1
|
Lokhorst C, van der Werf S, Berger RMF, Douwes JM. Prognostic Value of Serial Risk Stratification in Adult and Pediatric Pulmonary Arterial Hypertension: A Systematic Review. J Am Heart Assoc 2024; 13:e034151. [PMID: 38904230 DOI: 10.1161/jaha.123.034151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/10/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND In pulmonary arterial hypertension, it is recommended to base therapeutic decisions on risk stratification. This systematic review aims to report the prognostic value of serial risk stratification in adult and pediatric pulmonary arterial hypertension and to explore the usability of serial risk stratification as treatment target. METHODS AND RESULTS Electronic databases PubMed, Embase, and Web of Science were searched up to January 30, 2023, using terms associated with pulmonary arterial hypertension, pediatric pulmonary hypertension, and risk stratification. Observational studies and clinical trials describing risk stratification at both baseline and follow-up were included. Sixty five studies were eligible for inclusion, including only 2 studies in a pediatric population. C-statistic range at baseline was 0.31 to 0.77 and improved to 0.30 to 0.91 at follow-up. In 53% of patients, risk status changed (42% improved, 12% worsened) over 168 days (interquartile range, 137-327 days; n=22 studies). The average proportion of low-risk patients increased from 18% at baseline to 36% at a median follow-up of 244 days (interquartile range, 140-365 days; n=40 studies). In placebo-controlled drug studies, risk statuses of the intervention groups improved more and worsened less compared with the placebo groups. Furthermore, a low-risk status, but also an improved risk status, at follow-up was associated with a better outcome. Similar results were found in the 2 pediatric studies. CONCLUSIONS Follow-up risk stratification has improved prognostic value compared with baseline risk stratification, and change in risk status between baseline and follow-up corresponded to a change in survival. These data support the use of serial risk stratification as treatment target in pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Chantal Lokhorst
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital University Medical Center Groningen, University of Groningen the Netherlands
| | - Sjoukje van der Werf
- Central Medical Library University Medical Center Groningen, University of Groningen the Netherlands
| | - Rolf M F Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital University Medical Center Groningen, University of Groningen the Netherlands
| | - Johannes M Douwes
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital University Medical Center Groningen, University of Groningen the Netherlands
| |
Collapse
|
2
|
Sahay S, Villasmil Hernandez N, Wang F, Wooten M, Nguyen DT, Fauvel C, Benza R, Graviss EA. Comparison Between REVEAL Lite 2 and COMPERA 2.0 for Risk Stratification in Pulmonary Arterial Hypertension. Chest 2024:S0012-3692(24)00288-5. [PMID: 38447640 DOI: 10.1016/j.chest.2024.02.052] [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: 10/09/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Risk stratification is the cornerstone of the management of pulmonary arterial hypertension (PAH). Current European Society of Cardiology/European Respiratory Society guidelines recommend using the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) three-strata risk model at baseline and the COMPERA 2.0 four-strata model at follow-up. However, the guidelines did not take into consideration other available risk scores such as the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) Lite 2. RESEARCH QUESTION Is REVEAL Lite 2 better at discriminating risk than the COMPERA risk assessment models at baseline or follow-up evaluations? STUDY DESIGN AND METHODS This study analyzed data from patients with PAH consecutively enrolled between June 2011 and February 2022 in the PAH registry at our expert Pulmonary Hypertension Center. Patients were stratified according to REVEAL Lite 2 and COMPERA three- and four-strata risk scores at baseline and follow-up to predict the composite outcome for lung transplantation or death. Receiver-operating characteristic curves in predicting the binary outcome at 3, 5, and 7 years were plotted. Areas under the curve of the scores were compared by using the χ2 test. The performance of the scores was determined according to the Harrel C statistic. RESULTS A total of 296 patients were included for baseline and 196 for follow-up evaluation. The overall transplant-free survival in the patient population at 1, 3, 5, and 7 years was 93.6%, 81.3%, 75.1%, and 68.8%, respectively. At baseline, the C statistic of REVEAL Lite 2 was 0.74 (95% CI, 0.69-0.80), compared with 0.68 (95% CI, 0.63-0.74) for the COMPERA four-strata model and 0.63 (95% CI, 0.58-0.69) for the COMPERA three-strata model. All C statistic differences between REVEAL Lite 2 and the other models were statistically significant at baseline. INTERPRETATION Our analysis showed that REVEAL Lite 2 was better at baseline at discriminating risk in this patient population. Future guidelines should consider including REVEAL Lite 2 in the management algorithm to help clinicians make informed decisions. Further analysis in larger cohorts could help validate these findings.
Collapse
Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep Medicine, Houston Methodist Hospital, Houston, TX.
| | | | | | | | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Raymond Benza
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Medicine Research Institute, Houston, TX
| |
Collapse
|
3
|
Sahay S. Counterpoint: Should the Use of Upfront Triple Combination Therapy Be Standard of Care in Pulmonary Arterial Hypertension? No. Chest 2024; 165:494-496. [PMID: 38461012 DOI: 10.1016/j.chest.2023.07.4229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep Medicine, Houston Methodist Hospital, Houston, TX.
| |
Collapse
|
4
|
Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
Collapse
Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| |
Collapse
|
5
|
Majeed RW, Wilkins MR, Howard L, Hassoun PM, Anthi A, Cajigas HR, Cannon J, Chan SY, Damonte V, Elwing J, Förster K, Frantz R, Ghio S, Al Ghouleh I, Hilgendorff A, Jose A, Juaneda E, Kiely DG, Lawrie A, Orfanos SE, Pepe A, Pepke‐Zaba J, Sirenko Y, Swett AJ, Torbas O, Zamanian RT, Marquardt K, Michel‐Backofen A, Antoine T, Wilhelm J, Barwick S, Krieb P, Fuenderich M, Fischer P, Gall H, Ghofrani H, Grimminger F, Tello K, Richter MJ, Seeger W. Pulmonary Vascular Research Institute GoDeep: A meta-registry merging deep phenotyping datafrom international PH reference centers. Pulm Circ 2022; 12:e12123. [PMID: 36034404 PMCID: PMC9399782 DOI: 10.1002/pul2.12123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 11/08/2022] Open
Abstract
The Pulmonary Vascular Research Institute GoDeep meta-registry is a collaboration of pulmonary hypertension (PH) reference centers across the globe. Merging worldwide PH data in a central meta-registry to allow advanced analysis of the heterogeneity of PH and its groups/subgroups on a worldwide geographical, ethnical, and etiological landscape (ClinTrial. gov NCT05329714). Retrospective and prospective PH patient data (diagnosis based on catheterization; individuals with exclusion of PH are included as a comparator group) are mapped to a common clinical parameter set of more than 350 items, anonymized and electronically exported to a central server. Use and access is decided by the GoDeep steering board, where each center has one vote. As of April 2022, GoDeep comprised 15,742 individuals with 1.9 million data points from eight PH centers. Geographic distribution comprises 3990 enrollees (25%) from America and 11,752 (75%) from Europe. Eighty-nine perecent were diagnosed with PH and 11% were classified as not PH and provided a comparator group. The retrospective observation period is an average of 3.5 years (standard error of the mean 0.04), with 1159 PH patients followed for over 10 years. Pulmonary arterial hypertension represents the largest PH group (42.6%), followed by Group 2 (21.7%), Group 3 (17.3%), Group 4 (15.2%), and Group 5 (3.3%). The age distribution spans several decades, with patients 60 years or older comprising 60%. The majority of patients met an intermediate risk profile upon diagnosis. Data entry from a further six centers is ongoing, and negotiations with >10 centers worldwide have commenced. Using electronic interface-based automated retrospective and prospective data transfer, GoDeep aims to provide in-depth epidemiological and etiological understanding of PH and its various groups/subgroups on a global scale, offering insights for improved management.
Collapse
Affiliation(s)
- Raphael W. Majeed
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute of Medical InformaticsRWTH Aachen UniversityAachenGermany
| | - Martin R. Wilkins
- National Heart and Lung Institute and Imperial CollegeLondon NHS Healthcare TrustLondonUK
| | - Luke Howard
- National Heart and Lung Institute and Imperial CollegeLondon NHS Healthcare TrustLondonUK
| | - Paul M. Hassoun
- Department of MedicineDivision of Pulmonary and Critical Care Medicine, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Anastasia Anthi
- 1st Department of Critical CareNational & Kapodistrian University of Athens Medical School and Pulmonary Hypertension Clinic, Evangelismos General HospitalAthensGreece
| | - Hector R. Cajigas
- Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterNew YorkUSA
| | - John Cannon
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical CampusCambridgeUK
| | - Stephen Y. Chan
- Department of Medicine, Division of Cardiology, Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine InstituteUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Victoria Damonte
- Hospital de Niños, Hospital Privado Universitario, Clinica Universitaria Reina Fabiola and Instituto Oulton‐Catholic, University of CórdobaCórdobaArgentina
| | - Jean Elwing
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Kai Förster
- Ludwig‐Maximilians University of MunichMunchenGermany
| | - Robert Frantz
- Department of CardiologyMayo ClinicRochesterNew YorkUSA
| | | | - Imad Al Ghouleh
- Department of Medicine, Division of Cardiology, Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine InstituteUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | | | - Arun Jose
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ernesto Juaneda
- Hospital de Niños, Hospital Privado Universitario, Clinica Universitaria Reina Fabiola and Instituto Oulton‐Catholic, University of CórdobaCórdobaArgentina
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and University of SheffieldSheffieldUK
| | - Allan Lawrie
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and University of SheffieldSheffieldUK
| | - Stylianos E. Orfanos
- 1st Department of Critical CareNational & Kapodistrian University of Athens Medical School and Pulmonary Hypertension Clinic, Evangelismos General HospitalAthensGreece
| | | | - Joanna Pepke‐Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical CampusCambridgeUK
| | - Yuriy Sirenko
- Department of Symptomatic Hypertension“National Scientific Center ‘The M.D. Strazhesko Institute of Cardiology’” of National Academy of Medical ScienceKyivUkraine
| | - Andrew J. Swett
- Division of Pulmonary, Allergy, and Critical Care, and Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford UniversityStanfordCaliforniaUSA
| | - Olena Torbas
- Department of Symptomatic Hypertension“National Scientific Center ‘The M.D. Strazhesko Institute of Cardiology’” of National Academy of Medical ScienceKyivUkraine
| | - Roham T. Zamanian
- Division of Pulmonary, Allergy, and Critical Care, and Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford UniversityStanfordCaliforniaUSA
| | - Kurt Marquardt
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Achim Michel‐Backofen
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Tobiah Antoine
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Jochen Wilhelm
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | | | - Phillipp Krieb
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Meike Fuenderich
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Patrick Fischer
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Henning Gall
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Hossein‐Ardeschir Ghofrani
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Friedrich Grimminger
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Khodr Tello
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Manuel J. Richter
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Werner Seeger
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| |
Collapse
|
6
|
Vicenzi M, Caravita S, Rota I, Casella R, Deboeck G, Beretta L, Lombi A, Vachiery JL. The added value of right ventricular function normalized for afterload to improve risk stratification of patients with pulmonary arterial hypertension. PLoS One 2022; 17:e0265059. [PMID: 35587927 PMCID: PMC9119555 DOI: 10.1371/journal.pone.0265059] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Risk stratification is central to the management of pulmonary arterial hypertension (PAH). For this purpose, multiparametric tools have been developed, including the ESC/ERS risk score and its simplified versions derived from large database analysis such as the COMPERA and the French Pulmonary Hypertension Network (FPHN) registries. However, the distinction between high and intermediate-risk profiles may be difficult as the latter lacks granularity. In addition, neither COMPERA or FPHN strategies included imaging-derived markers. We thus aimed at investigating whether surrogate echocardiographic markers of right ventricular (RV) to pulmonary artery (PA) coupling could improve risk stratification in patients at intermediate-risk. Material and methods A single-center retrospective analysis including 102 patients with a diagnosis of PAH was performed. COMPERA and FPHN strategies were applied to stratify clinical risk. The univariate linear regression was used to test the influence of the echo-derived parameters qualifying the right heart (right ventricle basal diameter, right atrial area, and pressure, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion -TAPSE-). Among these, the TAPSE and tricuspid regurgitation velocity ratio (TAPSE/TRV) as well as the TAPSE and systolic pulmonary artery pressure ratio (TAPSE/sPAP) were considered as surrogate of RV-PA coupling. Results TAPSE/TRV and TAPSE/sPAP resulted the more powerful markers of prognosis. Once added to COMPERA, TAPSE/TRV or TAPSE/sPAP significantly dichotomized intermediate-risk group in intermediate-to-low-risk (TAPSE/TRV≥3.74 mm∙nm/s)-1 or TAPSE/sPAP≥0.24 mm/mmHg) and in intermediate-to-high-risk subgroups (TAPSE/TRV<3.74 mm∙(m/s)-1 or TAPSE/sPAP<0.24 mm/mmHg). In the same way, TAPSE/TRV or TAPSE/sPAP was able to select patients at lower risk among those with 2, 1, and 0 low-risk criteria of both invasive and non-invasive FPHN registries. Conclusions Our results suggest that adopting functional-hemodynamic echo-derived parameters may provide a more accurate risk stratification in patients with PAH. In particular, TAPSE/TRV or TAPSE/sPAP improved risk stratification in patients at intermediate-risk, that otherwise would have remained less characterized.
Collapse
Affiliation(s)
- Marco Vicenzi
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
| | - Irene Rota
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Rosa Casella
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gael Deboeck
- Faculty of Motricity Sciences, Department of Physiotherapy, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Lombi
- Department of Health Science, Pulmonology Unit, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| |
Collapse
|