cayman Chemical), P-
selectin, erythropoietin and VEGF (R&D Systems) according to manufacturer’s instructions (blood 
obtained from the TRIDOM initiative). 
 
e) Statistical Consideration 
The study will be powered to detect a 10% difference in myocardial blood flow in sickle cell patients with 
and without pulmonary hypertension.  Because myocardial blood flow has the highest variability of all the 
measurements to be collected in this study, the study will be adequately powered to detect differences in 
all the other measurements that will be made.  Based on my previously published work involving MRI 
measurements of myocardial blood flow, in order to detect an approximately 10% difference in perfusion 
reserve between groups, 54 subjects will be needed in each group (alpha 5%, beta 50%).  Approximately 
40% of sickle cell patients have pulmonary hypertension.  In order to recruit enough sickle cell patients 
with pulmonary hypertension to adequately power the study, approximately 150 subjects in total with 
sickle cell disease will need to be recruited. Differences in the various left and right ventricular function 
and size measurements derived from the sickle cell disease population will be compared to age and 
gender matched controls using t-tests.  The sickle cell disease population will be divided into two groups:  
those with pulmonary hypertension (as determined by Doppler echocardiography) and those without 

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pulmonary hypertension.  Differences in left ventricular and right ventricular systolic function, diastolic 
function, myocardial perfusion reserve, myocardial scar burden, and myocardial iron content that exist 
between the two groups will be determined by t-tests.  Linear regression analysis will be used to compare 
the severity of pulmonary hypertension with each of the above mentioned continuous variables.  The 
sickle cell disease population will also be divided into another 2 groups:  those with diastolic dysfunction 
and those without diastolic dysfunction. Once again, the above listed parameters will be compared using 
t-tests.  Patients with diastolic dysfunction will also be classified according to a well established grade of 
severity, and the relationship between the various continuous variables and the severity of diastolic 
dysfunction will be investigated through analysis of variance (ANOVA).  A p-value <0.05 will be 
considered statistically significant.   
 
f) Data Safety 
Included patients will be issued a unique identifying number that will be linked to the collected data. No 
personal identifiers such as name, medical record number or address will be stored with this data.  A 
separate list linking the patients’ unique identifying number and their medical record number will be stored 
on a different computer.  All electronic data will be protected using secure, password protected computer 
files. Physical charts will be kept in a cabinet under lock and key.  This system will ensure that patient 
information is protected and accessible only to the principal investigators and co-investigators. Data will 
only be used for the research study.   
 
4.  Special precautions to be taken by the researchers (including dose modifications and whether 
subjects will be asked to take a pregnancy test before and, as applicable, during the study). 
 
Any female patient that is enrolled in the study will be tested for pregnancy using a urine test. 
 
5.  Exact location where research is to be conducted: 
 
The following locations will be utilized for the proposed study: 
-University of Chicago Medical Center Outpatient Clinics 
-Dr. Nicole Artz’ Sickle Cell Clinic  
-University of Chicago Medical Center Echocardiography laboratory 
-University of Chicago Medical Center MRI facility 
-Outpatient lab collection 
 
6.  Duration of protocol: 
 
The duration of the protocol will depend on when all patients that are expected to enroll complete the 
proposed testing. This will include all of the patients seen in the clinic by Dr. Artz that are eligible for the 
study.  Therefore, the time to enroll such patients will be a gradual and open process given her clinic is 
scheduled on a per weekly basis for SCD patients.  We expect the protocol to be completed within 2 
years. 
 
7. Potential risks and benefits to subjects: 
 
The risks to the proposed study are the following: 
A. Patient discomfort and time- Patients will undergo a single blood draw which can be transiently 
painful/uncomfortable. The TTE can also take typically 10-15 minutes per exam. The MRI exam will be 
estimated to take ~ 45-60 minutes per exam, where patients will have to lie flat and steady for the 
duration which can lead to discomfort. Additional risks of MRI include intolerance to the noise created by 
the MRI machine and also feeling uncomfortable due to being in an enclosed space.  While there are no 
known serious hazards (assuming the patient does not have any contra-indications to MRI), MRI is not 
proven to be safe during pregnancy and hence, we have excluded them from this study. 
 
B. Gadolinium safety- The FDA declared Gadolinium safe for use in MRI in 1988. A few side effects, such 
as mild headache, nausea and local burning can occur. Very rarely (less than one in a thousand), 
patients are allergic to Gadolinium. The use of gadolinium has been associated with nephrogenic 

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systemic fibrosis (NSF) in patients with advanced renal insufficiency.  Hence, any patients that with 
advanced renal insufficiency (GFR<30 mL/min) will be excluded from this study. 
 
C. Regadenoson- Some individuals experience facial flushing, lightheadedness, diaphoresis, or nausea 
after administration of regadenoson. These symptoms are transitory. Only FDA approved dosing will be 
used.  The subjects blood pressure and heart rate will be monitored throughout the study.  If the patient 
has significant symptoms or changes in hemodynamics, the Regadenoson effect will be reversed by 
using aminophylline. 
 
8.  Description of how the subject’s primary physician will be notified of and, as appropriate, 
involved in the proposed research: 
 
A clinical report of all the tests performed on the subject will be provided to the patient’s primary care 
physician. 
 
9.  Description of anticipated coordination between appropriate interdepartmental faculty, and 
where necessary, inclusion of those faculty as participants: 
 
Given that this proposal requires an interdepartmental level of involvement, we will have monthly 
meetings with all co-investigators to address the status of the project, any areas of improvement, and the 
results to that point. 
 
10.  References: 
 
Appendixes – if applicable: 
 
 
1. 
Frenette, P.S. and G.F. Atweh, Sickle cell disease: old discoveries, new concepts, and future 
promise. J Clin Invest, 2007. 117(4): p. 850-8. 
2. 
Machado, R.F., Sickle cell anemia-associated pulmonary arterial hypertension. J Bras Pneumol, 
2007. 33(5): p. 583-91. 
3. 
Castro, O., et al., Age and prevalence of sickle-cell trait in a large ambulatory population. Genet 
Epidemiol, 1987. 4(4): p. 307-11. 
4. 
Quinn, C.T., Z.R. Rogers, and G.R. Buchanan, Survival of children with sickle cell disease. Blood, 
2004. 103(11): p. 4023-7. 
5. 
Machado, R.F. and M.T. Gladwin, Chronic sickle cell lung disease: new insights into the 
diagnosis, pathogenesis and treatment of pulmonary hypertension. Br J Haematol, 2005. 129(4): 
p. 449-64. 
6. 
Barnett, C.F., P.Y. Hsue, and R.F. Machado, Pulmonary hypertension: an increasingly 
recognized complication of hereditary hemolytic anemias and HIV infection. Jama, 2008. 299(3): 
p. 324-31. 
7. 
Smedema, J.P., S. Abrahams, and V.J. Louw, Partial reversal of hemolysis-associated pulmonary 
arterial hypertension in response to oral administration of L-arginine in a patient with hereditary 
spherocytosis. Acta Haematol, 2007. 118(3): p. 167-8. 
8. 
Singer, S.T., et al., Pulmonary hypertension in thalassemia: association with platelet activation 
and hypercoagulable state. Am J Hematol, 2006. 81(9): p. 670-5. 
9. 
Machado, R.F., et al., N-terminal pro-brain natriuretic peptide levels and risk of death in sickle cell 
disease. Jama, 2006. 296(3): p. 310-8. 
10. 
Castro, O., M. Hoque, and B.D. Brown, Pulmonary hypertension in sickle cell disease: cardiac 
catheterization results and survival. Blood, 2003. 101(4): p. 1257-61. 
11. 
Gladwin, M.T., et al., Pulmonary hypertension as a risk factor for death in patients with sickle cell 
disease. N Engl J Med, 2004. 350(9): p. 886-95. 
12. 
Sachdev, V., et al., Diastolic dysfunction is an independent risk factor for death in patients with 
sickle cell disease. J Am Coll Cardiol, 2007. 49(4): p. 472-9. 

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13. 
Pegelow, C.H., et al., Natural history of blood pressure in sickle cell disease: risks for stroke and 
death associated with relative hypertension in sickle cell anemia. Am J Med, 1997. 102(2): p. 
171-7. 
14. 
Rubin, L.J., BMPR2 mutation and outcome in pulmonary arterial hypertension: clinical relevance 
to physicians and patients. Am J Respir Crit Care Med, 2008. 177(12): p. 1300-1. 
15. 
Bull, T.M., et al., Gene microarray analysis of peripheral blood cells in pulmonary arterial 
hypertension. Am J Respir Crit Care Med, 2004. 170(8): p. 911-9. 
16. 
van Beers, E.J., et al., Cardiopulmonary imaging, functional and laboratory studies in sickle cell 
disease associated pulmonary hypertension. Am J Hematol, 2008. 
17. 
Kim, R.J., et al., Relationship of MRI delayed contrast enhancement to irreversible injury, infarct 
age, and contractile function. Circulation, 1999. 100(19): p. 1992-2002. 
18. 
Anderson, L.J., et al., Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of 
myocardial iron overload. Eur Heart J, 2001. 22(23): p. 2171-9. 
19. 
Christian, T.F., et al., Absolute myocardial perfusion in canines measured by using dual-bolus 
first-pass MR imaging. Radiology, 2004. 232(3): p. 677-84. 
20. 
Patel, A.R., F.H. Epstein, and C.M. Kramer, Evaluation of the microcirculation: advances in 
cardiac magnetic resonance perfusion imaging. J Nucl Cardiol, 2008. 15(5): p. 698-708. 
21. 
Raman, S.V., et al., Myocardial ischemia and right ventricular dysfunction in adult patients with 
sickle cell disease. Haematologica, 2006. 91(10): p. 1329-35. 
22. 
Kato, G.J., et al., Lactate dehydrogenase as a biomarker of hemolysis-associated nitric oxide 
resistance, priapism, leg ulceration, pulmonary hypertension, and death in patients with sickle cell 
disease. Blood, 2006. 107(6): p. 2279-85. 
23. 
Douglas, P.S., et al., ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria 
for transthoracic and transesophageal echocardiography: a report of the American College of 
Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working 
Group, American Society of Echocardiography, American College of Emergency Physicians, 
American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and 
Interventions, Society of Cardiovascular Computed Tomography, and the Society for 
Cardiovascular Magnetic Resonance. Endorsed by the American College of Chest Physicians 
and the Society of Critical Care Medicine. J Am Soc Echocardiogr, 2007. 20(7): p. 787-805. 
24. 
Douglas, P.S., et al., ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria 
for transthoracic and transesophageal echocardiography: a report of the American College of 
Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working 
Group, American Society of Echocardiography, American College of Emergency Physicians, 
American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and 
Interventions, Society of Cardiovascular Computed Tomography, and the Society for 
Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and 
the Society of Critical Care Medicine. J Am Coll Cardiol, 2007. 50(2): p. 187-204. 
25. 
Epstein, F.H. et al.  Multislice First-Pass Cardiac Perfusion MRI:  Validation in a Model of 
Myocardial Infarction.  MRM, 2002. 47: p. 482-491. 
26. 
Jerosch-Herold, M., N. Wilke, and A.E. Stillman, Magnetic resonance quantification of the 
myocardial perfusion reserve with a Fermi function model for constrained deconvolution. Med 
Phys, 1998. 25(1): p. 73-84.