Performance of the REVEAL pulmonary arterial hypertension prediction model using non-invasive and routinely measured parameters

Prognostic Value of Serial Risk Stratification in Adult and Pediatric Pulmonary Arterial Hypertension: A Systematic Review

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.

Right ventricular diastolic adaptation to pressure overload in different rat strains

Different rat strains are used in various animal models of pulmonary hypertension and right ventricular (RV) failure. No systematic assessment has been made to test differences in RV response to pressure overload between rat strains. We compared RV adaptation to pulmonary trunk banding (PTB) in Wistar (W), Sprague Dawley (SD), and Fischer344 (F) rats by hemodynamic profiling focusing on diastolic function. Age-matched male rat weanlings were randomized to sham surgery (W-sham, n = 5; SD-sham, n = 4; F-sham, n = 4) or PTB (W-PTB, n = 8; SD-PTB, n = 8; F-PTB, n = 8). RV function was evaluated after 5 weeks by echocardiography, cardiac MRI, and invasive pressure-volume measurements. PTB caused RV failure and increased RV systolic pressures four-fold in all three PTB groups compared with sham. W- and SD-PTB had a 2.4-fold increase in RV end-systolic volume index compared with sham, while F-PTB rats were less affected. Diastolic and right atrial impairment were evident by increased RV end-diastolic elastance, filling pressure, and E/e' in PTB rats compared with sham, again F-PTB the least affected. In conclusions, PTB caused RV failure with signs of diastolic dysfunction. Despite a similar increase in RV systolic pressure, F-PTB rats showed less RV dilatation and a more preserved diastolic function compared with W- and SD-PTB.

Unrecognized Pulmonary Hypertension in Non-Cardiac Surgical Patients: At-Risk Populations, Preoperative Evaluation, Intraoperative Management and Postoperative Complications

Pulmonary hypertension is a well-established independent risk factor for perioperative complications after elective non-cardiac surgery. Patients undergoing cardiac surgery are routinely evaluated for the presence of pulmonary hypertension in the preoperative period. Better monitoring in the postoperative critical care setting leads to more efficient management of potential complications. Data among patients with pulmonary hypertension undergoing elective non-cardiac surgery are scant. Moreover, the condition may be unidentified at the time of surgery. Also, monitoring after non-cardiac surgery can be very limited in the PACU setting, as opposed to the critical care setting. All these factors can result in a higher postoperative complication rate and poor outcomes.

Lung Transplantation for Pulmonary Arterial Hypertension: Optimized Referral and Listing Based on an Evolving Disease Concept

Pulmonary hypertension (PH) was once a devastating and fatal disease entity, the outlook of which has been significantly improved by the continued progress of medical treatment algorithms. However, some patients still ultimately fail to achieve an adequate clinical response despite receiving maximal medical treatment. Historically, lung transplantation (LTx) has been the only effective therapeutic option that could lead to satisfactory outcomes and save these advanced patients' lives. However, patients with PH tend to have the highest mortality rates on the transplant waiting list; especially after comprehensive medical treatment, they continue to deteriorate very rapidly, eventually missing optimal transplantation windows. Balancing optimized medical treatment with the appropriate timing of referral and listing has been highly controversial in LTx for patients with PH. The 2021 consensus document for the selection of lung transplant candidates from the International Society for Heart and Lung Transplantation (ISHLT) updated the specific recommendations for the LTx referral and listing time for patients with PH based on objective risk stratification. Herein, we review the evolving PH-related concepts and highlight the optimization of LTx referral and listing for patients with PH, as well as their management on the waiting list.

Diagnosis and management of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature that is characterised by elevated pressures within the pulmonary vascular tree. Recent decades have witnessed a dramatic expansion in our understanding of the pathobiology and the epidemiology of PAH, and improvements in treatment options and outcomes. The prevalence of PAH is estimated to be between 48 and 55 cases per million adults. The definition was recently amended and a diagnosis of PAH now requires evidence of a mean pulmonary artery pressure >20 mmHg, a pulmonary vascular resistance >2 Wood units and a pulmonary artery wedge pressure ≤15 mmHg at right heart catheterisation. Detailed clinical assessment and a number of additional diagnostic tests are required to assign a clinical group. Biochemistry, echocardiography, lung imaging and pulmonary function tests provide valuable information to assist in the assignment of a clinical group. Risk assessment tools have been refined, and these greatly facilitate risk stratification and enhance treatment decisions and prognostication. Current therapies target three therapeutic pathways: the nitric oxide, prostacyclin and endothelin pathways. While lung transplantation remains the only curative intervention for PAH, there are a number of promising therapies under investigation which may further reduce morbidity and improve outcomes. This review describes the epidemiology, pathology and pathobiology of PAH and introduces important concepts regarding the diagnosis and risk stratification of PAH. The management of PAH is also discussed, with a special focus on PAH specific therapy and key supportive measures.

Exercise MR-proANP unmasks latent right heart failure in CTEPH

OBJECTIVE

The present study was designed to investigate the dynamics of right atrial pressure (RAP) and mid-regional pro-atrial natriuretic peptide (MR-proANP) during physical exercise in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to determine whether these parameters might serve as a tool to measure exercise-dependent atrial stress as an indicator of right heart failure.

METHODS

This prospective observational cohort study included 100 CTEPH patients who underwent right heart catheterization during physical exercise (eRHC). Blood samples for MR-proANP measurement were taken prior, during, and after eRHC. MR-proANP levels were correlated to RAP levels at rest, at peak exercise (eRAP), and during recovery. RAP at rest ≤7 mmHg was defined as normal and eRAP >15 mmHg as suggestive of right heart failure.

RESULTS

During eRHC mean RAP increased from 6 mmHg (standard deviation, SD 4) to 16 mmHg (SD 7; p < 0.001). MR-proANP levels and dynamics correlated with RAP at rest (r_s = 0.61; p < 0.001) and at peak exercise (r_s = 0.66; p < 0.001). Logistic regression analysis revealed the peak MR-proANP level (B = 0.058; p = 0.004) and the right atrial area (B = 0.389; p < 0.001) to be associated with eRAP dynamics. A peak MR-proANP level ≥139 pmol/L (AUC = 0.81) and recovery level ≥159 pmol/L (AUC = 0.82) predicted an eRAP >15 mmHg. Physical exercise unmasked right heart failure in 39% of patients with normal RAP at rest; these patients were also characterized by a more distinct increase in MR-proANP levels (p = 0.005) and higher peak (p < 0.001) and recovery levels (p < 0.001).

CONCLUSIONS

RAP and MR-proANP dynamics unmask manifest and latent right heart failure in CTEPH patients.

The Role of Pulmonary Function Test for Pulmonary Arterial Hypertension in Patients with Connective Tissue Disease

Objective: The study aimed to investigate the value of pulmonary function test (PFT) in evaluating and predicting pulmonary arterial hypertension (PAH) in patients with connective tissue disease (CTD). Methods: This was a prospective observational study recruiting patients diagnosed with CTD-PAH. Patients with interstitial lung disease and pulmonary hypertension induced by other causes were not eligible for enrollment. All patients were assessed for PAH every 1–3 months. A patient was considered to have clinical improvement if the grade of risk stratification declined or at least two parameters improved during follow-up, otherwise no improvement. Results: A total of 31 patients with CTD-PAH were recruited in this study. Nearly 70% of patients had declined forced vital capacity (FVC), 60% had declined total lung capacity and maximum expiratory flow at 50% of vital capacity, and 95% had normal or mild decline in forced expiratory volume in 1 second (FEV1)/FVC. A decline in diffusing capacity of the lung for carbon monoxide (DLCO) was present in 96% of patients, and 60% were moderate to severe. Furthermore, 50% of patients had an FVC/DLCO ratio of less than 1.4. Univariate analysis showed that FEV1/FVC, DLCO, and FVC/DLCO were associated with disease prognosis. After adjusting for age as a confounding factor, multivariate logistic regression analysis revealed that DLCO was an independent predictive factor for the prognosis of CTD-PAH. Conclusion: The pulmonary function of patients with CTD-PAH is abnormal in parameters such as lung volume, small airway, and gas exchange. PFT can reveal complex pathophysiological changes in the lungs of CTD-PAH patients and predict prognosis.

Development and validation of prediction models for hypertension risks: A cross-sectional study based on 4,287,407 participants

Objective

To develop an optimal screening model to identify the individuals with a high risk of hypertension in China by comparing tree-based machine learning models, such as classification and regression tree, random forest, adaboost with a decision tree, extreme gradient boosting decision tree, and other machine learning models like an artificial neural network, naive Bayes, and traditional logistic regression models.

Methods

A total of 4,287,407 adults participating in the national physical examination were included in the study. Features were selected using the least absolute shrinkage and selection operator regression. The Borderline synthetic minority over-sampling technique was used for data balance. Non-laboratory and semi-laboratory analyses were carried out in combination with the selected features. The tree-based machine learning models, other machine learning models, and traditional logistic regression models were constructed to identify individuals with hypertension, respectively. Top features selected using the best algorithm and the corresponding variable importance score were visualized.

Results

A total of 24 variables were finally included for analyses after the least absolute shrinkage and selection operator regression model. The sample size of hypertensive patients in the training set was expanded from 689,025 to 2,312,160 using the borderline synthetic minority over-sampling technique algorithm. The extreme gradient boosting decision tree algorithm showed the best results (area under the receiver operating characteristic curve of non-laboratory: 0.893 and area under the receiver operating characteristic curve of semi-laboratory: 0.894). This study found that age, systolic blood pressure, waist circumference, diastolic blood pressure, albumin, drinking frequency, electrocardiogram, ethnicity (uyghur, hui, and other), body mass index, sex (female), exercise frequency, diabetes mellitus, and total bilirubin are important factors reflecting hypertension. Besides, some algorithms included in the semi-laboratory analyses showed less improvement in the predictive performance compared to the non-laboratory analyses.

Conclusion

Using multiple methods, a more significant prediction model can be built, which discovers risk factors and provides new insights into the prediction and prevention of hypertension.

Imaging assessment of the right atrium: anatomy and function

The right atrium (RA) is the cardiac chamber that has been least well studied. Due to recent advances in interventional cardiology, the need for greater understanding of the RA anatomy and physiology has garnered significant attention. In this article, we review how a comprehensive assessment of RA dimensions and function using either echocardiography, cardiac computed tomography, and magnetic resonance imaging may be used as a first step towards a better understanding of RA pathophysiology. The recently published normative data on RA size and function will likely shed light on RA atrial remodelling in atrial fibrillation (AF), which is a complex phenomenon that occurs in both atria but has only been studied in depth in the left atrium. Changes in RA structure and function have prognostic implications in pulmonary hypertension (PH), where the increased right ventricular (RV) afterload first induces RV remodelling, predominantly characterized by hypertrophy. As PH progresses, RV dysfunction and dilatation may begin and eventually lead to RV failure. Thereafter, RV overload and increased RV stiffness may lead to a proportional increase in RA pressure. This manuscript provides an in-depth review of RA anatomy, function, and haemodynamics with particular emphasis on the changes in structure and function that occur in AF, tricuspid regurgitation, and PH.

Non-Invasive Estimation of Right Atrial Pressure Using a Semi-Automated Echocardiographic Tool for Inferior Vena Cava Edge-Tracking

The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability. We propose novel methods, based on semi-automated edge-tracking of IVC size and cardiac collapsibility (cardiac caval index—CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 h in condition of clinical and therapeutic stability (170 patients, age 64 ± 14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea, or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features, selected by backward feature selection and included in a linear model (LM) and a support vector machine (SVM), which were cross-validated. Three RAP classes (low < 5 mmHg, intermediate 5−10 mmHg and high > 10 mmHg) were generated and RHC values used as comparator. LM and SVM showed a higher accuracy than Guidelines (63%, 71%, and 61% for LM, SVM, and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.

Prediction Models and Scores in Pulmonary Hypertension: A Review

BACKGROUND

Pulmonary arterial hypertension (PAH) is a serious disease with increased morbidity and mortality. The need for an individualized patient treatment approach necessitates the use of risk assessment in PAH patients. That may include a range of hemodynamic, clinical, imaging and biochemical parameters derived from clinical studies and registry data.

OBJECTIVE

In the current systematic review, we summarize the available data on risk prognostic models and scores in PAH and we explore the possible concordance amongst different risk stratification tools in PAH.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines aided the performance of this systematic review. Eligible studies were identified through a literature search in the electronic databases PubMed, Science Direct, Google Scholar and Cochrane with the use of various combinations of MeSH and non-MeSH terms, with a focus on PAH.

RESULTS

Overall, 25 studies were included in the systematic review; out of them, 9 were studies deriving prognostic equations and risk scores and 16 were validating studies of an existing score. The majority of risk stratification scores use hemodynamic data for the assessment of prognosis, while others also include clinical and demographic variables in their equations. The risk discrimination in the overall PAH population was adequate, especially in differentiating the low versus high-risk patients, but their discrimination ability in the intermediate groups remained lower. Current ESC/ERS proposed risk stratification score utilizes a limited number of parameters with prognostic significance, whose prognostic ability has been validated in European patient populations.

CONCLUSION

Despite improvement in risk estimation of prognostic tools of the disease, PAH morbidity and mortality remain high, necessitating the need for the risk scores to undergo periodic re-evaluation and refinements to incorporate new data into predictors of disease progression and mortality and, thereby, maintain their clinical utility.

Validation of the REVEAL Prognostic Models in Systemic Lupus Erythematosus-Associated Pulmonary Arterial Hypertension

No previous studies have investigated the predictive performance of the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL) prognostic equation and simplified risk score calculator in patients with systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH). We aimed to validate these prediction tools in an external cohort of patients with SLE-PAH. In this study, the validation cohort consisted of patients with SLE-PAH registered in a prospective, multicenter, nationwide database between November 2006 and May2016. The follow-up of patients was censored at 1 year. Discrimination, calibration, model fit, and risk stratification of the REVEAL prognostic equation and simplified risk score calculator were validated. As a result, a total of 306 patients with SLE-PAH were included. The 1-year overall survival rate was 91.5%. The C-index of the prognostic equation was 0.736, demonstrating reasonably good discrimination, and it was greater than that for the simplified risk score calculator (0.710). The overall calibration slope was 0.83, and the Brier score was 0.079. The risk of renal insufficiency and World Health Organization Functional Class III (WHO FC III) were underestimated, and the risk assigned to a heart rate >92 bpm in the REVEAL prognostic models was not observed in our validation cohort. Both model discrimination and calibration were poor in the very high-risk group. In conclusion, the REVEAL models exhibit good discriminatory ability when predicting 1-year overall survival in patients with SLE-PAH. Findings from both models should be interpreted with caution in cases of renal insufficiency, WHO FC III, and heart rate >92 bpm.

Risk assessment in precapillary pulmonary hypertension: a comparative analysis

Background

Risk stratification is essential to assess mortality risk and guide treatment in patients with precapillary pulmonary hypertension (PH). We herein compared the accuracy of different currently used PH risk stratification tools and evaluated the significance of particular risk parameters.

Methods

We conducted a retrospective longitudinal observational cohort study evaluating seven different risk assessment approaches according to the current PH guidelines. A comprehensive assessment including multi-parametric risk stratification was performed at baseline and 4 yearly follow-up time-points. Multi-step Cox hazard analysis was used to analyse and refine risk prediction.

Results

Various available risk models effectively predicted mortality in patients with precapillary pulmonary hypertension. Right-heart catheter parameters were not essential for risk prediction. Contrary, non-invasive follow-up re-evaluations significantly improved the accuracy of risk estimations. A lack of accuracy of various risk models was found in the intermediate- and high-risk classes. For these patients, an additional evaluation step including assessment of age and right atrium area improved risk prediction significantly.

Discussion

Currently used abbreviated versions of the ESC/ERS risk assessment tool, as well as the REVEAL 2.0 and REVEAL Lite 2 based risk stratification, lack accuracy to predict mortality in intermediate- and high-risk precapillary pulmonary hypertension patients. An expanded non-invasive evaluation improves mortality risk prediction in these individuals.

Prediction of pulmonary hypertension in older adults based on vital capacity and systolic pulmonary artery pressure

Objective

Right heart catheterization (RHC) is associated with a higher procedural risk in older adults, but non-invasive estimation of pulmonary hypertension (PH) is a challenge. We aimed to elaborate a non-invasive prediction model to estimate PH.

Methods and design

We retrospectively analysed 134 older adults (70.0 years ±12.3; 44.9% males) who reported to our clinic with unclear dyspnea between 01/2015 and 01/2020 and had received RHC as a part of their diagnostic workup. Lung function testing, analysis of blood gas samples, 6 min walk distance and echocardiography were performed within 24 hours of RHC.

Main outcome measures

In a stepwise statistical approach by using an in/exclusion algorithm (using the AIC criterion) we analysed non-invasive parameters to test their value in predicting PH (defined as mean pulmonary artery pressure, PA_mean, >25mmHg). Discrimination capability of the final model was measured by the AUC (area under curve) from an ROC (receiver operating characteristics) analysis.

Results

We yielded a sensitivity of 87.2% and a specificity of 62.5% in a combinatorial logistical model with systolic pulmonary artery pressure (sPAP) and forced vital capacity (VC_max), the discrimination index was 86.7%. The odds ratios for an increase of 10 mmHg of sPAP were 2.99 (2.08–4.65) and 1.86 (1.11–3.21) for a 1 l decrease in VC_max. On their own, VC_max proved to be specific (83.3%), while sPAP was a sensitive (79.1%) predictor for PH.

Conclusions

We provide a combinatorial model to predict PH from sPAP and VC_max in older adults, which may help to avoid invasive procedures.

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings

Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.

Initial combination therapy of ambrisentan and tadalafil in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) in the modified intention-to-treat population of the AMBITION study: post hoc analysis

OBJECTIVES

To evaluate initial combination therapy with ambrisentan plus tadalafil (COMB) compared with monotherapy of either agent (MONO), and the utility of baseline characteristics and risk stratification in predicting outcomes, in patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) and the systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) subpopulation.

METHODS

This post hoc analysis of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) study included patients with CTD-PAH from the modified intention-to-treat population. Time to clinical failure (TtCF) was assessed by baseline characteristics, treatment assignment and risk group (low, intermediate and high) at baseline and week 16. TtCF was compared between groups using Kaplan-Meier curves and Cox proportional hazards regression modelling.

RESULTS

The analysis included 216 patients (COMB, n=117; MONO, n=99). The risk of clinical failure was lower with COMB versus MONO (risk reduction: CTD-PAH 51.7%, SSc-PAH 53.7%), particularly in patients with haemodynamic parameters characteristic of typical PAH without features of left heart disease and/or restrictive lung disease at baseline. The risk of clinical failure was lower with COMB versus MONO in the baseline low-risk group (HR not calculated due to no events in COMB), baseline intermediate-risk group (HR 0.519, 95% CI 0.297 to 0.905) and in the week 16 low-risk group (HR 0.069, 95% CI 0.009 to 0.548).

CONCLUSIONS

The benefit of COMB over MONO was demonstrated in patients with CTD-PAH, particularly in those with typical PAH haemodynamic characteristics at baseline. COMB is appropriate for patients categorised as low risk and intermediate risk at baseline and low risk at follow-up.

TRIAL REGISTRATION NUMBER

NCT01178073.

Relationship between right atrium area and right ventricular ejection fraction on magnetic resonance imaging: comparison with other prognostic markers in patients with pulmonary arterial hypertension

Objective:

To compare the right atrium (RA) area and right ventricular ejection fraction (RVEF) with other known prognostic markers in patients with pulmonary arterial hypertension (PAH).

Materials and Methods:

This was a retrospective study of 74 patients diagnosed with PAH by right heart catheterization at a referral center between January 2018 and May 2018. All of the patients underwent cardiac magnetic resonance imaging (MRI) within 3 months of the right heart catheterization (RHC), as well as undergoing echocardiography, a 6-minute walk test, and determination of the level of N-terminal pro-brain natriuretic peptide (NT-proBNP) within a month of the RHC. We attempted to determine whether the cardiac MRI-derived RA area correlated with ions between RVEF and RA area measured by that determined by echocardiography, as well as whether the cardiac MRI-derived RA area and RVEF correlated with the 6-minute walk distance and NT-proBNP level.

Results:

The MRI-derived RA area demonstrated a weak correlation with the pulmonary vascular resistance measured by RHC (r = 0.268; p = 0.055) and a moderate correlation with the NT-proBNP (r = 0.429; p = 0.003). All correlations between clinical characteristics and the RVEF were statistically significant. In the univariate linear analysis, the RVEF showed stronger correlations with the clinical characteristics than did the RA area.

Conclusion:

In patients with PAH, cardiac MRI-derived RVEF appears to correlate more strongly with other prognostic factors than does RA area.

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.

[Risk stratification methods and their significance in pulmonary arterial hypertension]

Despite significant advances in therapy, pulmonary arterial hypertension (PAH) remains a progressive disease with a poor prognosis. Immediately after establishing the diagnosis of PAH, urgent treatment with PAH-specific therapy is required. Due to the progressive nature of the disease, all patients should be closely monitored and their treatment regimen should be promptly changed according to clinical need. Risk stratification is an important method for informing the clinician and the patient about the prognosis of disease and the choice of therapy methods. The REVEAL scale and the ESC/ERS 2015 risk assessment table are important multifactorial tools for making decisions about the prescription and correction of PAH therapy, as well as for assessment of patients' response to therapy. Current guidelines for PAH indicate that the most important task of treatment of PAH is to achieve the low - risk status.

Risk stratification and medical therapy of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) remains a severe clinical condition despite the availability over the past 15 years of multiple drugs interfering with the endothelin, nitric oxide and prostacyclin pathways. The recent progress observed in medical therapy of PAH is not, therefore, related to the discovery of new pathways, but to the development of new strategies for combination therapy and on escalation of treatments based on systematic assessment of clinical response. The current treatment strategy is based on the severity of the newly diagnosed PAH patient as assessed by a multiparametric risk stratification approach. Clinical, exercise, right ventricular function and haemodynamic parameters are combined to define a low-, intermediate- or high-risk status according to the expected 1-year mortality. The current treatment algorithm provides the most appropriate initial strategy, including monotherapy, or double or triple combination therapy. Further treatment escalation is required in case low-risk status is not achieved in planned follow-up assessments. Lung transplantation may be required in most advanced cases on maximal medical therapy.

Right atrial function in patients with pulmonary hypertension: A study with two-dimensional speckle-tracking echocardiography

BACKGROUND

The role of right atrial (RA) dysfunction in patients with pulmonary hypertension (PH), as evaluated by two-dimensional speckle-tracking echocardiography (2D-STE) remains to be determined.

METHODS

Sixty consecutive PH patients and 30 healthy volunteers were included. RA function was evaluated by 2D-STE, and the following parameters were recorded: an average longitudinal strain (LS) curve that included LSpos during RA filling and LSneg representing RA active contraction (their summation is LStot), the phasic RA volumes, total RA emptying fraction, and the ratio of RA passive and active emptying to total emptying. The associations between these indices and the results of invasive pulmonary hemodynamics, cardiac structure and function, and NT-terminal pro brain natriuretic peptide (NT-proBNP) level were evaluated.

RESULTS

LStot, total RA emptying fraction, LSpos, passive RA emptying fraction were significantly lower, while the contribution of active RA empting fraction/total RA emptying fraction was higher in PH patients than in controls. Among PH patients, LStot was negatively correlated with greater RA size, RA pressure, and pulmonary vascular resistance, but not pulmonary artery pressure, while LStot was also negatively associated with right ventricular enlargement and higher NT-proBNP. In receiver-operator characteristic analysis, RA LStot was of optimal accuracy for prediction of WHO-function class ≥III in PH patients.

CONCLUSIONS

PH was associated with impaired reservoir and conduit function, but enhanced active contract function of RA, while RA LStot confers an optimal predictive effect of poor WHO-function class in PH patients.

Pulse Wave Cycle Features Analysis of Different Blood Pressure Grades in the Elderly

Background and Objective

The same range of blood pressure values may reflect different vascular functions, especially in the elderly. Therefore, a single blood pressure value may not comprehensively reveal cardiovascular function. This study focused on identifying pulse wave features in the elderly that can be used to show functional differences when blood pressure values are in the same range.

Methods

First, pulse data were preprocessed and pulse cycles were segmented. Second, time domain, higher-order statistics, and energy features of wavelet packet decomposition coefficients were extracted. Finally, useful pulse wave features were evaluated using a feature selection and classifier design.

Results

A total of 6,075 pulse wave cycles were grouped into 3 types according to different blood pressure levels and each group was divided into 2 categories according to a history of hypertension. The classification accuracy of feature selection in the 3 groups was 97.91%, 95.24%, and 92.28%, respectively.

Conclusion

Selected features could be appropriately used to analyze cardiovascular function in the elderly and can serve as the basis for research on a cardiovascular risk assessment model based on Traditional Chinese Medicine pulse diagnosis.

Maximal systolic excursion of the tricuspid annulus is independent of right atrial size and function in chronic pulmonary hypertension

BACKGROUND

Even though the tricuspid annulus (TA) is anatomically and functionally related to right atrioventricular dependence and tricuspid annular plane systolic excursion (TAPSE) is a well-known measure of right ventricular (RV) systolic function, there is paucity of data regarding the potential impact that right atrial (RA) size and function have on TAPSE. Hence, we sought to determine whether RA volumetric and longitudinal measures affect TAPSE in patients with chronic pulmonary hypertension (cPH).

METHODS

In this retrospective study, echocardiographic data from 110 patients were reviewed and the studied population was divided into Group I consisting of 50 patients (50±11 years) without PH and Group II that included 60 patients (55±14 years) with cPH.

RESULTS

Even though RA areas, RA fractional area change, and maximal long-axis length measurements were abnormal in cPH patients, TA tissue Doppler imaging systolic velocity and RV fractional area change were the only useful variables in identifying patients with abnormal TAPSE (P<.0001 and P=.018, respectively). Additionally, TAPSE was independent of all RA measures, left ventricular ejection fraction, and age (P>.05).

CONCLUSIONS

Based on these results, TAPSE does not appear to be influenced by either RA size or function. Additional studies using strain echocardiography to interrogate RA mechanics might now be very useful to advance our understanding of TA motion in cPH patients given recent data showing that RA function accounts for a significantly greater proportion of total right heart function in patients with cPH than in normal subjects.

Right Atrial Function in Pulmonary Arterial Hypertension

BACKGROUND

Elevated right atrial (RA) pressure is an established prognostic measure in pulmonary arterial hypertension (PAH). However, little is known about perturbations in RA function in PAH.

METHODS AND RESULTS

Reservoir (RA longitudinal strain [RA LS]), conduit (RA early LS rate), and active (RA late LS rate) phases were assessed by 2D speckle tracking in 65 patients with PAH, 6-minute walk distance ≤450 m, and a pulmonary vascular resistance >800 dynes·s/cm(5), despite therapy with at least 2 PAH-specific medications enrolled in the Imatinib in Pulmonary Arterial Hypertension, a Randomized Efficacy Study (IMPRES) trial and were compared with 30 healthy controls of similar age and sex. We studied the association of RA functional measures with invasive pulmonary hemodynamics, cardiac structure and function, and N-terminal pro brain natriuretic peptide. RA LS and early LS rate were reduced in PAH patients compared with controls (27.1±11.6 versus 56.9±12.7, adjusted P<0.001 and -0.6±0.5 versus -1.5±0.5, adjusted P<0.001, respectively) even after adjusting for RA area and invasive RA pressure, whereas RA late LS rate was similar between groups (-1.4±0.7 versus -1.5±0.4, P=0.42). Among PAH patients, worse RA LS correlated with greater RA size (r=-0.50, P<0.0001) and pressure (r=-0.37, P=0.002), but not pulmonary artery pressure (r=-0.07, P=0.58). Worse RA LS was also associated with right ventricular enlargement and dysfunction and higher N-terminal pro brain natriuretic peptide independent of RA size and pressure.

CONCLUSIONS

RA reservoir and passive conduit functions are impaired in PAH, independent of RA size and pressure, and likely reflect right ventricular failure and overload.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00902174.