Pulmonary hypertension: the importance of a multidisciplinary approach

Bariatric Surgery and Cardiovascular Disease Risk in Patients with Pulmonary Hypertension: A Propensity Score Matched Analysis of US National Inpatient Sample

PURPOSE

Previous research has suggested the ameliorating effect of bariatric surgery (BaS) on patients with pulmonary hypertension (PH), but there is a lack of data on the effect of bariatric surgery on the odds of cardiovascular diseases in PH patients. The current study aims to evaluate the association of BaS and coronary artery diseases (CAD), heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), cardiac valve diseases, cardiac rhythm disorders, acute pulmonary embolism, and in-hospital mortality in patients with PH.

METHODS

The national inpatient sample (NIS) data from 2016 to 2019 were analyzed by using ICD-10 codes. A propensity score matching in a 3:1 ratio was performed to match the BaS and non-BaS groups.

RESULTS

A total of 3605 patients with a history of BaS and 501419 patients without a history of BaS were included. After propensity matching, BaS was independently associated with a lower CAD hospital admission and a lower rate of in-hospital mortality. On the contrary, BaS was associated with a higher prevalence of atrial fibrillation (AF) and acute pulmonary embolism in patients with PH. HFpEF, HFrEF, other cardiac rhythm disorders, complete heart block, cardiac valve diseases, and ischemic stroke were not significantly different between the two groups in patients with PH.

CONCLUSION

BaS is independently associated with a reduced rate of in-hospital mortality and CAD hospital admission in patients with PH. However, the risk of atrial fibrillation and acute pulmonary embolism was higher in these patients.

In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A 6-Year Population Cohort Study of Over One Million Patients

INTRODUCTION

There is a paucity of data on the influence of sex, race, insurance, pulmonary hypertension-related complications, and cirrhosis-related complications on mortality, hospital length of stay (LOS), and total hospital charges. The aim of this study was to identify risk factors in a national population cohort (in the USA) admitted to hospital between 2012 and 2017.

METHODS

All patients aged > 18 years with pulmonary hypertension and cirrhosis, who had been admitted to hospital between 2012 and 2017, were identified from the US Nationwide Inpatient Sample (NIS), a large publicly available all-payer inpatient care database in the USA. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, average length of hospital stay, and hospital charges, after adjusting for age, gender, race, primary insurance payer status, hospital type and size (number of beds), hospital region, hospital teaching status, and other demographic characteristics.

RESULTS

Our study identified 1,111,594 patients who had been discharged from hospital from 2012 to 2017. Of these patients, 355,455 were admitted with pulmonary hypertension, with 9.8% having cirrhosis as a complication (n = 34,986). The analysis revealed that patients with both pulmonary hypertension and cirrhosis compared to patients with only pulmonary hypertension experience increased mortality, hospital LOS, total hospital charges, and pulmonary hypertension-related and cirrhosis-related complications. Independent positive predictors of mortality were Asian/Pacific Islander race and "other" insurance status (worker's compensation; other US health benefits plans [CHAMPUS/TRICARE, CHAMPVA, Title V]). Independent positive predictors of increased hospital LOS were black race and "other" patients (more than one race/mixed). Independent positive predictors of increased total hospital charges were male gender, Hispanic ethnicity, Asian/Pacific Islander race, and other insurance status. Pulmonary hypertension-related complications (cor pulmonale, pulmonary embolism, hemoptysis, cardiac arrest, atrial fibrillation, ventricular tachycardia) and cirrhosis-related complications (ascites, hepatorenal syndrome, hepatic encephalopathy, variceal bleeding, portal hypertension) were independent positive predictors of mortality, hospital LOS, and total hospital charges.

CONCLUSIONS

Patients with pulmonary hypertension and cirrhosis have increased mortality and hospital utilization compared to patients with only pulmonary hypertension. We identified key drivers for these outcomes. Targeted interventions, such as novel medications, right-to-left shunts, more evaluations for lung transplantation, and reversal of pulmonary vacular remodeling, are needed for the subgroups identified in this study in order to improve outcomes.

Pulmonary Arterial Hypertension: a Pharmacotherapeutic Update

PURPOSE OF REVIEW

Pulmonary arterial hypertension (PAH) leads to progressive increases in pulmonary vascular resistance (PVR), right heart failure, and death if left untreated. This review will summarize and discuss recent updates in the classification and management of patients with PAH.

RECENT FINDINGS

PAH requires careful hemodynamic assessment and is defined by a mean pulmonary artery pressure > 20 mmHg with normal left-sided filling pressures and a PVR ≥ 3 Wood units. Most patients with PAH require targeted pharmacotherapy based on multiparametric risk stratification. Significant improvements in clinical outcome have been realized through the approval of 14 unique pharmacotherapeutic options. The latest clinical recommendations provide the updated hemodynamic definition and clinical classification as well as evidence-based treatment recommendations. An important change is the focus on initial upfront combination therapy for most patients with PAH. Structured follow-up and escalation of treatment for those not achieving low-risk status is paramount.