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Gialamas I, Arvanitaki A, Rosenkranz S, Wort SJ, Rådegran G, Badagliacca R, Giannakoulas G. The impact of cardiovascular and lung comorbidities in patients with pulmonary arterial hypertension: A systematic review and meta-analysis. J Heart Lung Transplant 2024; 43:1383-1394. [PMID: 38744353 DOI: 10.1016/j.healun.2024.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/14/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Contemporary patients with pulmonary arterial hypertension (PAH) are older and exhibit cardiovascular or/and lung comorbidities. Such patients have typically been excluded from major PAH drug trials. This systematic review compares baseline characteristics, hemodynamic parameters, and mortality rate between PAH patients with significant number of comorbidities compared to those with fewer or no comorbidities. ΜETHODS: A systematic literature search in PubMed, Web of Science, and Cochrane databases was conducted searching for studies comparing PAH patients with more than 2 cardiovascular comorbidities or/and at least a lung comorbidity against those with fewer comorbidities. RESULTS Seven observational studies were included. PAH patients with comorbidities were older, with an almost equal female-to-male ratio, shorter 6-minute walk distance, higher N-terminal pro-brain natriuretic peptide levels, and lower lung diffusion for carbon monoxide. In terms of hemodynamics, they had higher mean right atrial pressure and pulmonary artery wedge pressure, lower mean pulmonary arterial pressure, pulmonary vascular resistance and mixed venous oxygen saturation. Pooled analysis of 6 studies demonstrated a higher mortality risk for PAH patients with comorbidities compared to those without (HR 1.86, 95% CI 1.20 to 2.89, p < 0.001, I²=92%), with the subgroup of PAH patients with lung comorbidities having an even higher mortality risk (test for subgroup differences: p < 0.001). Combination drug therapy for PAH was less frequently used in patients with comorbidities. CONCLUSIONS Cardiovascular and lung comorbidities impact the clinical characteristics and outcomes of PAH patients, highlighting the need for optimal phenotyping and tailored management for this high-risk population.
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Affiliation(s)
- Ioannis Gialamas
- Third Department of Cardiology, National and Kapodistrian University of Athens, Sotiria Chest Disease Hospital, Athens, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; National Pulmonary Hypertension Service, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Department of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - S John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Göran Rådegran
- Department of Clinical Sciences Lund, The Section for Cardiology, Lund University, Lund, Sweden; The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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McLaughlin VV, Sitbon O, Chin KM, Galiè N, Hoeper MM, Kiely DG, MacDonald G, Martin N, Mathai SC, Peacock A, Tawakol A, Torbicki A, Noordegraaf AV, Rosenkranz S. Initial combination therapy with macitentan and tadalafil in patients with pulmonary arterial hypertension, with and without cardiac comorbidities. Eur J Heart Fail 2024. [PMID: 38966990 DOI: 10.1002/ejhf.3319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/23/2024] [Accepted: 05/15/2024] [Indexed: 07/06/2024] Open
Abstract
AIMS According to current guidelines, initial monotherapy should be considered for pulmonary arterial hypertension (PAH) patients with cardiopulmonary comorbidities. This analysis of combined data from the TRITON and REPAIR clinical trials, assesses efficacy and safety of initial double combination therapy in patients without vs. with 1-2 cardiac comorbidities. METHODS AND RESULTS Data were combined for patients from TRITON (NCT02558231) and REPAIR (NCT02310672) on initial macitentan and tadalafil double combination therapy (overall set, n = 148) and two subgroups defined as patients without cardiac comorbidities (n = 62) and those with 1-2 cardiac comorbidities (n = 78). Patients with ≥3 comorbidities were excluded from these studies. For the overall set, the median (Q1-Q3) duration of combined macitentan and tadalafil exposure was 513.0 (364.0-778.0) days, and was similar between subgroups. Change from baseline to Week 26 for pulmonary vascular resistance was -55% and -50% for patients without and with 1-2 cardiac comorbidities, respectively; marked improvements in other hemodynamic and functional parameters were also observed, although functional parameters improved to a lesser extent in patients with comorbidities. At Week 26, the majority of patients had improved PAH risk status, according to the non-invasive four-strata and REVEAL Lite 2.0 methods. The safety profile of initial macitentan plus tadalafil combination therapy was consistent with the known profiles of the two drugs, and similar between the subgroups. CONCLUSIONS Initial double combination therapy with macitentan plus tadalafil is efficacious in patients with PAH with 1-2 cardiac comorbidities and those without, with similar safety and tolerability profiles between the two groups.
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Affiliation(s)
| | - Olivier Sitbon
- Université Paris-Saclay, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento DIMEC, Università di Bologna, Bologna, Italy
| | - Marius M Hoeper
- Hannover Medical School and German Centre for Lung Research, Hannover, Germany
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, NIHR Biomedical Research Centre Sheffield and University of Sheffield, Sheffield, UK
| | - Gwen MacDonald
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Medical Affairs, Allschwil, Switzerland
| | - Nicolas Martin
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Statistical Decision Science, Allschwil, Switzerland
| | | | | | - Ahmed Tawakol
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, ECZ-Otwock, ERN-LUNG Member, Otwock, Poland
| | | | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Skowasch D, Klose H, Ewert R, Wilkens H, Richter M, Rosenkranz S, Setzer G, Grünig E, Halank M. Phenotypes and treatment outcomes in idiopathic pulmonary arterial hypertension patients with comorbidities. ERJ Open Res 2024; 10:00668-2023. [PMID: 38288083 PMCID: PMC10823369 DOI: 10.1183/23120541.00668-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/28/2023] [Indexed: 01/31/2024] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is often diagnosed in elderly patients with many comorbidities. Whereas a clear treatment strategy and risk assessment is recommended for patients with rare classical IPAH, monotherapy with phosphodiesterase type 5 inhibitors or endothelin receptor antagonists followed by regular follow-up and individualised therapy should be used for patients with many cardiopulmonary comorbidities. Here, we focus on these patients with IPAH and comorbidities, present a review of the literature with a focus on recently published work and summarise factors that may help to provide guidance for individualised treatment approaches in such patients.
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Affiliation(s)
- Dirk Skowasch
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Hans Klose
- II. Medical Clinic and Polyclinic, Department of Pulmonology, Center for Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, Internal Medicine, Pulmonology, Internal Intensive Care Medicine, University Medical Center Greifswald, Greifswald, Germany
| | - Heinrike Wilkens
- Internal Medicine V – Pneumology, Saarland University Hospital and Faculty of Medicine Saarland University, Homburg, Germany
| | - Manuel Richter
- Department of Medicine II, Pulmonology, University Hospital Giessen, Giessen, Germany
| | - Stephan Rosenkranz
- Department III of Internal Medicine – Cardiology, Pulmonology, Angiology and Internal Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Gesine Setzer
- Scientific and Medical Affairs, Janssen-Cilag GmbH, Neuss, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH, and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Michael Halank
- Division of Pneumology, Medical Department – I, University Hospital Carl Gustav Carus of TU Dresden, Dresden, Germany
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Sargent T, Tsang Y, Panjabi S, Funtanilla V, Germack HD, Gauthier-Loiselle M, Manceur AM, Cloutier M, Lefebvre P. Real-World Treatment Patterns Among Patients with Connective Tissue Disorder-Related Pulmonary Arterial Hypertension in the United States: A Retrospective Claims-Based Analysis. Adv Ther 2023; 40:5037-5054. [PMID: 37728697 PMCID: PMC10567881 DOI: 10.1007/s12325-023-02658-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Connective tissue disorders (CTDs) are the most frequent diseases associated with pulmonary arterial hypertension (PAH). Despite advances in treatment, the prognosis of CTD-related PAH remains poor. To help identify areas for improvement in the management of CTD-related PAH, this study assessed real-world PAH treatment patterns in this population in the US. METHODS Eligible adult patients with PAH initiated on a PAH treatment (index date: 1st initiation date) were identified from Optum's de-identified Clinformatics® Data Mart Database (10/01/2015-09/30/2021) and categorized into mutually exclusive cohorts (CTD + PAH; PAH) based on the presence of CTD diagnosis claims. Treatment patterns were assessed from the index date to the earliest of death or end of continuous insurance eligibility, or data availability. Treatment persistence was assessed using Kaplan-Meier analysis. RESULTS A total of 4751 patients were included (CTD + PAH: n = 728, mean follow-up of 18.8 months; PAH: n = 4023, mean follow-up of 19.6 months). For both cohorts, the most common first treatment regimens were sildenafil (CTD + PAH: 38.7%; PAH: 51.5%), tadalafil (10.0%; 9.4%), and macitentan (8.1%; 5.4%) monotherapy; these were also the most frequent agents included in any of the first 3 treatment regimens. Combination therapy was more frequent in the CTD + PAH versus PAH cohort (any regimen: 40.9% vs. 27.2%; 1st treatment regimen: 26.9% vs. 18.5%; 2nd: 52.8% vs. 42.0%; 3rd: 55.2% vs. 48.5%). Treatment persistence was similar across cohorts and the first three treatment regimens, with persistence rates ranging from 42.6 to 49.7% at 12 months. CONCLUSIONS Treatment patterns were generally similar between the CTD + PAH and PAH cohorts, although combination therapy was more frequent in the CTD + PAH cohort. Both cohorts may benefit from broader use of all available PAH treatment classes, including combination therapy. Considering the life-threatening nature of PAH, our findings also highlight the need to address the low persistence rates with PAH therapies regardless of etiology.
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Affiliation(s)
| | - Yuen Tsang
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560 USA
| | - Sumeet Panjabi
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560 USA
| | - Vienica Funtanilla
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560 USA
| | - Hayley D. Germack
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560 USA
| | - Marjolaine Gauthier-Loiselle
- Analysis Group, Inc., 1190 Avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC H3B 0M7 Canada
| | - Ameur M. Manceur
- Analysis Group, Inc., 1190 Avenue des Canadiens-de-Montréal, Montreal, QC H3B 0G7 Canada
| | - Martin Cloutier
- Analysis Group, Inc., 1190 Avenue des Canadiens-de-Montréal, Montreal, QC H3B 0G7 Canada
| | - Patrick Lefebvre
- Analysis Group, Inc., 1190 Avenue des Canadiens-de-Montréal, Montreal, QC H3B 0G7 Canada
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Scagliola R, Brunelli C, Balbi M. Pulmonary Arterial Hypertension in the Elderly: Peculiar Features and Challenges for a Proper Phenotyping Approach. J Cardiovasc Dev Dis 2023; 10:401. [PMID: 37754830 PMCID: PMC10531962 DOI: 10.3390/jcdd10090401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
(1) Introduction. Although pulmonary arterial hypertension (PAH) usually affects young people with a low cardiovascular risk profile, progressive epidemiologic changes have been providing a codified phenotype of elderly subjects with PAH and increased risk predictors for left heart disease. We therefore conducted a systematic review to describe the current knowledge and characteristics of elderly individuals with PAH and further insights concerning their prognostic outcomes and therapeutic response. (2) Methods. A search was conducted in PubMed, Embase, and Cochrane Library for publications evaluating the epidemiology, diagnostic work-up, and treatment of PAH in elderly subjects. (3) Among the 74 publications initially retrieved, 16 full-text articles were selected for the present systematic review. Compared to their younger counterparts, elderly individuals with PAH showed greater clinical deterioration, reduced exercise capacity, and worse prognostic outcomes, as well as less response to PAH-targeted therapy and higher rates of PAH drug discontinuation. (4) Conclusions. Demographic changes over time contributed to define a peculiar PAH phenotype in elderly patients, with an increased burden of cardiovascular comorbidities and distinctive features compared to young patients. Further investigations are needed in order to better clarify the nosologic criteria, and management in this subset population.
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Affiliation(s)
- Riccardo Scagliola
- Cardiology Division, Department of Emergency, Cardinal G. Massaia Hospital, 14100 Asti, Italy
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
| | - Claudio Brunelli
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
| | - Manrico Balbi
- Pulmonary Hypertension Outpatient Clinic, Cardiovascular Disease Unit, San Martino Hospital, 16132 Genoa, Italy
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Tsai CY, Shen CW, Lai HL, Chen CY. Adherence and treatment patterns of disease-specific drugs among patients with pulmonary arterial hypertension: A nationwide, new-user cohort study. Front Pharmacol 2023; 13:1030693. [PMID: 36712686 PMCID: PMC9877219 DOI: 10.3389/fphar.2022.1030693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is an incurable pulmonary disease that might result in right heart failure and death. Treatment guidelines recommend upfront or sequential combination therapy for patients with PAH. Recently, several PAH-targeted medications have been approved in Taiwan. This study aimed to investigate treatment patterns and medication adherence in real-world settings. Method: This was a new-user design study on patients treated with PAH-specific medication between 1 January 2014, and 31 December 2019. Data were extracted from the National Health Insurance Research Database. Medication adherence was evaluated by the proportion of days covered (PDC). Adherence was defined as PDC ≥ .8. Statistical analyses were performed to compare the study outcomes. Logistic regression analysis was performed to identify the association between baseline characteristics and adherence. P < .05 indicated statistical significance. Results: A total of 1,900 patients with PAH were identified, and 75.3% of them were females. The mean (standard deviation (SD)) age was 57.2 (17.5) years. Only 23 (1.2%) patients began the initial combination therapy. A total of 148 (7.8%) patients switched their initial treatment to another treatment, and 159 (8.4%) patients had sequential combination therapy. The most common combination therapy was endothelin receptor antagonist (ERA) plus phosphodiesterase-5 inhibitor (PDE5i), mostly macitentan plus sildenafil, for initial or sequential combination. The mean (SD) PDC was .71 (.33), and 1,117 (58.8%) patients were adherent. A significant difference in mean PDC was observed between initial ERA users and PDE5i users (p < .0001). No factor was significantly associated with medication adherence. Conclusion: Patients with PAH mostly initiated sildenafil as monotherapy, and macitentan was added as a sequential combination therapy. The initial ERA and combination groups showed higher medication adherence. Further investigations are needed to identify other factors associated with adherence.
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Affiliation(s)
- Cheng-Yu Tsai
- Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chuan-Wei Shen
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsuan-Lin Lai
- Division of Pharmacy, Zuoying Branch of Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan,*Correspondence: Chung-Yu Chen, ; Hsuan-Lin Lai,
| | - Chung-Yu Chen
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan,Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan,*Correspondence: Chung-Yu Chen, ; Hsuan-Lin Lai,
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