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Goktekin MC, Aksu F, Perilioglu AZ, Akkoc RF. Relationship of Main Pulmonary Artery (Truncus Pulmonalis) Diameter With Hospital Stay and Mortality in Pulmonary Hypertension Patients Admitted to the Emergency Department. Cureus 2023; 15:e47918. [PMID: 38034206 PMCID: PMC10683929 DOI: 10.7759/cureus.47918] [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] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a haemodynamic and pathophysiological disease significantly associated with morbidity and mortality. The increase in pulmonary vascular resistance, high pulmonary artery pressure and wall tension that occurs in PH results in dilatation of the main pulmonary artery (truncus pulmonalis), one of the largest and most important vessels in the body. The aim of this study is to investigate the relationship between the diameter of the truncus pulmonalis and hospitalization, length of hospital stay, and mortality in patients diagnosed with PH. METHODS Demographic characteristics, number of Emergency Department (ED) admissions, post-admission status, treatment, truncus pulmonalis diameter, and mortality were evaluated statistically through the patient files of 115 PH patients who presented to the ED of Fırat University Faculty of Medicine, Elazığ, Türkiye, between January 2022 and December 2022. RESULTS Of the 115 PH patients who came to the ED, 70 (60.8%) were women and 45 (39.2%) were men, with a mean age of 78.77±8.72 years. Fifty-one of these patients were discharged from the ED after treatment, and 64 were hospitalized. The mean length of hospital stay was two (min=0, max=38) days. Thoracic CT scans demonstrated that the mean diameter of the truncus pulmonalis of the patients was 34.874±3.288 mm (35.20±3.6509 mm in women, 34.367±2.5836 mm in men; p₌0.351) and there was no statistically significant relationship with mortality (p=0.496), hospitalization (p=0.806), and length of hospital stay (p=0.416). There was a statistically significant relationship between mortality rate and male gender (p=0.02) and comorbidity (p=0.001). CONCLUSION It was determined that there was no statistically significant relationship between the truncus pulmonalis diameter and gender, comorbidity, hospitalization, length of hospital stay, and mortality in this study in which single-centre one-year admissions of PH, which differ in aetiology, epidemiology, and demographic features were examined. However, among the patient demographics, a significant relationship was determined between gender and the number of comorbidities and mortality.
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Affiliation(s)
- Mehmet Cagrı Goktekin
- Department of Emergency Medicine, Faculty of Medicine, Firat University, Elazığ, TUR
| | - Feyza Aksu
- Department of Anatomy, Faculty of Medicine, Firat University, Elazığ, TUR
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Intensive care unit admission for patients with pulmonary hypertension presenting to U.S. Emergency Departments. Am J Emerg Med 2021; 50:237-241. [PMID: 34403975 DOI: 10.1016/j.ajem.2021.07.029] [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: 06/07/2021] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients seeking emergency care, resulting in high acuity presentations and resource utilization. The objective was to characterize the rate of intensive care unit (ICU) admission for PH among adult patients presenting to the emergency department (ED) along with other important clinical outcomes. METHODS We analyzed data from the State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) from two geographically separated U.S. states (New York and Nebraska). The primary outcome measure was admission to an ICU. Other measures of interest included the hospital admission rate, hospital length of stay (LOS), inpatient mortality, and rate of critical care procedures performed. RESULTS From 2010 to 2014, in a sample of 34 million ED visits, patients with a diagnosis of PH accounted for 0.71% of all ED visits. Of the PH visits, 20.2% were admitted to the ICU, compared to 2.6% of all other visits (P < 0.001), with an aOR of 1.74 (95% CI 1. 72-1.76). The vast majority (94.6%) of PH patients were admitted to the hospital, compared to 20.5% for all other ED visits (P < 0.001). Hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients. With the exception of invasive mechanical ventilation, a significantly higher percentage of patients with PH admitted to the ICU than other patients underwent all critical care procedures evaluated. CONCLUSIONS In this study, patients with PH who sought emergency care in U.S. EDs from 2010 to 2014 were significantly more likely to require ICU admission than all other patients. They were also significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, increased risk of inpatient mortality, and underwent more critical care procedures. These findings indicate the high acuity of PH patients seeking emergency care and demonstrate the need for additional research into this population.
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Pulmonary arterial hypertension in the emergency department: A focus on medication management. Am J Emerg Med 2021; 47:101-108. [PMID: 33794472 DOI: 10.1016/j.ajem.2021.03.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/24/2021] [Indexed: 01/14/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic progressive incurable condition associated with a high degree of morbidity and mortality. With over five drug classes FDA approved in the last decade, the significant advancements in the pharmacologic management of PAH has improved long-term outcomes. Drug therapies have been developed to directly target the underlying pathogenesis of PAH including phosphodiesterase type-5 inhibitors (PDE-5i), endothelin-receptor antagonists (ERAs), guanylyl-cyclase inhibitors, prostacyclin analogues, and prostacyclin receptor agonists. Although these agents offer remarkable benefits, there are significant challenges with their use such as complexities in medication dosing, administration, and adverse effects. Given these consequences, PAH medications are classified as high-risk, and the transitions of care process to and from the hospital setting are a vulnerable area for medication errors in this population. Thus, it is crucial for the emergency department provider to appropriately identify, manage, and triage these patients through close collaboration with a multidisciplinary team to ensure safe and effective medication management for PAH patients in the acute care setting.
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Showalter K, Ma X, Pinheiro L, Sobol I, Gordon JK, Mehta B. Thirty-day hospital readmission in systemic sclerosis associated pulmonary hypertension: A nationwide study. Semin Arthritis Rheum 2021; 51:324-330. [PMID: 33465591 DOI: 10.1016/j.semarthrit.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/22/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk-factors for 30-day hospital readmission in systemic sclerosis pulmonary hypertension (SSc-PH) and to compare trends and characteristics of 30-day readmissions in SSc-PH versus non-SSc pulmonary arterial hypertension (non-SSc PAH). METHODS In this retrospective study, we identified SSc-PH and non-SSc PAH hospitalizations using ICD-9 codes within the Healthcare Cost and Utilization Project-National Readmission Database. Thirty-day readmission rates were calculated between 2010 and 2015. Characteristics were compared using chi-square, Wilcoxon rank-sum, or two-sample t-tests between (A) SSc-PH patients with versus without readmission and (B) patients with ≥1 readmission with SSc-PH versus non-SSc PAH. Adjusted logistic regression models were generated for readmission in SSc-PH. RESULTS 4,846 of 22,420 (22%) with SSc-PH and 10,573 of 49,254 (21%) with non-SSc PAH had ≥1 30-day readmission. Between 2010-2015, readmission rate decreased in non-SSc PAH (23% to 20%; p<0.001) and was unchanged in SSc-PH (23% to 23%; p = 0.77). In SSc-PH, independent predictors of 30-day readmission include male sex, age <60, Medicare or Medicaid, higher Charlson/Deyo comorbidity index, and congestive heart failure (CHF). A higher proportion of patients with SSc-PH (vs. non-SSc PAH) died during index hospitalizations (p = 0.001) and readmissions (p <0.001). Readmitted patients with SSc-PH (vs. non-SSc PAH) were younger and less often had CHF. In SSc-PH, the most common readmission primary diagnosis was infection, followed by respiratory and heart failure. CONCLUSION In SSc-PH, 30-day readmission is frequent, and in-hospital deaths occur at a higher rate compared to those with non-SSc PAH. This study identifies factors that may characterize those with SSc-PH at highest risk for readmission.
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Affiliation(s)
- Kimberly Showalter
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
| | - Xiaoyue Ma
- Weill Cornell Medicine, Department of Healthcare Policy and Research, 402 East 67th Street, New York, NY 10065, United States.
| | - Laura Pinheiro
- Weill Cornell Medicine, Department of Medicine, Division of General Internal Medicine, 420 East 70th Street, 3rd Floor, New York, NY 10065, United States.
| | - Irina Sobol
- Weill Cornell Medicine, Department of Medicine, Division of Cardiology, 520 East 70th Street, New York, NY 10021, United States.
| | - Jessica K Gordon
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
| | - Bella Mehta
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
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An Introduction to Advanced Lung Disease. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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6
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Patients with pulmonary hypertension presenting to the emergency department. Am J Emerg Med 2020; 38:2313-2317. [DOI: 10.1016/j.ajem.2019.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 11/20/2022] Open
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Simon E, Bridwell RE, Montrief T, Koyfman A, Long B. Evaluation and management of pulmonary hypertension in the emergency department setting. Am J Emerg Med 2020; 38:1237-1244. [DOI: 10.1016/j.ajem.2020.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/17/2022] Open
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Wilcox SR, Faridi MK, Camargo CA. Demographics and Outcomes of Pulmonary Hypertension Patients in United States Emergency Departments. West J Emerg Med 2020; 21:714-721. [PMID: 32421524 PMCID: PMC7234722 DOI: 10.5811/westjem.2020.2.45187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/27/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a common, yet under-diagnosed, contributor to morbidity and mortality. Our objective was to characterize the prevalence of PH among adult patients presenting to United States (US) emergency departments (ED) and to identify demographic patterns and outcomes of PH patients in the ED. METHODS We analyzed the Nationwide Emergency Department Sample (NEDS) database, with a focus on ED patients aged 18 years and older, with any International Classification of Diseases, Clinical Modification (ICD)-9-CM or ICD-10-CM diagnosis code for PH from 2011 to 2015. The primary outcome was inpatient, all-cause mortality. The secondary outcomes were hospital admission rates and hospital length of stay (LOS). RESULTS From 2011 to 2015, in a sample of 121,503,743 ED visits, representing a weighted estimate of 545,500,486 US ED visits, patients with a diagnosis of PH accounted for 0.78% (95% confidence interval [CI], 0.75-0.80%) of all US ED visits. Of the PH visits, 86.9% were admitted to the hospital, compared to 16.3% for all other ED visits (P <0.001). Likewise, hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients (e.g., inpatient mortality 4.5% vs 2.6%, P < 0.001) with an adjusted odds ratio (aOR) of 1.34 (95% CI, 1.31-1.37). Age had the strongest association with mortality, with an aOR of 10.6 for PH patients over 80 years (95% CI, 10.06-11.22), compared to a reference of ages 18 to 30 years. CONCLUSION In this nationally representative sample, presentations by patients with PH were relatively common, accounting for nearly 0.8% of US ED visits. Patients with PH were significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, and increased risk of inpatient mortality.
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Affiliation(s)
- Susan R Wilcox
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - M Kamal Faridi
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Goiter in a Patient with Pulmonary Arterial Hypertension Treated with Epoprostenol. Case Rep Pulmonol 2020; 2020:1617253. [PMID: 32082680 PMCID: PMC6998745 DOI: 10.1155/2020/1617253] [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: 09/22/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022] Open
Abstract
A 35-year-old female with pulmonary arterial hypertension (PAH) who presented with complaints of progressively worsening dysphagia, facial swelling, and shortness of breath, was found to have a large goiter. In patients treated with epoprostenol for long periods of time, thyroid disease is common. Most cases of thyroid disease describe thyrotoxicosis and hyperthyroid statues, but our case was a patient on long term IV epoprostenol presenting with a superior vena cava-syndrome (SVC) like appearance and airway compromise found to have a goiter incidentally during workup.
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Daizadeh I. Pulmonary Arterial Hypertension: A Case Study in FDA Expedited Program Designations. Ther Innov Regul Sci 2019; 53:264-269. [DOI: 10.1177/2168479018778529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pulmonary Arterial Hypertension Emergency Complications and Evaluation: Practical Guide for the Advanced Practice Registered Nurses in the Emergency Department. Adv Emerg Nurs J 2019; 40:246-259. [PMID: 30365438 PMCID: PMC6221388 DOI: 10.1097/tme.0000000000000210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pulmonary hypertension (PH) complicates common diseases and can lead to worsening symptoms and increased mortality. A specific group of PH, pulmonary arterial hypertension (PAH), World Health Organization Group 1, may present to the emergency department (ED). We review common ED presentations of patients with PAH such as cardiac arrest/sudden death, right ventricular failure, syncope, hypoxemic respiratory failure, arrhythmias, hemoptysis, pulmonary embolism, chest pain/left main compression syndrome, infection, and considerations for PAH medication administration. We include a case study to illustrate a real example with a positive outcome, and an algorithm for evaluating and triaging patients with PAH in the ED. The ability to recognize, triage, and communicate changes in PAH disease status in a multidisciplinary team approach between the patient, family, specialty pharmacy, and specialized health care providers such as the PH team, is essential for ED providers who are evaluating and treating patients with PAH.
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Zhao J, Yang M, Wu X, Yang Z, Jia P, Sun Y, Li G, Xie L, Liu B, Liu H. Effects of paclitaxel intervention on pulmonary vascular remodeling in rats with pulmonary hypertension. Exp Ther Med 2019; 17:1163-1170. [PMID: 30679989 PMCID: PMC6327549 DOI: 10.3892/etm.2018.7045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 03/23/2018] [Indexed: 12/18/2022] Open
Abstract
The aim of the present study was to investigate the effects of paclitaxel (PTX), at a non-cytotoxic concentration, on pulmonary vascular remodeling (PVR) in rats with pulmonary hypertension (PAH), and to explore the mechanisms underlying the PTX-mediated reversal of PVR in PAH. A total of 36 rats were divided into control group (n=12), model group (n=12) receiving a subcutaneous injection of monocrotaline (60 mg/kg) in the back on day 7 following left pneumonectomy and PTX group (n=12) with PTX (2 mg/kg) injection via the caudal vein 3 weeks following establishing the model. The degree of PVR among all groups, as well as the expression levels of Ki67, p27Kip1 and cyclin B1, were compared. The mean pulmonary artery pressure, right ventricular hypertrophy index [right ventricle/(left ventricle + septum) ratio] and the thickness of the pulmonary arterial tunica media in the model group were 58.34±2.01 mmHg, 0.64±0.046 and 65.3±3.3%, respectively, which were significantly higher when compared with 23.30±1.14 mmHg, 0.32±0.028 and 16.2±1.3% in the control group, respectively (P<0.01). The mean pulmonary artery pressure, right ventricular hypertrophy index and thickness of the pulmonary arterial tunica media in the PTX group were 42.35±1.53 mmHg, 0.44±0.029 and 40.5±2.6%, respectively, which were significantly lower when compared with the model group (P<0.01). Compared with the control group, the expression levels of Ki67 and cyclin B1 in the model group were significantly increased (P<0.01), while p27Kip1 expression was significantly reduced (P<0.01). Following PTX intervention, the expression levels of Ki67 and cyclin B1 were significantly reduced when compared with the model group (P<0.01), while p27Kip1 expression was significantly increased (P<0.01). The results of the present study suggest that PTX, administered at a non-cytotoxic concentration, may reduce PAH in rats, and prevent the effects of PVR in PAH. These effects of PTX may be associated with increased expression of p27Kip1 and decreased expression of cyclin B1.
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Affiliation(s)
- Jian Zhao
- Department of Pediatric Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Meifang Yang
- School of Nursing, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Xindan Wu
- Department of Pediatrics, Chengdu Women and Children's Central Hospital, Chengdu, Sichuan 610091, P.R. China
| | - Zhangya Yang
- Department of Pediatrics, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, P.R. China
| | - Peng Jia
- Department of Pediatric Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Yuqin Sun
- Department of Pediatric Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Gang Li
- Department of Pediatric Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Liang Xie
- Department of Pediatric Cardiology, West China Second University Hospital, Chengdu, Sichuan 610041, P.R. China
| | - Bin Liu
- Department of Pediatric Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Hanmin Liu
- Department of Pediatric Cardiology, West China Second University Hospital, Chengdu, Sichuan 610041, P.R. China
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Hauck A, Camarda J. Rare Cardiac Emergencies: Aortic Dissection, Pulmonary Hypertensive Crisis, and Pulmonary Embolism. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gillmeyer KR, Lee MM, Link AP, Klings ES, Rinne ST, Wiener RS. Accuracy of Algorithms to Identify Pulmonary Arterial Hypertension in Administrative Data: A Systematic Review. Chest 2018; 155:680-688. [PMID: 30471268 DOI: 10.1016/j.chest.2018.11.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/14/2018] [Accepted: 11/05/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The diagnosis of pulmonary arterial hypertension (PAH) is challenging, and there is significant overlap with the more heterogenous diagnosis of pulmonary hypertension (PH). Clinical and research efforts that rely on administrative data are limited by current coding systems that do not adequately reflect the clinical classification scheme. The aim of this systematic review is to investigate current algorithms to detect PAH using administrative data and to appraise the diagnostic accuracy of these algorithms against a reference standard. METHODS We conducted comprehensive searches of Medline, Embase, and Web of Science from their inception. We included English-language articles that applied an algorithm to an administrative or electronic health record database to identify PAH in adults. RESULTS Of 2,669 unique citations identified, 32 studies met all inclusion criteria. Only four of these studies validated their algorithm against a reference standard. Algorithms varied widely, ranging from single International Classification of Diseases (ICD) codes to combinations of visit, procedure, and pharmacy codes. ICD codes alone performed poorly, with positive predictive values ranging from 3.3% to 66.7%. The addition of PAH-specific therapy and diagnostic procedures to the algorithm improved the diagnostic accuracy. CONCLUSIONS Algorithms to identify PAH in administrative databases vary widely, and few are validated. The sole use of ICD codes performs poorly, potentially leading to biased results. ICD codes should be revised to better discriminate between PH groups, and universally accepted algorithms need to be developed and validated to capture PAH in administrative data, better informing research and clinical efforts.
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Affiliation(s)
- Kari R Gillmeyer
- The Pulmonary Center, Boston University School of Medicine, Boston, MA.
| | - Ming-Ming Lee
- The Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - Alissa P Link
- Alumni Medical Library, Boston University School of Medicine, Boston, MA
| | | | - Seppo T Rinne
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA
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Ivarsson B, Rådegran G, Hesselstrand R, Kjellström B. Coping, social support and information in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension: A 2-year retrospective cohort study. SAGE Open Med 2018; 6:2050312117749159. [PMID: 29326818 PMCID: PMC5758958 DOI: 10.1177/2050312117749159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives: Pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension are severe diseases with complicated treatment that need care at specialist clinics. The aim was to investigate changes in the patients’ perceptions on coping, social support and received information when attending a newly started nurse-coordinated pulmonary arterial hypertension-outpatient clinic. Methods: The present study was a descriptive, questionnaire-based cohort study including 42 adult patients. To evaluate coping, the Pearlin Mastery Scale was used. Social support, information and health-related quality of life were measured using Social Network and Support Scale, QLQ-INFO25 and the EQ-5D. Results: Attending the pulmonary arterial hypertension-outpatient clinic increased coping ability (Mastery Scale) significantly (baseline 16.0 ± 3.3 points vs 2-year follow-up 19.6 ± 5.2 points, p < 0.001) while there was no difference in social network and support or in perception of received information after. Patients who improved their coping ability (67%) were younger, had better exercise capacity, experienced better health-related quality of life and were more satisfied with received information about treatment and medical tests than those who reduced the coping ability. There was no difference in gender, diagnosis, time since diagnose, pulmonary arterial hypertension–specific treatment, education level or civil status between the two groups. Conclusion: This study suggests that the pulmonary arterial hypertension-team, in partnership with the patient, can support patients to take control of their disease and increase their health-related quality of life.
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Affiliation(s)
- Bodil Ivarsson
- Division of Cardiothoracic Surgery, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.,Medicine Services University Trust, Region Skåne, Lund, Sweden
| | - Göran Rådegran
- Section for Heart Failure and Valvular Disease, Division of Cardiology, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Roger Hesselstrand
- Rheumatology, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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Russell FM, Kline JA, Lahm T. High rate of isolated right ventricular dysfunction in patients with non-significant CT pulmonary angiography. Am J Emerg Med 2017; 36:281-284. [PMID: 29050845 DOI: 10.1016/j.ajem.2017.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/22/2017] [Accepted: 10/08/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction and pulmonary hypertension (PH) are commonly unrecognized in the emergency department (ED), but are associated with poor outcomes. Prior research has found a 30% prevalence of isolated RV dysfunction in ED patients after non-significant computed tomographic pulmonary angiography (CTPA). We aimed to prospectively define the prevalence of RV dysfunction and/or PH in short of breath ED patients, and assess outcomes. METHODS Prospective observational study of patients with a non-significant CTPA. Isolated RV dysfunction and/or PH was defined as normal left ventricular function plus RV dilation, moderate to severe tricuspid regurgitation or RV systolic pressure>40mmHg on comprehensive echocardiography. RESULTS Of 83 patients, 20 (24%, 95% [confidence interval] CI: 16-34%) had isolated RV dysfunction and/or PH. These patients had 40% ED recidivism and 30% hospital readmission at 30-days. When compared to patients with normal echocardiographic function, they had significantly longer intensive care unit and hospital length of stays. CONCLUSIONS In a prospective cohort of ED patients, we found a high prevalence of isolated RV dysfunction and/or PH after a non-significant CTPA. These patients had high rates of recidivism and hospital readmission. This data supports a continued need for ED based screening and specialty referral.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, United States.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, United States.
| | - Timothy Lahm
- Department of Internal Medicine, Division of Pulmonology, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, United States.
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Allison JD, Macedo FY, Hamzeh IR, Birnbaum Y. Correlation of right atrial enlargement on ECG to right atrial volume by echocardiography in patients with pulmonary hypertension. J Electrocardiol 2017; 50:555-560. [PMID: 28511781 DOI: 10.1016/j.jelectrocard.2017.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Indexed: 12/01/2022]
Abstract
Previous attempts to validate ECG criteria for right atrial (RA) enlargement (RAE) have been limited by sample sizes and lack of accepted standards for measuring RA size. New guidelines have recommended that RA volume (RAV) be used to determine RA size. Since these guidelines were released, no studies have been published that correlate RAE by ECG to RAV using the new standards. We aimed to validate previously proposed ECG criteria for RAE, commonly called P pulmonale, and to establish whether a correlation exists between P wave amplitudes and RAV as determined by echocardiogram in patients from the pulmonary hypertension (PHT) clinic. We identified patients from the PHT clinic that had an echocardiogram and ECG done at most 30days apart. We defined increased P wave amplitude as ≥2mm in lead II and ≥1mm in lead V1. The RA was determined to be enlarged if the RAV index (RAVI) was ≥39mL/m2 for men and ≥33mL/m2 for women. Patients were stratified into four groups: those with P II≥2mm, those with P V1≥1mm, those that met both criteria, and those that met neither. Right atrial volumes were then compared. Sixty-three patients were included in the study (7 men, 56 women). Three men and 36 women had an ECG that met criteria for P pulmonale. Five men and 28 women had an enlarged RA on echocardiogram. Sixty-nine percent of ECGs that met criteria for RAE were associated with increased RAV by echocardiogram. The specificity of each of the ECG criteria for P pulmonale at detecting RAE was 100% for men. The criterion with the highest specificity among women was P II≥2mm AND P V1≥1mm (94%). The least specific criterion for women was P II≥2mm (70%). The sensitivity of each criterion was much lower. The most sensitive criteria for men and women were P V1≥1mm (66.6%) and P II≥2mm (48%), respectively. The correlation of P wave amplitude in leads II and V1 and RAVI was not statistically significant for any of the ECG criteria for P pulmonale. In patients from the PHT clinic, the specificity of P pulmonale for detecting RAE is high, but the sensitivity is relatively low. These results suggest that in PHT, P pulmonale can be used to confirm that the RA is enlarged, but it is not a reliable test for diagnosing RAE.
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Affiliation(s)
- John D Allison
- Department of Medicine, Baylor College of Medicine, Houston, TX.
| | - Francisco Yuri Macedo
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Ihab Rafic Hamzeh
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
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Gallo de Moraes A, Vakil A, Moua T. Patent foramen ovale in idiopathic pulmonary arterial hypertension: Long-term risk and morbidity. Respir Med 2016; 118:53-57. [PMID: 27578471 DOI: 10.1016/j.rmed.2016.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Little is known about the presence of patent foramen ovale in idiopathic pulmonary arterial hypertension. While there is suspected worsening of hypoxemia confounding assessment and management of pulmonary hypertension, as well as possible increased morbidity from paradoxical emboli, there may be theoretical relief of worsening right-sided pressures by the same mechanism of right-to-left shunting. METHODS Retrospective review of consecutive patients diagnosed with idiopathic pulmonary arterial hypertension (WHO Group 1) via right heart catheterization, from 1998 to 2010. All patients also underwent a four chamber transthoracic echocardiogram with agitated saline contrast for the evaluation of patent foramen ovale. Primary clinical data was collected and compared between patients with and without patent foramen ovale along with univariable and multivariable predictors of long term survival. RESULTS One hundred and fifty five patients were included in the study, 42 with patent foramen ovale (27%). Patients with patent foramen ovale were younger at pulmonary arterial hypertension diagnosis and trended towards higher right ventricular systolic pressures on echocardiography and mean pulmonary arterial pressures by right heart catheterization. Predictors of mortality included age, diffusing capacity for carbon monoxide, and severe hypoxemia. Only diffusing capacity and age were predictive of mortality after adjustment for a priori covariables. CONCLUSION Patent foramen ovale is seen in a quarter of patients with idiopathic pulmonary arterial hypertension and associated with increased prevalence of severe hypoxemia but had no effect on long term survival.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abhay Vakil
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Teng Moua
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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Voelkel NF, Tamosiuniene R, Nicolls MR. Challenges and opportunities in treating inflammation associated with pulmonary hypertension. Expert Rev Cardiovasc Ther 2016; 14:939-51. [PMID: 27096622 DOI: 10.1080/14779072.2016.1180976] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Inflammatory cells are present in the lungs from patients with many, if not all, forms of severe pulmonary hypertension. AREAS COVERED Historically the first inflammatory cell identified in the pulmonary vascular lesions was the mast cell. T and B lymphocytes, as well as macrophages, are present in and around the pulmonary arterioles and many patients have elevated blood levels of interleukin 1 and 6; some patients show elevated levels of leukotriene B4. An overlap between collagen-vascular disease-associated pulmonary arterial hypertension (PAH) and idiopathic PAH exists, yet only a few studies have been designed that evaluate the effect of anti-inflammatory treatments. Here we review the pertinent data that connect PAH and inflammation/autoimmune dysregulation and evaluate experimental models of severe PAH with an emphasis on the Sugen/athymic rat model of severe PAH. Expert commentary: We postulate that there are several inflammatory phenotypes and predict that there will be several anti-inflammatory treatment strategies for severe PAH.
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Affiliation(s)
- Norbert F Voelkel
- a School of Pharmacy , Virginia Commonwealth University , Richmond , VA , USA
| | - Rasa Tamosiuniene
- b Pulmonary and Critical Care Medicine Division , Stanford University , Palo Alto , CA , USA
| | - Mark R Nicolls
- b Pulmonary and Critical Care Medicine Division , Stanford University , Palo Alto , CA , USA
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Pulmonary Hypertension and Right Ventricular Failure in Emergency Medicine. Ann Emerg Med 2015; 66:619-28. [PMID: 26342901 DOI: 10.1016/j.annemergmed.2015.07.525] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/08/2015] [Accepted: 07/15/2015] [Indexed: 01/19/2023]
Abstract
Pulmonary hypertension is a hemodynamic condition, defined as a mean pulmonary artery pressure by right-sided heart catheterization of at least 25 mm Hg at rest. It is classified into 5 general groups based on the underlying cause, with left ventricular failure and chronic obstructive pulmonary disease being 2 of the most common causes in the United States. Although the specifics of the pathophysiology will vary with the cause, appreciating the risks of pulmonary hypertension and right ventricular failure is critical to appropriately evaluating and resuscitating pulmonary hypertension patients in the emergency department (ED). Patients may present to the ED with complaints related to pulmonary hypertension or unrelated ones, but this condition will affect all aspects of care. Exertional dyspnea is the most common symptom attributable to pulmonary hypertension, but the latter should be considered in any ED patient with unexplained dyspnea on exertion, syncope, or signs of right ventricular dysfunction. Patients with right ventricular failure are often volume overloaded, and careful volume management is imperative, especially in the setting of hypotension. Vasopressors and inotropes, rather than fluid boluses, are often required in shock to augment cardiac output and reduce the risk of exacerbating right ventricular ischemia. Intubation should be avoided if possible, although hypoxemia and hypercapnia may also worsen right-sided heart function. Emergency physicians should appreciate the role of pulmonary vasodilators in the treatment of pulmonary arterial hypertension and recognize that patients receiving these medications may rapidly develop right ventricular failure and even death without these therapies. Patients may require interventions not readily available in the ED, such as a pulmonary artery catheter, inhaled pulmonary vasodilators, and mechanical support with a right ventricular assist device or extracorporeal membrane oxygenation. Therefore, early consultation with a pulmonary hypertension specialist and transfer to a tertiary care center with invasive monitoring and mechanical support capabilities is advised.
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