Comorbid conditions and outcomes in patients with pulmonary arterial hypertension: a REVEAL registry analysis

Pulmonary hypertension surveillance: United States, 2001 to 2010

Pulmonary hypertension (PH) is an uncommon but progressive condition, and much of what we know about it comes from specialized disease registries. With expanding research into the diagnosis and treatment of PH, it is important to provide updated surveillance on the impact of this disease on hospitalizations and mortality. This study, which builds on previous PH surveillance of mortality and hospitalization, analyzed mortality data from the National Vital Statistics System and data from the National Hospital Discharge Survey between 2001 and 2010. PH deaths were identified using International Classification of Diseases, Tenth Revision codes I27.0, I27.2, I27.8, or I27.9 as any contributing cause of death on the death certificate. Hospital discharges associated with PH were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 416.0, 416.8, or 416.9 as one of up to seven listed medical diagnoses. The decline in death rates associated with PH among men from 1980 to 2005 has reversed and now shows a significant increasing trend. Similarly, the death rates for women with PH have continued to increase significantly during the past decade. PH-associated mortality rates for those aged 85 years and older have accelerated compared with rates for younger age groups. There have been significant declines in PH-associated mortality rates for those with pulmonary embolism and emphysema. Rates of hospitalization for PH have increased significantly for both men and women during the past decade; for those aged 85 years and older, hospitalization rates have nearly doubled. Continued surveillance helps us understand and address the evolving trends in hospitalization and mortality associated with PH and PH-associated conditions, especially regarding sex, age, and race/ethnicity disparities.

Impact of diabetes on survival and right ventricular compensation in pulmonary arterial hypertension

Insulin resistance is highly prevalent in pulmonary arterial hypertension (PAH) patients. However, the long-term impact of diabetes mellitus (DM) on survival in PAH is unclear. Insulin resistance and DM are associated with left ventricular steatosis and dysfunction, but whether the right ventricle (RV) might be affected by DM in PAH is unknown. We hypothesized that PAH patients with DM would have worse survival than PAH patients without DM and that this would be due to impaired RV compensation. From a large registry of PAH patients at our institution, we analyzed the effect of DM on survival in patients with idiopathic or heritable PAH. Clinical and hemodynamic differences were compared between PAH patients with DM and those without DM. Twenty-nine patients with DM and 84 without DM were included. Gender, body mass index, PAH type and duration, and 6-minute walk distance were similar between groups. PAH patients with DM had significantly lower survival at 10 years than PAH patients without DM. Right atrial pressure, pulmonary arterial pressure, and cardiac output did not differ significantly between the two groups. However, right ventricular stroke work index (RVSWI) was lower in the PAH DM group than in the no-DM patients. Among PAH patients with DM, patients who died had a lower RVSWI than survivors. In conclusion, survival in PAH patients with DM was reduced compared to that of patients without DM; impaired RV compensation may underlie this finding. Further study is needed to understand this effect.

Clinical variability of respiratory pulmonary hypertension: implications for diagnosis and management

Pulmonary Hypertension (PH) associated to chronic respiratory diseases is currently classified in the 3^rd group, as a mild to moderate form of pre-capillary PH that progressively complicates the prognosis of associated pulmonary disease. In clinical practice, however, some unresolved issues in the respiratory PH should be considered: 1) the PH heterogeneity in some respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD), where the prevalence of unrecognized left heart disease, or chronic pulmonary thromboembolism may change the clinical classification; 2) the combining form of severe PH which often is not correlated to chronic ventilator impairment, while outcome is strictly related to pulmonary haemodynamics. The recognition of out of proportion respiratory PH in several chronic respiratory diseases which include COPD, Idiopathic Pulmonary Fibrosis (IPF), Combined Pulmonary Fibrosis and Emphysema, Obstructive Sleep Apnea (OSA), Obesity Hypoventilation Syndrome (OHS) may be important for a comprehensive clinical classification of severe respiratory PH, as well as, for the inclusion of these patients in randomized clinical trials on PH targeted therapy.

Impact of cardiac involvement on the risk of mortality among patients with systemic sclerosis: a 5-year follow-up of a single-center cohort

Cardiac involvement is among the leading causes of mortality in patients with systemic sclerosis (SSc). Previously, we demonstrated in a single-center, cross-sectional study the frequent coexistence of different forms of cardiac involvement in systemic sclerosis including pulmonary arterial hypertension (PAH), coronary artery disease (CAD), and microvascular dysfunction (MVD). The aim of the present study was to investigate the prognostic significance of cardiac involvement. One hundred twenty patients with SSc were enrolled. All cases underwent a non-invasive cardiovascular protocol. In 30 patients with suspected cardiac involvement, right heart catheterization and intra-coronary pressure-wire-supplemented coronary angiography were performed. Clinical follow-up was 5 years. Patients with CAD at the baseline showed a trend for higher cardiovascular mortality while in patients with MVD this difference was significant (26.7 % versus 9.5 %, p = 0.077 and 30 % versus 10.1 %, p < 0.05, respectively). Cardiovascular mortality of PAH cases was higher but, however, did not reach statistical significance 21.4 % versus 10.4 %, p = 0.261. Cardiovascular event-free survival was significantly lower among patients with combinations of two or three disorders (p < 0.05). Multivariate analysis of organ involvements and comorbidities showed that the diffuse cutaneous subset, the presence of kidney involvement, the velocity of the tricuspid regurgitation, as well as diabetes mellitus were independent predictors of overall mortality. MVD and CAD alone or in combination with PAH significantly affected the 5-year cardiovascular mortality. These findings highlight the prognostic importance of coronary disease in patients with SSc [ www.clinicaltrials.gov (Reg. Nr.: NCT00843102)].