The experiences of patients with pulmonary arterial hypertension receiving continuous intravenous infusion of epoprostenol (Flolan) and their support persons

The Role of Palliative Care in Cardiovascular Disease

The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.

Can self-compassion help us better understand the impact of pulmonary hypertension on those with the condition and their carers? A cross-sectional analysis

Pulmonary hypertension (PH) can have a multifaced impact both on the affected individual and close family members. However there are relatively few studies that have sought to identify potential protective factors. Individual differences in ability to be self-compassionate are known to be implicated in adjustment in other long-term conditions and are now featuring in the provision of care for a number of conditions. This is a cross-sectional study that investigated the relationship between self-compassion, demographic, PH-related information, and measures of psychosocial functioning in adults with PH (n = 65) and caregivers (n = 29). Individuals with PH and caregivers of someone with PH completed self-report measures on demographic and clinical factors, anxiety, depression, self-compassion, and in those with PH, health-related quality of life, and in carers, caregiver burden. Data were analyzed using hierarchical regression analyses. Surprisingly, participants with PH and caregivers did not significantly differ on rates of depression (p = 0.19) or anxiety (p = 0.57) with both scoring relatively high. Components of self-compassion were associated with psychological functioning in both individuals and caregivers. Greater self-compassion was associated with fewer symptoms of anxiety and depression, and greater health-related quality of life in individuals with PH and lower burden in caregivers. More specifically, multiple regression analyses revealed after controlling for age, gender, and duration of PH, self-compassion was a significant predictor of anxiety and depression in people with PH, and of anxiety and caregiver burden in carers. These findings add to the evidence base indicating that there can be a range of burdens experienced by both people living with PH and their wider families. Further, this study uniquely suggests that psychological and supportive interventions that seek to build self-compassion may be useful to develop and test in this clinical group.

Comparison of Healthcare Encounters and Drug Persistence in Patients With Pulmonary Arterial Hypertension Receiving Oral Selexipag, Inhaled Iloprost, or Parenteral Treprostinil: A Retrospective Database Analysis

Background: Agents targeting the prostacyclin (PGI2) pathway are important in managing pulmonary arterial hypertension (PAH). No head-to-head clinical trials have compared outcomes between the 3 different PGI2-pathway drugs most commonly available in countries with advanced healthcare: oral selexipag, inhaled iloprost, and parenteral (subcutaneous or intravenous) treprostinil. Objectives: To conduct retrospective database analyses to describe characteristics of patients with PAH initiating therapy with these agents and compare the rate and risk of healthcare facility encounters and drug persistence. Methods: Data were obtained from the Optum™ Clinformatics® Data Mart and Truven™ Health Analytics® MarketScan® Commercial Claims and Encounters databases from July 1, 2008, to September 30, 2020 (Optum™), or October 31, 2020 (Truven™). Patients were categorized into index-drug cohorts based on first pharmacy claims for selexipag, inhaled iloprost, or parenteral treprostinil. Eligible patients were ≥18 years of age with ≥1 ICD-9-CM or ICD-10-CM diagnosis code indicating pulmonary hypertension and no diagnosis code suggesting Group 3-5 pulmonary hypertension. Rates of hospitalization (inpatient admissions), emergency room visits, or outpatient visits per person-year were calculated. Drug persistence was measured as time to discontinuation of index drug. Multivariable analyses were performed to compare outcomes with selexipag vs inhaled iloprost and parenteral treprostinil, adjusting for baseline characteristics using inverse probability of treatment weighting. Results: Overall, 583 patients were included in the Optum™ sample and 482 in the Truven™ sample. Mean (SD) age was 61.7 (14.5) and 49.3 (11.3) years, respectively; 74.4% and 75.7% of patients, respectively, were women. In the pooled samples, after adjustment for baseline characteristics, selexipag had a lower risk than inhaled iloprost or parenteral treprostinil for hospitalization (relative rate ratio [95% CI], 0.40 [0.22, 0.75], and 0.26 [0.17, 0.39]) and outpatient visits (0.66 [0.56, 0.78] and 0.76 [0.66, 0.88]). Trends toward lower risk of emergency room visits did not attain statistical significance. Drug discontinuation risk was 16% and 36% lower with selexipag vs parenteral treprostinil and inhaled iloprost, respectively. Conclusions: In real-world use, selexipag appears to be associated with lower rates of hospitalization and outpatient visits than inhaled iloprost or parenteral treprostinil. Further research is required to identify factors underlying these differences.

Examining the impact of pulmonary hypertension on nonprofessional caregivers: A mixed-methods systematic review

Pulmonary hypertension (PH) is a heterogeneous condition, associated with a high symptom burden and high rates of disability. While nonprofessional caregivers are essential in helping patients live better, little is known about the impact on caregivers and support that is currently available. This review has synthesised evidence examining experiences of caregivers of adults with PH. Web of Science, PubMed, PsycINFO, and Cochrane Library were searched for all types of study design. Articles were evaluated and analysed using a Joanna Briggs Institute approach. Eight articles primarily focussed on pulmonary arterial hypertension and chronic thromboembolic PH were identified investigating 456 caregivers from at least 10 countries. Four categories were identified describing caregiver demographics, responsibilities, impact, and support. Four integrated themes emerged identifying possible unmet needs and therapeutic targets: (1) Change, reflecting the various demands caring had on people as they attempted to balance the needs of the patient and their own; (2) Preparedness, discussing how caregivers could feel uncertain and unskilled for their duties and unsupported; (3) Isolation, with caregivers often encountering challenges to gaining information on PH turning to PH organisations and others affected for support and connection; and (4) Physical and mental demands, reflecting the multifaceted impact of caring. Findings add to the evidence demonstrating that PH can have a considerable impact on patients' support network. Providing support for caregivers of people with PH is an unmet need and may have a positive impact on patients and is an area that requires further research.

Health-related quality of life and disease progression in pulmonary arterial hypertension patients: a 3-year study

Objectives

The role of health-related quality of life (HRQoL) and psychological variables in pulmonary arterial hypertension (PAH) progression remains poorly quantified. We aimed to investigate the relationship between disease progression in PAH patients and HRQoL and psychological characteristics.

Methods

A 3-year longitudinal cohort was initiated. Patients with stable PAH (groups I-IV ineligible for angioplasty/endarterectomy) were included (n=55). Standard clinical variables, including invasive haemodynamic parameters, were prospectively recorded. A battery of questionnaires was used to characterise the psychological status of patients upon study initiation, and HRQoL was quantified using the SF-36 Questionnaire every 3 months for 24 months, and then again at 36 months. Guideline-defined disease progression and progression-free survival were recorded for 36 months.

Measurements and main results

Psychological distress was highly prevalent at baseline. The Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the HRQoL were poor (PCS=37.13±8.18; MCS=42.42±10.88) but stable over 3 years of follow-up. Among PCS subscales, Physical Functioning (PF) (p=0.012) was identified as being independently associated with disease progression (Cox survival model), along with mean pulmonary arterial pressure (p=0.003) and cardiac output (p=0.005). Depression was the unique independent psychological characteristic associated with PF (p=0.0001).

Conclusions

PAH patients have poor HRQoL. In addition to already known criteria related to disease severity, the HRQoL PF subscale is independently associated with disease progression in PAH. This may be explained by depression.

Integrated Review of Psychosocial and Behavioral Health Assessments and Interventions in Pulmonary Hypertension

BACKGROUND

The medical management of patients with pulmonary hypertension (PH) has advanced, with few evidence-based recommendations about psychosocial and behavioral health interventions. There is also a lack of comprehensive understanding of PH psychosocial and behavioral health needs. Some psychosocial and behavioral health interventions have been tested; however, there is a gap in the systematic evaluation of nonpharmacological complementary approaches to augment PH management when addressing psychosocial and behavioral health needs.

OBJECTIVES

The objectives are to explore psychosocial and behavioral health needs and describe psychosocial and behavioral health interventions for patients with PH.

METHODS

We conducted an integrative systematic review of publications between January 1, 2010, and January 31, 2020, obtained from electronic databases: EMBASE, PubMed, Cumulative Index of Nursing and Allied Health Literature, Cochrane, PsycINFO, and Web of Science. The literature searches focused on empirical literature reporting psychosocial needs and psychosocial and behavioral health interventions for adult PH patients. We included peer-reviewed studies published in English. Search terms used in the study were: "hypertension," "pulmonary hypertension," "psychosocial," "depression," "anxiety," "quality of life," "behavioral health," "self-management," "psychosocial intervention," and "psychological distress." Excluded were opinion and discussion publications, reviews, non-PH populations, and pediatric articles. We used the constant comparison method to guide the synthesis of reports applying the Joanna Briggs quality assessment guidelines.

RESULTS

A total of 44 articles meeting the criteria were included for final consideration. We conducted an integrative systematic review of 27 quantitative studies, narrative synthesis of 10 qualitative studies, and 7 psychosocial and behavioral health intervention studies. PH patients reported psychosocial needs, such as financial, social connections, sexual health, and palliative care needs, as well as levels of psychological distress symptoms. The results from both quantitative and qualitative studies revealed similar overarching psychosocial and behavioral health conceptual categories. Patients described their ongoing needs in PH management by relying on their psychosocial and behavioral health capabilities to adjust to changes at each stage of disease progression. Patients had high levels of psychosocial and behavioral health needs requiring interventions beyond medical treatment.

DISCUSSION

Pilot studies testing psychosocial and behavioral health interventions reported improvement in levels of anxiety and depression and health-related quality of life. Larger scale studies are needed to advance this knowledge. Psychosocial and behavioral health interventions with cognitive-guided foci have the potential of meeting these unmet needs.

Adults' experiences of living with pulmonary hypertension: a thematic synthesis of qualitative studies

OBJECTIVES

Pulmonary hypertension is a life-shortening disease that has a considerable impact on quality of life. Improving our understanding of how individuals are affected and cope with the disease will help to improve services and outcomes. This review synthesises the published qualitative research that has listened to adults discuss their experiences of living with the disease.

DESIGN

A comprehensive systematic search of four databases was conducted in May 2020: Web of Science, PubMed, PsycINFO and Cochrane Library. Suitable studies were evaluated using the Critical Appraisal Skills programme. Findings from the studies were extracted and subjected to a thematic synthesis.

RESULTS

Nineteen articles were identified reflecting the experiences of over 1900 individuals impacted by pulmonary hypertension from Europe, North and South America and Asia. Ten studies did not report participant's WHO functional class of pulmonary hypertension, which resulted in comparing experiences between different severity difficult. All studies met the majority of the quality assessment items. Six descriptive themes emerged discussing participant's experiences of diagnosis, treatment, prognosis, healthcare professionals, impact and coping with pulmonary hypertension. Four higher order analytical themes were developed from the descriptive themes, reflecting: (i) uncertainties and anxiety that participants encountered related to pulmonary hypertension; (ii) lack of recognition of the impact of the condition; (iii) frustration at the paucity of awareness of pulmonary hypertension in society and healthcare settings and (iv) participant's accounts of transitioning through different stages of living with the disease.

CONCLUSIONS

These findings form the first synthesis of experiences of life in individuals impacted by pulmonary hypertension and illustrate the multifaceted impact of the condition. The voices of numerous groups are missing from the literature highlighting the need for additional research. The results have implications for clinical practice emphasising the role of educational and psychological therapies to support those with the disease.

Ambulatory Transition from Parenteral Prostanoid to Inhaled Treprostinil in Patients with Pulmonary Arterial Hypertension

PURPOSE

The intravenous or subcutaneous delivery of prostanoid drugs for moderate to severe pulmonary arterial hypertension has been fraught with complications and patient dissatisfaction. Combination therapy including inhaled treprostinil is an attractive alternative in clinically stable patients. Uncertainties exist about the patient characteristics and the optimal setting (inpatient versus office/home) for transition.

METHODS

Sixteen stable patients with pulmonary arterial hypertension and favorable risk profile were transitioned from parenteral prostanoid to combination therapy including inhaled treprostinil in the home setting. Nine patients were using intravenous treprostinil, two patients were using subcutaneous treprostinil, and five patients were using intravenous epoprostenol at a median dose of 80 (interquartile range, IQR 72-90), 76.5 (68 and 85), and 28 (IQR 26-30) ng/kg/min respectively. Patients were followed up for a median of 732.5 days after transition (IQR 506.5-1294 days).

RESULTS

Patients tolerated the transition to inhaled treprostinil well without significant change in functional class (81.25% FC I/II before transition vs. 87.5% after), 6-min walk distance [349 m (IQR 226-461 m) to 364 m (IQR 238-565 m), p = 0.09] or NT-proBNP [149 pg/ml (IQR 71.5-383 pg/ml) to 186.5 pg/ml (IQR 83.5-444 pg/ml), p = 0.38]. Hemodynamic data, where available, showed significant improvements in mean pulmonary artery pressure and pulmonary vascular resistance from 36 mmHg (IQR 27-46.5 mmHg) and 5.2 Wood Units (WU) (IQR 3.1-5.6 WU) to 28.5 mmHg (IQR 22-35.5 mmHg) and 3.2 WU (IQR 2.4-4.2 WU) (p-values 0.022 and 0.003). More patients were on triple therapy after transition, and side effects reported were less severe.

CONCLUSION

For select patients, transition from a parenteral prostanoid-based therapy to a combination regimen including inhaled treprostinil in the home setting appears safe and well tolerated.

Palliative care in pulmonary arterial hypertension: an underutilised treatment

Pulmonary arterial hypertension (PAH) is a condition characterised by increased pulmonary vascular resistance which can lead to right heart failure and premature death. It imposes a significant burden on patients' lives, affecting their physical, emotional and social wellbeing. Pharmacological therapies are the mainstay of treatment; while they are not curative, they can alleviate patient suffering, improve quality of life and delay disease progression. Despite these therapies, disease progresses in a significant number of patients, who are faced with the debilitating symptoms of PAH and treatment adverse effects. Palliative care is focused on providing relief from symptoms caused by a chronic illness. Palliative care aims to improve the health-related quality of life for patients and families, and although it is deemed appropriate at any stage of disease, it is most helpful when explored early in the course of disease. Importantly, palliative care can be provided in concert with pharmacological treatment. Despite its potential benefits, palliative care is frequently underutilised. There is a paucity of clinical studies testing the impact of palliative care in PAH which prompted us to summarise the available evidence, recognise obstacles in its utilisation and identify areas for future research.

Palliative care remains an underutilised treatment option in PAH. This article attempts to highlight its importance in the management of PAH and highlight the barriers faced by both physicians and patients in seeking palliative care.http://ow.ly/quBH30mt9Pl

An advanced protocol-driven transition from parenteral prostanoids to inhaled trepostinil in pulmonary arterial hypertension

Patients with pulmonary arterial hypertension (PAH) often require parenteral prostanoids to improve symptoms and signs of PAH. Complications of parenteral prostanoids-such as catheter-related infections and intolerable adverse effects-may develop, prompting transition to inhaled prostanoids. We report a prospective, protocol-driven transition from parenteral prostanoids to inhaled prostanoids with monitoring of exercise gas exchange and acute hemodynamics. Three PAH centers recruited patients transitioning from parenteral prostanoids to inhaled trepostinil. Rigid inclusion criteria were used, including parenteral prostanoid dose < 30 ng/kg/min, New York Heart Association functional class (FC) < 3, and pulmonary vascular resistance (PVR) < 6 Wood units. Of the 9 patients meeting initial inclusion criteria, 3 were excluded. In the remaining patients, the parenteral prostanoid was reduced and the inhaled prostanoid was increased over 24-36 hours with continuous hemodynamic monitoring. Exercise capacity and FC were measured at baseline and weeks 1, 4, and 12. All patients were successfully weaned from parenteral prostanoids. An acute PVR decrease was seen with most inhaled prostanoid doses, but PVR varied throughout the transition. Patients tolerated inhaled prostanoids for 9-12 breaths 4 times a day with no treatment-limiting adverse events. At week 12, FC was unchanged, and all patients continued to receive inhaled prostanoids without serious adverse events or additional PAH therapy. In 5 of 6 patients, 6-minute walk distance and peak [Formula: see text] were within 10% of baseline. Using a strict transition protocol and rigid patient selection criteria, the parenteral prostanoid to inhaled prostanoid transition appeared safe and well tolerated and did not result in clinical deterioration over 12 weeks. Hemodynamic variability noted acutely during transition in our study did not adversely affect successful transition. (Trial registration: ClinicalTrials.gov identifier: NCT01268553).

Treatment satisfaction is associated with improved quality of life in patients treated with inhaled treprostinil for pulmonary arterial hypertension

Background

Patient treatment satisfaction is likely to be a highly relevant outcome measure in pulmonary arterial hypertension (PAH), a condition for which the benefits of treatment must be weighed against frequent, undesirable side effects, inconvenience, and complications associated with therapy. In this study, we sought to evaluate the psychometric properties of a patient-reported treatment satisfaction measure and its relationship to quality of life (QoL) among patients transitioning from inhaled iloprost (iILO) to inhaled treprostinil (iTRE).

Methods

We studied treatment satisfaction among 66 subjects with PAH in a single-arm, open-label, multi-center trial of iTRE following transition from iILO. Treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM, version 1.4) administered to subjects immediately before and 12 weeks after transition of inhaled therapy. The TSQM is comprised of 4 domains: effectiveness, side effects, convenience, and global satisfaction. Scores range from 0 to 100 with higher scores indicating greater satisfaction. Six-minute walk distance (6MWD), functional class, adverse events, drug administration time, and PAH-specific QoL (CAMPHOR) were concurrently assessed.

Results

Domains of the TSQM demonstrated evidence of strong internal consistency at baseline and at 12 weeks (Cronbach α = 0.88-0.93). Transition from iILO to iTRE was associated with an improvement in 3 of 4 TSQM domains: effectiveness (+20 ± 21, p < 0.0001), side effects (0 ± 22, p = 0.97), convenience (+39 ± 26, p < 0.0001), and global satisfaction (+20 ± 24, p = 0.0005). Change in effectiveness scores correlated with change in 6MWD (r = 0.43, p = 0.0004) and side effects scores at 12 weeks correlated inversely with number of severity-weighted treatment-emergent adverse events (r = −0.44, p = 0.0002). In multiple regression models adjusted for baseline characteristics, changes in effectiveness and convenience satisfaction scores were significantly associated with improvement in PAH-specific QoL (p = 0.002 and p = 0.01).

Conclusions

The TSQM demonstrated acceptable performance characteristics in patients with PAH. Changes in treatment satisfaction resulting from transitioning from iILO to iTRE were associated with improvements in PAH-specific QoL.