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Kaymaz C, Akbal OY, Hakgor A, Tokgoz HC, Tanyeri S. Dart to the target: an alternative bull's eye parametric display for European Society of Cardiology / European Respiratory Society goal-orientated risk reduction strategy in pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018780522. [PMID: 29767575 PMCID: PMC6055270 DOI: 10.1177/2045894018780522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite the significant mortality and mobidity benefits being obtained with the targeted therapies in patients with pulmonary arterial hypertension (PAH), mid- to long-term survival of patients with this disease has remained unsatisfactory. For earlier and reliable risk stratification in PAH and tailoring the dynamic management strategies, various risk assessment models have been developed. Currently available risk reduction strategy recommended by the European Society of Cardiology (ESC)/European Respiratory Society (ERS) 2015 Pulmonary Hypertension Guidelines has been utilized in three recent registries. In this review, we evaluated the risk prediction models and management algorithms in this setting and propose an alternative parametric display, a bull's eye, dart table scheme for ESC/ERS goal-orientated risk reduction strategy in patients with PAH.
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Affiliation(s)
- Cihangir Kaymaz
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Ozgur Yasar Akbal
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Aykun Hakgor
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Hacer Ceren Tokgoz
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Seda Tanyeri
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
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Rudkovskaia AA, Tonelli AR, Rao Y, Hammel JP, Buller GK, Dweik RA, Fares WH. Is hyponatremia associated with mortality in pulmonary arterial hypertension? Pulm Circ 2018; 8:2045894018776888. [PMID: 29697294 PMCID: PMC5991194 DOI: 10.1177/2045894018776888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hyponatremia is associated with poor prognosis in left heart failure and liver disease. Its prognostic role in pulmonary arterial hypertension (PAH) is not well defined. We investigated the association between hyponatremia and one-year mortality in two large cohorts of PAH. This study is a secondary analysis evaluating the association between hyponatremia and one-year mortality in patients treated with subcutaneous treprostinil (cohort 1). The results are validated using a PAH registry at a tertiary referral center (cohort 2). Eight-hundred and twenty patients were enrolled in cohort 1 (mean age = 47 ± 14 years) and 791 in cohort 2 (mean age = 55 ± 15 years). Sodium level is negatively correlated with mean right atrial pressure (r = -0.09, P = 0.018; r = -0.089, P = 0.015 in cohorts 1 and 2, respectively). In unadjusted analyses of cohort 1, the sodium level (as a continuous variable) is associated with one-year mortality (hazard ratio = 0.94; P = 0.035). Hyponatremia loses its significance (as a continuous variable and when dichotomized at ≤ 137 mmol/L; P = 0.12) when adjusted for functional class (FC), which is identified as the variable whose presence turns the effect of sodium level into non-significant. Secondary analyses using a cut-off value of < 135 mmol/L showed similar results. These results are validated in cohort 2. Although the sample size for patients with sodium < 130 mmol/L is small (n = 31), severe hyponatremia is associated with higher overall mortality (47% versus 23%; P = 0.01), even when adjusting for age, FC, and baseline 6-min walk distance ( P < 0.001). Although baseline hyponatremia is associated with one-year mortality, it loses its significance when adjusted for FC.
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Affiliation(s)
| | | | - Youlan Rao
- 3 United Therapeutics Inc., Research Triangle Park, NC, USA
| | | | - Gregory K Buller
- 4 Yale New Haven Health, Bridgeport Hospital, Nephrology Section, Department of Medicine, Bridgeport, CT, USA
| | - Raed A Dweik
- 2 Cleveland Clinic, Respiratory Institute, Cleveland, OH, USA
| | - Wassim H Fares
- 5 Yale University, Pulmonary Critical Care & Sleep Medicine, New Haven, CT, USA
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REVEAL risk scores applied to riociguat-treated patients in PATENT-2: Impact of changes in risk score on survival. J Heart Lung Transplant 2018; 37:513-519. [DOI: 10.1016/j.healun.2017.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 11/18/2022] Open
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Hou CJ, Wei R, Tang JL. Can Magnetic Resonance Imaging Effectively Evaluate the Prognosis of Patients with Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2018; 197:675-676. [PMID: 28961026 DOI: 10.1164/rccm.201707-1530le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chun-Jie Hou
- 1 Zhejing Provincial People's Hospital Hangzhou, China.,2 People's Hospital of Hangzhou Medical College Hangzhou, China and
| | - Ran Wei
- 3 Hua-shan Hospital, Fudan University Shanghai, China
| | - Jing-Lan Tang
- 1 Zhejing Provincial People's Hospital Hangzhou, China.,2 People's Hospital of Hangzhou Medical College Hangzhou, China and
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Benza RL, Farber HW, Frost A, Grünig E, Hoeper MM, Busse D, Meier C, Nikkho S, Ghofrani HA. REVEAL risk score in patients with chronic thromboembolic pulmonary hypertension receiving riociguat. J Heart Lung Transplant 2018; 37:836-843. [PMID: 29580746 DOI: 10.1016/j.healun.2018.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The REVEAL risk score (RRS) was developed to predict survival in patients with pulmonary arterial hypertension (PAH), based on multiple patient characteristics. Herein we calculated RRS for patients in the randomized CHEST-1 study and open-label CHEST-2 extension study of riociguat in inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH). We investigated the effect of riociguat vs placebo on RRS in the CHEST-1 study, and the relationship between RRS and long-term outcomes in the CHEST-2 study. METHODS RRS was calculated post hoc for baseline and Week 16 of CHEST-1 and Week 12 of CHEST-2, based on 9 evaluable elements. Patients were grouped into risk strata by RRS. Relationships between RRS and both survival and clinical worsening-free survival were examined by Kaplan-Meier and Cox proportional hazards analyses. RESULTS Overall, 237 patients completed CHEST-1 and entered CHEST-2. In CHEST-1, riociguat significantly improved RRS (p < 0.0001) and risk stratum (p < 0.001) vs placebo from baseline to Week 16. RRS at baseline, and at Week 16, and change in RRS during CHEST-1 were significantly associated with survival (hazard ratios for a 1-point reduction in RRS: 0.702, 0.692, and 0.682, respectively) and clinical worsening-free survival (hazard ratios: 0.697, 0.719, and 0.754, respectively) over 2 years in CHEST-2. CONCLUSIONS Riociguat improved RRS in patients with inoperable and persistent/recurrent CTEPH. RRS at baseline and Week 16, and change in RRS from baseline, predicted survival and clinical worsening-free survival. This analysis of RRS in patients with inoperable or persistent/recurrent CTEPH suggests utility for the RRS in indications beyond PAH.
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Affiliation(s)
- Raymond L Benza
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
| | - Harrison W Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Adaani Frost
- Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas, USA
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, member of the German Center for Lung Research (DZL), Hannover, Germany
| | | | | | - Sylvia Nikkho
- Global Clinical Development, Bayer AG, Berlin, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Medicine, Imperial College London, London, UK
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Benza RL, Lohmueller LC, Kraisangka J, Kanwar M. Risk Assessment in Pulmonary Arterial Hypertension Patients: The Long and Short of it. ACTA ACUST UNITED AC 2018. [DOI: 10.21693/1933-088x-16.3.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a chronic and rapidly progressive disease that is characterized by extensive narrowing of the pulmonary vasculature, leading to increases in pulmonary vascular resistance, subsequent right ventricular dysfunction, and eventual death. There are currently multiple approved drugs—developed as single or combination therapies in the last few years—that have improved outcome and functionality in PAH. However, despite improvement in short-term survival with these new effective therapies, PAH remains an incurable disease with a median survival of 7 years (Figure 1).1 This chronic disease state may be characterized by morbid events such as hospitalizations that herald rapid disease progression and account for a significant disease burden (Figure 2).23 Physician ability to predict PAH disease progression is critical for determining optimal care of patients. Accurate risk assessment allows clinicians to determine the patient's prognosis, identify treatment goals, and monitor disease progression and the patient's response to treatment. Risk assessment for PAH patients should include a range of clinical, hemodynamic, and exercise parameters, performed in a serial fashion over the treatment course. Patient risk stratification can also help physicians better allocate treatment resources in settings where they are scarce. If widely adopted, risk prediction can enhance the consistency of treatment approaches across PAH practitioners and improve the timeliness of referral for lung transplantation. Hence, along with advancing PAH treatment options, comprehensive risk prediction is essential to make individualized treatment decisions in the current treatment era.
Several tools are currently available for assessing risk in PAH (Figure 3). These include the 2015 European Society of Cardiology/European Respiratory Society pulmonary hypertension guidelines' risk variables,4 the French registry equation,5 the National Institutes of Health risk equation,6 or a risk score such as the one derived from the Registry to Evaluate Early And Long-term PAH Disease Management.1 These registries and evaluations of clinical trial sets have provided important insights into the importance of both modifiable (eg, 6-minute walk distance, functional class, brain natriuretic peptide, and nonmodifiable (eg, age, gender, PAH etiology) risk factors that predict survival. The following review explores commonly cited risk factors, both modifiable and nonmodifiable, and their implications for patient outcomes.
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Gaine S, McLaughlin V. Pulmonary arterial hypertension: tailoring treatment to risk in the current era. Eur Respir Rev 2017; 26:26/146/170095. [PMID: 29263175 PMCID: PMC9488605 DOI: 10.1183/16000617.0095-2017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/07/2017] [Indexed: 11/24/2022] Open
Abstract
Recent advances in the treatment of pulmonary arterial hypertension (PAH) have led to improved patient outcomes. Multiple PAH therapies are now available and optimising the use of these drugs in clinical practice is vital. In this review, we discuss the management of PAH patients in the context of current treatment guidelines and supporting clinical evidence. In clinical practice, considerable emphasis is placed on the importance of making treatment decisions guided by each patient's risk status, which should be assessed using multiple prognostic parameters. As PAH is a progressive disease, regular assessments are essential to ensure that any change in risk is detected in a timely manner and treatment is adjusted accordingly. With the availability of therapies that target three different pathogenic pathways, combination therapy is now the standard of care. For most patients, this involves dual combination therapy with agents targeting the endothelin and nitric oxide pathways. Therapies targeting the prostacyclin pathway should be added for patients receiving dual combination therapy who do not achieve a low-risk status. There is also a need for a holistic approach to treatment beyond pharmacological therapies. Implementation of all these approaches will ensure that PAH patients receive maximal benefit from currently available therapies. Optimal PAH treatment requires frequent multiparameter risk assessment and early initiation of combination therapyhttp://ow.ly/IA6t30fPceT
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Swift AJ, Capener D, Johns C, Hamilton N, Rothman A, Elliot C, Condliffe R, Charalampopoulos A, Rajaram S, Lawrie A, Campbell MJ, Wild JM, Kiely DG. Magnetic Resonance Imaging in the Prognostic Evaluation of Patients with Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2017; 196:228-239. [PMID: 28328237 DOI: 10.1164/rccm.201611-2365oc] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Prognostication is important when counseling patients and defining treatment strategies in pulmonary arterial hypertension (PAH). OBJECTIVES To determine the value of magnetic resonance imaging (MRI) metrics for prediction of mortality in PAH. METHODS Consecutive patients with PAH undergoing MRI were identified from the ASPIRE (Assessing the Spectrum of Pulmonary Hypertension Identified at a Referral Centre) pulmonary hypertension registry. MEASUREMENTS AND MAIN RESULTS During the follow-up period of 42 (range, 17-142) months 576 patients were studied and 221 (38%) died. A derivation cohort (n = 288; 115 deaths) and validation cohort (n = 288; 106 deaths) were identified. We used multivariate Cox regression and found two independent MRI predictors of death (P < 0.01): right ventricular end-systolic volume index adjusted for age and sex, and the relative area change of the pulmonary artery. A model of MRI and clinical data constructed from the derivation cohort predicted mortality in the validation cohort at 1 year (sensitivity, 70 [95% confidence interval (CI), 53-83]; specificity, 62 [95% CI, 62-68]; positive predictive value [PPV], 24 [95% CI, 16-32]; negative predictive value [NPV], 92 [95% CI, 87-96]) and at 3 years (sensitivity, 77 [95% CI, 67-85]; specificity, 73 [95% CI, 66-85]; PPV, 56 [95% CI, 47-65]; and NPV, 87 [95% CI, 81-92]). The model was more accurate in patients with idiopathic PAH at 3 years (sensitivity, 89 [95% CI, 65-84]; specificity, 76 [95% CI, 65-84]; PPV, 60 [95% CI, 46-74]; and NPV, 94 [95% CI, 85-98]). CONCLUSIONS MRI measurements reflecting right ventricular structure and stiffness of the proximal pulmonary vasculature are independent predictors of outcome in PAH. In combination with clinical data MRI has moderate prognostic accuracy in the evaluation of patients with PAH.
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Affiliation(s)
- Andrew J Swift
- 1 Department of Infection, Immunity and Cardiovascular Disease and.,2 Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Dave Capener
- 1 Department of Infection, Immunity and Cardiovascular Disease and
| | - Chris Johns
- 1 Department of Infection, Immunity and Cardiovascular Disease and
| | - Neil Hamilton
- 3 Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and
| | - Alex Rothman
- 1 Department of Infection, Immunity and Cardiovascular Disease and.,2 Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Charlie Elliot
- 3 Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and
| | - Robin Condliffe
- 3 Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and
| | | | - Smitha Rajaram
- 4 Radiology Department, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom; and
| | - Allan Lawrie
- 1 Department of Infection, Immunity and Cardiovascular Disease and.,2 Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | | | - Jim M Wild
- 1 Department of Infection, Immunity and Cardiovascular Disease and.,2 Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - David G Kiely
- 1 Department of Infection, Immunity and Cardiovascular Disease and.,2 Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom.,3 Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and
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Lau EMT, Giannoulatou E, Celermajer DS, Humbert M. Epidemiology and treatment of pulmonary arterial hypertension. Nat Rev Cardiol 2017; 14:603-614. [DOI: 10.1038/nrcardio.2017.84] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Raina A, Humbert M. Risk assessment in pulmonary arterial hypertension. Eur Respir Rev 2017; 25:390-398. [PMID: 27903661 PMCID: PMC9487550 DOI: 10.1183/16000617.0077-2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/13/2016] [Indexed: 11/23/2022] Open
Abstract
Regular patient assessment is essential for the management of chronic diseases, such as pulmonary arterial hypertension (PAH). Comprehensive patient assessment and risk stratification in PAH are important to guide treatment decisions and to monitor disease progression as well as patients' response to treatment. Approaches for assessing risk in PAH patients include the use of risk variables, as recommended in the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) pulmonary hypertension (PH) guidelines, and the application of risk equations and scores, such as the French registry risk equation and the REVEAL registry risk score. Risk stratification and risk scores are both useful predictors of survival on a population basis, and provide an estimate for individual patients' risk. The 2015 ESC/ERS PH guidelines recommend regular assessment of multiple variables at an expert centre. The respective merits and limitations of different risk assessment methods in PAH are discussed in this article, as well as some considerations that can be taken into account in the future development of risk assessment tools. Regular risk assessment with multiple parameters evaluates PAH disease progression and treatment responsehttp://ow.ly/Nq0I305kgpU
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PN, USA
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Abstract
PURPOSE OF REVIEW The article is intended to provide an overview of the most current modalities for the diagnosis and management of pulmonary hypertension in the pediatric population. RECENT FINDINGS The WHO has recently updated the classification for pulmonary hypertension to include an expanded range of pediatric disease cohorts. We continue to gain knowledge of traditional pulmonary hypertension therapies (phosphodiesterase inhibitors, endothelin-receptor antagonists, and prostanoids) and remain optimistic that new therapeutic modalities [cyclic guanosine monophosphate (cGMP) stimulators, oral prostacyclins, and gene therapy] will lead to improved outcomes in pediatric patients. SUMMARY Pediatric pulmonary hypertension is a heterogeneous disorder that has the potential to improve in some cases as children grow throughout childhood. Utilization of dedicated multidisciplinary teams of medical providers is necessary to deliver the highest level of medical care to this complex patient population. Ongoing development of enhanced screening protocols, novel disease-specific therapeutic targets, and comprehensive registries will hopefully lead to improved morbidity and mortality in the future.
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Al-Naamani N, Sagliani KD, Dolnikowski GG, Warburton RR, Toksoz D, Kayyali U, Hill NS, Fanburg BL, Roberts KE, Preston IR. Plasma 12- and 15-hydroxyeicosanoids are predictors of survival in pulmonary arterial hypertension. Pulm Circ 2016; 6:224-33. [PMID: 27252849 DOI: 10.1086/686311] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This study aimed to characterize alterations in select eicosanoids in experimental and human pulmonary arterial hypertension (PAH) and to assess their potential utility as predictors of outcome. Using liquid chromatography-mass spectrometry, we performed targeted lipidomic analyses of the lungs and right ventricles (RVs) of chronically hypoxic rats and plasma of consecutive PAH patients and healthy controls. In rat lungs, chronic hypoxia was associated with significantly decreased lung prostacyclin (PGI2)/thromboxane B2 (TXB2) ratio and elevated lung 8-hydroxyeicosanoid (HETE) acid concentrations. RV eicosanoids did not exhibit any changes with chronic hypoxia. PAH treatment-naïve patients had significantly increased plasma concentrations of TXB2 and 5-, 8-, 12-, and 15-HETE. The PGI2/TXB2 ratio was lower in PAH patients than in controls, especially in the treatment-naïve cohort (median: 2.1, 0.3, and 1.3 in controls, treatment-naïve, and treated patients, respectively, P = 0.001). Survival was significantly worse in PAH patients with 12-HETEhigh (≥57 pg/mL) and 15-HETEhigh (≥256 pg/mL) in unadjusted and adjusted analyses (hazard ratio [HR]: 2.8 [95% confidence interval (CI): 1.1-7.3], P = 0.04 and HR: 4.3 [95% CI: 1.6-11.8], P = 0.004, respectively; adjustment was performed with the REVEAL [Registry to Evaluate Early and Long-Term PAH Disease Management] risk score). We demonstrate significant alterations in eicosanoid pathways in experimental and human PAH. We found that 12- and 15-HETE were independent predictors of survival in human PAH, even after adjusting for the REVEAL score, suggesting their potential role as novel biomarkers.
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Affiliation(s)
- Nadine Al-Naamani
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA; Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, Massachusetts, USA
| | - Kristen D Sagliani
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gregory G Dolnikowski
- Mass Spectrometry Laboratory, Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts, USA
| | - Rod R Warburton
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Deniz Toksoz
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Usamah Kayyali
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Barry L Fanburg
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kari E Roberts
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Huertas A, Phan C, Bordenave J, Tu L, Thuillet R, Le Hiress M, Avouac J, Tamura Y, Allanore Y, Jovan R, Sitbon O, Guignabert C, Humbert M. Regulatory T Cell Dysfunction in Idiopathic, Heritable and Connective Tissue-Associated Pulmonary Arterial Hypertension. Chest 2016; 149:1482-93. [DOI: 10.1016/j.chest.2016.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/27/2015] [Accepted: 01/04/2016] [Indexed: 12/21/2022] Open
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Thakkar V, Lau EMT. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol 2016; 30:22-38. [PMID: 27421214 DOI: 10.1016/j.berh.2016.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/12/2016] [Accepted: 03/29/2016] [Indexed: 01/05/2023]
Abstract
Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH.
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Affiliation(s)
- Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Ingham Institute, Liverpool, Australia.
| | - Edmund M T Lau
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Camperdown, Australia.
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Ghofrani HA, Grimminger F, Grünig E, Huang Y, Jansa P, Jing ZC, Kilpatrick D, Langleben D, Rosenkranz S, Menezes F, Fritsch A, Nikkho S, Humbert M. Predictors of long-term outcomes in patients treated with riociguat for pulmonary arterial hypertension: data from the PATENT-2 open-label, randomised, long-term extension trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:361-71. [PMID: 27067479 DOI: 10.1016/s2213-2600(16)30019-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension is a chronic disease associated with poor long-term outcomes. Identifying predictors of long-term outcome in pulmonary arterial hypertension is important to assess disease severity and guide treatment. We investigate associations between efficacy parameters and long-term outcomes in patients with pulmonary arterial hypertension receiving riociguat in the PATENT-2 study. We also present safety and efficacy data from the final data cutoff of PATENT-2, where most patients had received at least 2 years of riociguat treatment. METHODS Eligible patients from the PATENT-1 study entered the PATENT-2 open-label extension, which will continue until all patients transition to the commercial drug. All patients received riociguat individually adjusted to a maximum dose of 2·5 mg three times a day. The primary endpoint was safety and tolerability, assessed with recording adverse events, serious adverse events, discontinuations, and deaths; exploratory assessments included 6-min walking distance (6MWD), WHO functional class, N-terminal prohormone of brain natriuretic peptide (NT-proBNP)concentrations, Borg dyspnoea score, health-related quality of life (EQ-5D score), survival, and clinical worsening-free survival. Association between efficacy parameters and long-term outcomes was assessed using Kaplan-Meier analyses and a Cox proportional-hazards regression model. PATENT-2 is registered at ClinicalTrials.gov, number NCT00863681. FINDINGS 396 patients entered PATENT-2, of whom 197 patients were receiving riociguat monotherapy and 199 were receiving riociguat in combination with endothelin receptor antagonists or prostanoids, or both. A significant association was noted between 6MWD, NT-proBNP concentration, and WHO functional class and overall survival at baseline (p=0·0006, 0·0225, and 0·0191, respectively), and at follow-up (p=0·021, 0·0056, and 0·0048, respectively). Riociguat was well tolerated in PATENT-2. Serious adverse events were recorded in 238 (60%) of the total population, and 45 (11%) patients discontinued treatment because of an adverse event. Improvements in 6MWD, WHO functional class, and NT-proBNP concentrations were maintained after 2 years of treatment. INTERPRETATION These results support the long-term use of riociguat in patients with pulmonary arterial hypertension, and emphasise the prognostic value of 6MWD, WHO functional class, and NT-proBNP concentrations. FUNDING Bayer Pharma AG.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center (UGMLC) and German Centre of Lung Research (DZL), Giessen, Germany; Department of Medicine, Imperial College London, London, UK.
| | - Friedrich Grimminger
- University of Giessen and Marburg Lung Center (UGMLC) and German Centre of Lung Research (DZL), Giessen, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension at the Thoraxclinic of University Hospital Heidelberg, Heidelberg, Germany
| | - Yigao Huang
- Department of Cardiology, Guangdong General Hospital and Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Pavel Jansa
- Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic
| | - Zhi-Cheng Jing
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - David Kilpatrick
- Discipline of Medicine, University of Tasmania, Hobart, Australia
| | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
| | - Stephan Rosenkranz
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | | | - Arno Fritsch
- Global Clinical Development, Bayer Pharma AG, Wuppertal, Germany
| | - Sylvia Nikkho
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marc Humbert
- Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France; Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Sitbon O, Sattler C, Bertoletti L, Savale L, Cottin V, Jaïs X, De Groote P, Chaouat A, Chabannes C, Bergot E, Bouvaist H, Dauphin C, Bourdin A, Bauer F, Montani D, Humbert M, Simonneau G. Initial dual oral combination therapy in pulmonary arterial hypertension. Eur Respir J 2016; 47:1727-36. [DOI: 10.1183/13993003.02043-2015] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/22/2016] [Indexed: 11/05/2022]
Abstract
Treatment for pulmonary arterial hypertension (PAH) has been underpinned by single-agent therapy to which concomitant drugs are added sequentially when pre-defined treatment goals are not met.This retrospective analysis of real-world clinical data in 97 patients with newly diagnosed PAH (86% in New York Heart Association functional class III−IV) explored initial dual oral combination treatment with bosentan plus sildenafil (n=61), bosentan plus tadalafil (n=17), ambrisentan plus tadalafil (n=11) or ambrisentan plus sildenafil (n=8).All regimens were associated with significant improvements in functional class, exercise capacity, dyspnoea and haemodynamic indices after 4 months of therapy. Over a median follow-up period of 30 months, 75 (82%) patients were still alive, 53 (71%) of whom received only dual oral combination therapy. Overall survival rates were 97%, 94% and 83% at 1, 2 and 3 years, respectively, and 96%, 94% and 84%, respectively, for the patients with idiopathic PAH, heritable PAH and anorexigen-induced PAH. Expected survival rates calculated from the French equation for the latter were 86%, 75% and 66% at 1, 2 and 3 years, respectively.Initial combination of oral PAH-targeted medications may offer clinical benefits, especially in PAH patients with severe haemodynamic impairment.
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Preston IR, Roberts KE, Miller DP, Sen GP, Selej M, Benton WW, Hill NS, Farber HW. Effect of Warfarin Treatment on Survival of Patients With Pulmonary Arterial Hypertension (PAH) in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL). Circulation 2015; 132:2403-11. [PMID: 26510696 PMCID: PMC4689180 DOI: 10.1161/circulationaha.115.018435] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term anticoagulation is recommended in idiopathic pulmonary arterial hypertension (IPAH). In contrast, limited data support anticoagulation in pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc-PAH). We assessed the effect of warfarin anticoagulation on survival in IPAH and SSc-PAH patients enrolled in Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL), a longitudinal registry of group I PAH. METHODS AND RESULTS Patients who initiated warfarin on study (n=187) were matched 1:1 with patients never on warfarin, by enrollment site, etiology, and diagnosis status. Descriptive analyses were conducted to compare warfarin users and nonusers by etiology. Survival analyses with and without risk adjustment were performed from the time of warfarin initiation or a corresponding quarterly update in matched pairs to avoid immortal time bias. Time-varying covariate models were used as sensitivity analyses. Mean warfarin treatment was 1 year; mean international normalized ratios were 1.9 (IPAH) and 2.0 (SSc-PAH). Two-thirds of patients initiating warfarin discontinued treatment before the last study assessment. There was no survival difference with warfarin in IPAH patients (adjusted hazard ratio, 1.37; P=0.21) or in SSc-PAH patients (adjusted hazard ratio, 1.60; P=0.15) in comparison with matched controls. However, SSc-PAH patients receiving warfarin within the previous year (hazard ratio, 1.57; P=0.031) or any time postbaseline (hazard ratio, 1.49; P=0.046) had increased mortality in comparison with warfarin-naïve patients. CONCLUSIONS No significant survival advantage was observed in IPAH patients who started warfarin. In SSc-PAH patients, long-term warfarin was associated with poorer survival than in patients not receiving warfarin, even after adjusting for confounders. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00370214.
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Affiliation(s)
- Ioana R Preston
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Kari E Roberts
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Dave P Miller
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Ginny P Sen
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Mona Selej
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Wade W Benton
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Nicholas S Hill
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Harrison W Farber
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.).
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McLaughlin VV, Shah SJ, Souza R, Humbert M. Management of pulmonary arterial hypertension. J Am Coll Cardiol 2015; 65:1976-97. [PMID: 25953750 DOI: 10.1016/j.jacc.2015.03.540] [Citation(s) in RCA: 245] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/23/2015] [Indexed: 12/18/2022]
Abstract
Pulmonary hypertension (PH) is common and may result from a number of disorders, including left heart disease, lung disease, and chronic thromboembolic disease. Pulmonary arterial hypertension (PAH) is an uncommon disease characterized by progressive remodeling of the distal pulmonary arteries, resulting in elevated pulmonary vascular resistance and, eventually, in right ventricular failure. Over the past decades, knowledge of the basic pathobiology of PAH and its natural history, prognostic indicators, and therapeutic options has exploded. A thorough evaluation of a patient is critical to correctly characterize the PH. Cardiac studies, including echocardiography and right heart catheterization, are key elements in the assessment. Given the multitude of treatment options currently available for PAH, assessment of risk and response to therapy is critical in long-term management. This review also underscores unique situations, including perioperative management, intensive care unit management, and pregnancy, and highlights the importance of collaborative care of the PAH patient through a multidisciplinary approach.
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Affiliation(s)
| | - Sanjiv J Shah
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rogerio Souza
- Pulmonary Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Marc Humbert
- University of Paris-Sud, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; and INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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