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McLaughlin V, Alsumali A, Liu R, Klok R, Martinez EC, Nourhussein I, Bernotas D, Chevure J, Pausch C, De Oliveira Pena J, Lautsch D, Hoeper MM. Population Health Model Predicting the Long-Term Impact of Sotatercept on Morbidity and Mortality in Patients with Pulmonary Arterial Hypertension (PAH). Adv Ther 2024; 41:130-151. [PMID: 37851297 PMCID: PMC10796519 DOI: 10.1007/s12325-023-02684-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a rare, progressive disease associated with significant morbidity and mortality. The phase 3 STELLAR trial tested sotatercept plus background therapy (BGT) versus placebo plus BGT. BGT was comprised of mono-, double-, or triple-PAH targeted therapy. Building on STELLAR findings, we employed a population health model to assess the potential long-term clinical impact of sotatercept. METHODS Based on the well-established ESC/ERS 4-strata risk assessment approach, we developed a six-state Markov-type model (low risk, intermediate-low risk, intermediate-high risk, high risk, lung/heart-lung transplant, and death) to compare the clinical outcomes of sotatercept plus BGT versus BGT alone over a lifetime horizon. State-transition probabilities were obtained from STELLAR. Risk stratum-adjusted mortality and lung/heart-lung transplant probabilities were based on COMPERA PAH registry data, and the post-transplant mortality probability was obtained from existing literature. Model outcomes were discounted at 3% annually. Sensitivity analyses were conducted to examine model robustness. RESULTS In the base case, sotatercept plus BGT was associated with longer life expectancy from model baseline (16.5 vs 5.1 years) versus BGT alone, leading to 11.5 years gained per patient. Compared with BGT alone, sotatercept plus BGT was further associated with a gain in infused prostacyclin-free life years per patient, along with 683 PAH hospitalizations and 4 lung/heart-lung transplant avoided per 1000 patients. CONCLUSIONS According to this model, adding sotatercept to BGT increased life expectancy by roughly threefold among patients with PAH while reducing utilization of infused prostacyclin, PAH hospitalizations, and lung/heart-lung transplants. Real-world data are needed to confirm these findings. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04576988 (STELLAR).
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Affiliation(s)
- Vallerie McLaughlin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| | | | | | | | | | | | | | | | - Christine Pausch
- Innovation Center Real-World Evidence, GWT-TUD GmbH, Dresden, Germany
| | | | | | - Marius M Hoeper
- Department for Respiratory Medicine and Infectious Diseases and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
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2
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de Barros JA, Sant'Ana G, Martins G, Madlum L, Scremim C, Petterle R, Escuissato D, Lima E. Severity of precapillary pulmonary hypertension: Predictive factor. Pulmonology 2023; 29 Suppl 4:S25-S35. [PMID: 34969648 DOI: 10.1016/j.pulmoe.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pulmonary arterial hypertension (PAH) require risk assessments for prognosis and appropriate therapy. These assessments need to be improved by incorporating clinical and laboratory data such as the analysis of the right ventricle. We aim to establish echocardiographic morphometric data of the right ventricle and its relationship with the left ventricle, to estimate the hemodynamic severity of precapillary pulmonary hypertension (PHprecapillary). METHODS This cohort, prospective, observational, and cross-sectional study included 41 consecutive patients with PHprecapillary using echocardiographic study and cardiac catheterization. RESULTS Patients' mean age was 44.0±16.4 years, and 37 were women (90.2%). Idiopathic PAH was diagnosed in 18 patients (43.9%). The World Health Organization/New York Association functional class was III or IV in 31 patients (75.6%). The ratio of the right to left ventricles (RV/LV) echocardiographic diastolic diameters was associated with pulmonary arterial pressures in cardiac catheterization, with the best cutoff per receiver operating characteristic curve being 0.8 for systolic pressure (sensitivity 90.0%, specificity 78.3%, area under the curve [AUC] 0.882) and mean pressure (sensitivity 60.0%, specificity 95.7%, AUC 0.823). Spearman's correlation (R) of RV/LV echocardiographic ratio and the hemodynamic variables was significant for systolic pressure (R = 0.7015, p < 0.0001), mean pressure (R = 0.6332, p < 0.0001), transpulmonary pressure gradient (R = 0.6524, p < 0.0001), pulmonary vascular resistance (R = 0.6076, p = 0.0021), and pulmonary vascular resistance index (R = 0.6229, p = 0.0014). CONCLUSION The ratio of RV/LV echocardiographic diastolic diameters contribute to the estimates the hemodynamic severity of precapillary pulmonary hypertension. The best cutoff for this assessment was RV/LV of 0.8.
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Affiliation(s)
- J A de Barros
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil.
| | - G Sant'Ana
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - G Martins
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - L Madlum
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - C Scremim
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - R Petterle
- Federal University of Paraná, Department of Integrative Medicine, Curitiba, Brazil
| | - D Escuissato
- Federal University of Paraná, Department of Internal Medicine, Radiology Unit, Curitiba, Brazil
| | - E Lima
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
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3
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Arogundade F, Jani B, Church C, Brewis M, Johnson M, Stubbs H. The MRC Dyspnoea Scale and mortality risk prediction in pulmonary arterial hypertension: A retrospective longitudinal cohort study. Pulm Circ 2023; 13:e12257. [PMID: 37404903 PMCID: PMC10315452 DOI: 10.1002/pul2.12257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/06/2023] Open
Abstract
Risk stratification models in pulmonary arterial hypertension (PAH) rely on World Health Organisation Functional Class (WHO FC). A high proportion of patients are classified as WHO FC III, a heterogenous group which limits the stratification abilities of risk models. The Medical Research Council (MRC) Dyspnoea Scale may allow a more precise assessment of functional status and improve current risk models. We investigated the ability of the MRC Dyspnoea Scale to assess survival in PAH and compared performance to WHO FC and the COMPERA 2.0 models. Patients with Idiopathic, Hereditary or Drug-induced PAH who were diagnosed between 2010 and 2021 were included. The MRC Dyspnoea Scale was retrospectively applied as derived from a combination of patient notes, 6MWD tests results and WHO functional status using a purpose-designed algorithm. Survival was assessed using Kaplan-Meier analyses, log rank testing and Cox proportional hazard ratios. Model performance was compared with Harrell's C Statistic. Data from 216 patients were retrospectively analyzed. At baseline, of 120 patients classified as WHO FC III, 8% were MRC Dyspnoea Scale 2, 12% Scale 3, 71% Scale 4 and 10% Scale 5. The MRC Dyspnoea Scale performed well compared to the WHO FC and COMPERA models at follow up (respectively, C-statistic 0.74 vs. 0.69 vs. 0.75). It was possible to use the MRC Dyspnoea Scale to subdivide patients in WHO FC III into groups which had distinct survival estimates. We conclude that at follow-up, the MRC Dyspnoea Scale may be a valid tool for the assessment of risk stratification in pulmonary arterial hypertension.
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Affiliation(s)
| | - Bhautesh Jani
- School of Health & WellbeingUniversity of GlasgowGlasgowUK
| | - Colin Church
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Melanie Brewis
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Martin Johnson
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
- School of Cardiovascular & Metabolic HealthUniversity of GlasgowGlasgowUK
| | - Harrison Stubbs
- School of Health & WellbeingUniversity of GlasgowGlasgowUK
- Scottish Pulmonary Vascular UnitGolden Jubilee National HospitalGlasgowUK
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4
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Nathan SD, Waxman AB. Response. Chest 2023; 164:e22. [PMID: 37423705 DOI: 10.1016/j.chest.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
| | - Aaron B Waxman
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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5
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Vraka A, Diamanti E, Kularatne M, Yerly P, Lador F, Aubert JD, Lechartier B. Risk Stratification in Pulmonary Arterial Hypertension, Update and Perspectives. J Clin Med 2023; 12:4349. [PMID: 37445381 DOI: 10.3390/jcm12134349] [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: 06/01/2023] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Risk stratification in pulmonary arterial hypertension (PAH) is crucial in assessing patient prognosis. It serves a prominent role in everyday patient care and can be determined using several validated risk assessment scores worldwide. The recently published 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines underline the importance of risk stratification not only at baseline but also during follow-up. Achieving a low-risk status has now become the therapeutic goal, emphasising the importance of personalised therapy. The application of these guidelines is also important in determining the timing for lung transplantation referral. In this review, we summarise the most relevant prognostic factors of PAH as well as the parameters used in PAH risk scores and their evolution in the guidelines over the last decade. Finally, we describe the central role that risk stratification plays in the current guidelines not only in European countries but also in Asian countries.
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Affiliation(s)
- Argyro Vraka
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Eleni Diamanti
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Patrick Yerly
- Division of Cardiology, Cardiovascular Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Division, Geneva University Hospital, 1211 Geneva, Switzerland
| | - John-David Aubert
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Benoit Lechartier
- Pulmonary Division, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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Zannad F, Alikhaani J, Alikhaani S, Butler J, Gordon J, Jensen K, Khatib R, Mantovani L, Martinez R, Moore WF, Murakami M, Roessig L, Stockbridge N, Van Spall HGC, Yancy C, Spertus JA. Patient-reported outcome measures and patient engagement in heart failure clinical trials: multi-stakeholder perspectives. Eur J Heart Fail 2023; 25:478-487. [PMID: 36924142 DOI: 10.1002/ejhf.2828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/18/2023] Open
Abstract
There are many consequences of heart failure (HF), including symptoms, impaired health-related quality of life (HRQoL), and physical and social limitations (functional status). These have a substantial impact on patients' lives, yet are not routinely captured in clinical trials. Patient-reported outcomes (PROs) can quantify patients' experiences of their disease and its treatment. Steps can be taken to improve the use of PROs in HF trials, in regulatory and payer decisions, and in patient care. Importantly, PRO measures (PROMs) must be developed with involvement of patients, family members, and caregivers from diverse demographic groups and communities. PRO data collection should become more routine not only in clinical trials but also in clinical practice. This may be facilitated by the use of digital tools and interdisciplinary patient advocacy efforts. There is a need for standardization, not only of the PROM instruments, but also in procedures for analysis, interpretation and reporting PRO data. More work needs to be done to determine the degree of change that is important to patients and that is associated with increased risks of clinical events. This 'minimal clinically important difference' requires further research to determine thresholds for different PROMs, to assess consistency across trial populations, and to define standards for improvement that warrant regulatory and reimbursement approvals. PROs are a vital part of patient care and drug development, and more work should be done to ensure that these measures are both reflective of the patient experience and that they are more widely employed.
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Affiliation(s)
- Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center at Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, Nancy, France
| | | | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jason Gordon
- HEOR- Health Economics and Outcomes Research, Ltd, Cardiff, UK
| | | | - Rani Khatib
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds; Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lorenzo Mantovani
- Value-Based Healthcare Unit, IRCCS Multimedica Hospital, Milan, Italy
| | | | - Wanda F Moore
- Sarver Heart Center Women's Heart Health Education Comm., University of Arizona, Tucson, AZ, USA
| | | | - Lothar Roessig
- Clinical Development Group, Bayer AG, Leverkusen, Germany
| | - Norman Stockbridge
- Division of Cardiology and Nephrology, Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Research Institute of St. Joseph's, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Clyde Yancy
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
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7
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Dong Y, Li Y, Song L. Evaluation of right ventricular function in patients with pulmonary arterial hypertension by different right ventricular-pulmonary artery coupling methods. Medicine (Baltimore) 2022; 101:e30873. [PMID: 36181031 PMCID: PMC9524992 DOI: 10.1097/md.0000000000030873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
To compare the accuracy of end-systolic elasticity (Ees)/arterial elasticity (Ea) ratio measured by single beat estimation, pressure-volume loop and cardiac magnetic resonance (CMR) combined volume method in patients with pulmonary artery hypertension, and to find a feasible and reliable method to quantitatively evaluate the function of right ventricle in patients with pulmonary artery hypertension. Forty-nine pulmonary artery hypertension patients enrolled between May 2017 and May 2018 in our hospital were retrospectively analyzed. Firstly, measure Ees/Ea ratio by single beat estimation, pressure-volume loop and CMR combined volume method, then, compare Ees/Ea ratio with New York Heart Association (NYHA) classification and NT-proBNP value respectively to evaluate the accuracy of the 3 methods. Ees/Ea ratio measured by single beat estimation is 2.07 ± 1.01, correlation analysis is not statistically significant when compare with NYHA classification and NT-proBNP value (P > .05). Ees/Ea ratio measured by pressure-volume loop is 2.64 ± 1.48, correlation analysis is not statistically significant when compare with NYHA classification and NT-proBNP value (P > .05). Ees/Ea ratio measured by CMR combined volume method is 0.72 ± 0.43, correlation analysis is statistically significant when compare with NYHA classification and NT-proBNP with negative correlation (P < .05). Ees/Ea ratio decrease according to the increase of NT-proBNP value and the NYHA classification. There is linear regression equation between Ees/Ea ratio measured by CMR combined volume method and log (NT-proBNP) value: Y = -0.257X + 1.45, and the linear regression equation is statistically significant (P = .001). Ees/Ea ratio measured by CMR combined volume method is a feasible and reliable method to quantitatively evaluate the function of right ventricule in patients with pulmonary artery hypertension, which might be further verified in a larger patient population.
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Affiliation(s)
- Yaling Dong
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, PR China
| | - Yu Li
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, PR China
| | - Laichun Song
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, PR China
- *Correspondence: Laichun Song, Department of Cardiac Surgery, Asia Heart Hospital, Wuhan University of Science and Technology, No. 753 Jinghan Road, Hankou District, Wuhan 430022, PR China (e-mail: )
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McLaughlin VV, Channick RN, Lynum KSB, Oudiz RJ, Selej M, Tapson VF, Rubin LJ. Using a knowledge translation program to facilitate guideline‐based and evidence‐based patient management: the PAH‐QuERI Extension Program. Pulm Circ 2022; 12:e12134. [PMID: 36172596 PMCID: PMC9469640 DOI: 10.1002/pul2.12134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 06/29/2022] [Accepted: 08/24/2022] [Indexed: 11/23/2022] Open
Abstract
The Pulmonary Arterial Hypertension‐Quality Enhancement Research Initiative Extension Program was designed to support physicians’ adherence to pulmonary arterial hypertension (PAH) guidelines. Guidelines were followed in >95% of patients with functional class (FC) II/III, but for only 28.6% of FC IV patients (Month 36). Low adherence was driven by FC IV patients’ preference to avoid parenteral treatment.
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Affiliation(s)
| | | | | | - Ronald J. Oudiz
- Lundquist Institute for Biomedical Research and Innovation at Harbor‐UCLA Medical Center Torrance California USA
| | - Mona Selej
- Actelion Pharmaceuticals US, Inc. Titusville New Jersey USA
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Zhang A, De Gala V, Lementowski PW, Cvetkovic D, Xu JL, Villion A. Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review. Cureus 2022; 14:e28234. [PMID: 36158355 PMCID: PMC9488858 DOI: 10.7759/cureus.28234] [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] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.
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10
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Göransson C, Vejlstrup N, Carlsen J. Clinically important changes of right ventricular volume and function in pulmonary arterial hypertension assessed with cardiac magnetic resonance imaging. Pulm Circ 2022; 12:e12097. [PMID: 35833097 PMCID: PMC9262318 DOI: 10.1002/pul2.12097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/22/2022] [Accepted: 05/26/2022] [Indexed: 11/25/2022] Open
Abstract
Right ventricular (RV) dilatation predicts clinical worsening in pulmonary arterial hypertension (PAH) and RV volumes can be measured with high precision using cardiovascular magnetic resonance imaging. In regular follow‐up of patients and in studies of improvement in RV function, knowledge of clinically significant changes of RV volumes and function are of relevance. Patients with PAH were followed with cardiovascular magnetic resonance imaging and clinical assessment at 6‐month intervals. Changes in RV volumes associated with changes in clinical status were assessed. Twenty‐five patients with PAH (Group 1) were included and examined every 6 months for 2.5 years, with a total of 107 MRI scans. For a step change in WHO functional class, the associated change in RV volume was 11% (confidence interval 7%−14%, p < 0.0001) and in stroke volume 9% (confidence interval 3%−15%, p = 0.003). This study found an 11% change in RV volume to be clinically significant. The combination of clinically significant changes and the known precision in the measurements enables individualized follow‐up of RV‐function in PAH. To our knowledge, this study is the first to use repeated assessments to suggest clinically significant changes of RV volume based on changes in clinical presentation.
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Affiliation(s)
- Christoffer Göransson
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital 9‐ Blegdamsvej Copenhagen Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital 9‐ Blegdamsvej Copenhagen Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital 9‐ Blegdamsvej Copenhagen Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Blegdamsvej 3B Copenhagen 2200 Denmark
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Highland KB, Crawford R, Classi P, Morrison R, Doward L, Nelsen AC, Castillo H, Mathai SC, DuBrock HM. Development of the Pulmonary Hypertension Functional Classification Self-Report: a patient version adapted from the World Health Organization Functional Classification measure. Health Qual Life Outcomes 2021; 19:202. [PMID: 34429110 PMCID: PMC8386063 DOI: 10.1186/s12955-021-01782-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 04/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is characterized by progressive limitations on physical activity, right heart failure, and premature death. The World Health Organization functional classification (WHO-FC) is a clinician-rated assessment used widely to assess PAH severity and functioning, but no equivalent patient-reported version of PAH symptoms and activity limitations exists. We developed a version of the WHO-FC for self-completion by patients: the Pulmonary Hypertension Functional Classification Self-Report (PH-FC-SR). Methods Semistructured interviews were conducted with three health care providers (HCPs) via telephone to inform development of the draft PH-FC-SR. Two rounds of semi-structured interviews were conducted with 14 US patients with a self-reported PAH diagnosis via telephone/online to elicit concepts and iteratively refine the PH-FC-SR. Results HCPs reported that the WHO-FC was a useful tool for evaluating patients’ PAH severity over time and for making treatment decisions but acknowledged that use of the measure is subjective. Patients in round 1 interviews (n = 6) reported PAH symptoms, including shortness of breath (n = 6), fatigue (n = 5), syncope (n = 5), chest pains (n = 3), and dizziness (n = 3). Round 1 patients identified challenges with the original WHO-FC, including comprehensibility of clinical terms and overlapping descriptions of class II and III, and preferred the Draft 1 PH-FC-SR over the original WHO-FC. After minor changes were made to Draft 2, round 2 interviews (n = 8) confirmed patients understood the PH-FC-SR class descriptions, interpreting them consistently. Conclusions The HCP and patient interviews identified and confirmed certain limitations inherent within the clinician-rated WHO-FC, including subjective assessment and overlapping definitions for class II and III. The PH-FC-SR includes patient-appropriate language, symptoms, and physical activity impacts relevant to patients with PAH. Future research is recommended to validate the PH-FC-SR and explore its correlation with the physician-assessed WHO-FC and other outcomes.
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Affiliation(s)
| | - Rebecca Crawford
- RTI Health Solutions, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester, M20 2LS, UK.
| | | | - Ross Morrison
- RTI Health Solutions, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester, M20 2LS, UK
| | - Lynda Doward
- RTI Health Solutions, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester, M20 2LS, UK
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12
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Stamp KD, Prasun MA, McCoy TP, Rathman L. Providers' assignment of NYHA functional class in patients with heart failure: A vignette study. Heart Lung 2021; 51:87-93. [PMID: 34399995 DOI: 10.1016/j.hrtlng.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Accuracy of New York Heart Association Functional Classification (NYHA-FC) I-IV assessment is critical to promoting guideline directed care. OBJECTIVE Examine providers' accuracy when diagnosing NYHA-FC I-IV in patients with heart failure (HF). METHODS A web-based survey using validated vignettes was conducted with 244 physicians, nurse practitioners (NP), clinical nurse specialists (CNS) and physician assistants (PA) who provide care to patients with HF. RESULTS Providers comprised of 65% NPs, 19% physicians, 14% CNSs, 2% PAs with an average of 15 years working with HF patients. Accuracy ranged from 36.9% for Class IV to 78.7% for Class I. Increased HF patient volume seen (p=0.024), physician vs. NP/PA/CNS (p=0.021), and typically assigned a HF stage (p<0.001) were associated with increased total correct score accuracy in multivariable modeling. CONCLUSION It is critical that NYHA-FC is accurately assigned to promote optimal outcomes. Research in the future should focus on improving accuracy in assigning NYHA-FC.
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Affiliation(s)
- Kelly D Stamp
- Professor & Chair, Family & Community Nursing Department, Eloise R. Lewis Excellence Professor, UNC Greensboro, School of Nursing, 264 Nursing Instructional Building, Greensboro, North Carolina, 27402-6170, USA.
| | - Marilyn A Prasun
- Carle BroMenn Medical Center Endowed Professor, Illinois State University, Mennonite College of Nursing, Normal, Illinois, USA
| | - Thomas P McCoy
- Clinical Professor, UNC Greensboro, School of Nursing, Greensboro, North Carolina, USA
| | - Lisa Rathman
- Acute Care Heart Failure Nurse Practitioner, Penn Medicine, Lancaster General Health, Lancaster, Pennsylvania, USA
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Murthy S, Benza R. The Evolution of Risk Assessment in Pulmonary Arterial Hypertension. Methodist Debakey Cardiovasc J 2021; 17:134-144. [PMID: 34326933 PMCID: PMC8298117 DOI: 10.14797/lrpr7655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 11/08/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic debilitating disease that
carries an unacceptably high morbidity and mortality rate despite improved
survival with modern therapies. The combination of several modifiable and
nonmodifiable variables yields a robust risk assessment across various available
clinical calculators. The role of risk calculation is integral to managing PAH
and aids in the timely referral to expert centers and potentially lung
transplantation. Studies are ongoing to determine the role of risk calculators
in the framework of clinical trials and to elucidate novel markers of high risk
in PAH.
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Affiliation(s)
| | - Raymond Benza
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Enabling patient-reported outcome measures in clinical trials, exemplified by cardiovascular trials. Health Qual Life Outcomes 2021; 19:164. [PMID: 34120618 PMCID: PMC8201736 DOI: 10.1186/s12955-021-01800-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES There has been limited success in achieving integration of patient-reported outcomes (PROs) in clinical trials. We describe how stakeholders envision a solution to this challenge. METHODS Stakeholders from academia, industry, non-profits, insurers, clinicians, and the Food and Drug Administration convened at a Think Tank meeting funded by the Duke Clinical Research Institute to discuss the challenges of incorporating PROs into clinical trials and how to address those challenges. Using examples from cardiovascular trials, this article describes a potential path forward with a focus on applications in the United States. RESULTS Think Tank members identified one key challenge: a common understanding of the level of evidence that is necessary to support patient-reported outcome measures (PROMs) in trials. Think Tank participants discussed the possibility of creating general evidentiary standards depending upon contextual factors, but such guidelines could not be feasibly developed because many contextual factors are at play. The attendees posited that a more informative approach to PROM evidentiary standards would be to develop validity arguments akin to courtroom briefs, which would emphasize a compelling rationale (interpretation/use argument) to support a PROM within a specific context. Participants envisioned a future in which validity arguments would be publicly available via a repository, which would be indexed by contextual factors, clinical populations, and types of claims. CONCLUSIONS A publicly available repository would help stakeholders better understand what a community believes constitutes compelling support for a specific PROM in a trial. Our proposed strategy is expected to facilitate the incorporation of PROMs into cardiovascular clinical trials and trials in general.
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15
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Chao HY, Hsu CH, Wang ST, Yu CY, Chen HM. Mediating effect of social support on the relationship between illness concealment and depression symptoms in patients with pulmonary arterial hypertension. Heart Lung 2021; 50:706-713. [PMID: 34107395 DOI: 10.1016/j.hrtlng.2021.03.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Depression symptoms are common in patients with pulmonary arterial hypertension (PAH). Social support may mediate the effect of illness concealment on depression symptoms. OBJECTIVE To examine the relationships between illness concealment, dimensions of social support, and depression symptoms and the mediating effect of the dimensions of social support on depression symptoms in PAH patients. METHODS A cross-sectional design and convenience sampling were applied. Data were collected with three questionnaires and analyzed with hierarchical regression and the PROCESS macro. RESULTS Ninety-seven participants were enrolled (mean age 50 ± 14 years). In total, 8% had a Patient Health Questionnaire (PHQ)-9 score ≥15. Hierarchical regression analysis showed that education level (β = 0.28, p < 0.05), illness concealment (β = 0.21, p < 0.05), and emotional support (β = 0.29, p < 0.01) were determinants of depression symptoms. Emotional support mediated the relationship between illness concealment and depression symptoms. CONCLUSIONS Emotional support can help patients reduce the effect of illness concealment on depression symptoms.
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Affiliation(s)
- Hsin-Yu Chao
- Department of Nursing, College of Medical, National Cheng Kung University, Tainan City, Taiwan.
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.
| | - Shan-Tair Wang
- Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan; Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Ching-Yun Yu
- School of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan.
| | - Hsing-Mei Chen
- Department of Nursing, College of Medical, National Cheng Kung University, Tainan City, Taiwan.
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16
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Giri PC, Stevens GJ, Merrill-Henry J, Oyoyo U, Balasubramanian VP. Participation in pulmonary hypertension support group improves patient-reported health quality outcomes: a patient and caregiver survey. Pulm Circ 2021; 11:20458940211013258. [PMID: 34035896 PMCID: PMC8132099 DOI: 10.1177/20458940211013258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022] Open
Abstract
Support group participation has been shown to be effective in many chronic medical conditions. The evidence for integrating support group into pulmonary hypertension care and its effect on quality of life, physical and psychological well-being is limited. We sought to assess the effect of support group participation on quality of life in patients diagnosed with pulmonary hypertension and their caregivers. The emPHasis-10 questionnaire (a tool validated for quality of life assessment in pulmonary hypertension) was used to evaluate the effect of support group participation. Additional demographic and health-related quality measures were examined. Results showed that 165 subjects were enrolled in the study; 122 (74.4%) were patients with pulmonary hypertension, 41 (25.0%) were their caregivers, and 2 (0.02%) did not respond. The cohort was predominantly female (n = 128, 78%), Caucasian (n = 10, 61%), and the principal self-reported classification of pulmonary hypertension was World Health Organization Group 1 (n = 85, 51.8%) and the self-reported New York Heart Association Functional Class was II and III (n = 43, 57.3%). Most participants (n = 118, 71.5%) attended support groups and of them, a majority (n = 107, 90.6%) stated it helped them. There was no difference in quality of life as assessed by emPHasis-10 scores with support group participation (median score 30 vs 32, p = 0.387). There was self-reported improvement in understanding condition better including procedures such as right heart catheterization, medication compliance, and confidence in self-care (p < 0.05). Using multivariate logistic regression, baseline variables that were independently associated with emPHasis-10 scores for the entire cohort included knowledge of New York Heart Association Functional Class (odds ratio: 1.919, 95% CI: 1.004–3.67, p = 0.04) and greater distance traveled to visit pulmonary hypertension physician (odds ratio: 1.391, 95% CI: 0.998--1.94, p = 0.05). In conclusion, support group participation does not improve quality of life as assessed by emPHasis-10 scores but improves other meaningful health-related quality outcomes.
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Affiliation(s)
- Paresh C Giri
- Pulmonary and Critical Care Department, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Gizelle J Stevens
- Pulmonary and Critical Care Department, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Udochukwu Oyoyo
- Department of Dental Education Services, Loma Linda University School of Dentistry, Loma Linda, CA, USA
| | - Vijay P Balasubramanian
- Pulmonary and Critical Care Department, University of California San Francisco-Fresno, Fresno, CA, USA
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17
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Marsico A, Dal Corso S, Farah de Carvalho E, Arakelian V, Phillips S, Stirbulov R, Polonio I, Navarro F, Consolim-Colombo F, Cahalin LP, Malosa Sampaio LM. A more effective alternative to the 6-minute walk test for the assessment of functional capacity in patients with pulmonary hypertension. Eur J Phys Rehabil Med 2021; 57:645-652. [PMID: 33619942 DOI: 10.23736/s1973-9087.21.06561-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The prognosis of Pulmonary Hypertension (PH) is directly correlated with the functional capacity (FC). The most common FC test is the 6-Minute Walk Test (6MWT), however, there is evidence to suggest that the 6MWT does not reflect the real FC in PH patients. OBJECTIVE To compare physiological responses among three field walk tests and cardiopulmonary exercise testing (CPET) in patients with pulmonary hypertension (PH), and to determine the determinants of distance walked in the field walk tests. DESIGN Cross sectional. SETTING Outpatient clinic. PARTICIPANTS 26 volunteers (49.8 ± 14.6 years), WHO functional class II-III and a mean pulmonary artery pressure of 45 mmHg. INTERVENTIONS Patients underwent three field walk test: 6MWT, incremental shuttle walk test (ISWT), and endurance shuttle walk test (ESWT) and CPET on different, nonconsecutive days. MAIN OUTCOME MEASURES Heart rate and perception of effort at the peak of exercise. RESULTS The ISWT achieved maximum levels of effort without significant difference in any physiologic response compared to CPET. The physiological responses during ISWT were significantly higher than 6MWT and ESWT responses. CONCLUSIONS The ISWT produced the greatest physiologic response of the field tests safely for which reason it appears to be the most effective test to assess FC of PH patients.
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Affiliation(s)
- Aline Marsico
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Simone Dal Corso
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Etiene Farah de Carvalho
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Vivian Arakelian
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Shane Phillips
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil.,Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | | | - Igor Polonio
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Flavia Navarro
- Santa Casa de São Paulo School of Medicine, São Paulo, Brazil
| | | | - Lawrence P Cahalin
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA.,Department of Physical Therapy, University of Miami, Miami, FL, USA
| | - Luciana M Malosa Sampaio
- Master's and Doctoral Programs in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil -
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18
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Lachtrupp CL, Valente AM, Gurvitz M, Landzberg MJ, Brainard SB, Opotowsky AR. Interobserver agreement of the anatomic and physiological classification system for adult congenital heart disease. Am Heart J 2020; 229:92-99. [PMID: 32947058 DOI: 10.1016/j.ahj.2020.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/20/2020] [Indexed: 01/06/2023]
Abstract
The Anatomic and Physiological (AP) classification system proposed in the 2018 American College of Cardiology/American Heart Association adult congenital heart disease (ACHD) guidelines assigns 2 dimensions to each patient: anatomic class (AnatC) and physiological stage (PhyS). This approach has not been tested in practice; we assessed interrater reliability and identified sources of disagreement. METHODS Consensus definitions for AP categories were developed with input from 4 experts. Research assistants (RAs) assigned AnatC/PhyS for patients in the Boston ACHD Biobank, a prospectively enrolled cohort of ambulatory ACHD patients ≥18 years old seen between 2012 and 2019. Two (of 4) expert reviewers then independently assigned AnatC/PhyS for 41 patients. Interrater reliability was assessed with linearly weighted kappa (κω) for agreement between (1) experts and (2) an RA and an expert. Experts examined disagreements and identified sources of variability and areas requiring clarification. RESULTS Interexpert agreement for AnatC was excellent, with agreement on 38/41 (92.7%) cases and κω 0.88 [0.75, 1.01]. Agreement for PhyS was less robust, with consensus on 24/41 cases (59.5%), κω 0.57 [0.39, 0.75]. Expert-RA agreement was lower for AnatC (κω 0.77 [0.60, 0.95]), whereas PhyS was similar to interexpert agreement (κω 0.53 [0.34, 0.72]). There was ambiguity in the definitions of (1) arrhythmia status, (2) cyanotic CHD, and (3) valve disease. CONCLUSIONS Although AnatC can be assessed reliably, that is not true for the PhyS part of the AP classification proposed in the 2018 American College of Cardiology/American Heart Association guidelines. Reliability of PhyS would be strengthened by more precise definitions readily interpretable in clinical practice.
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Affiliation(s)
- Cara L Lachtrupp
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael J Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sarah B Brainard
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA; The Heart Institute, Cincinnati Children's Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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19
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Abstract
Identifying patients with heart failure at high risk for poor outcomes is important for patient care, resource allocation, and process improvement. Although numerous risk models exist to predict mortality, hospitalization, and patient-reported health status, they are infrequently used for several reasons, including modest performance, lack of evidence to support routine clinical use, and barriers to implementation. Artificial intelligence has the potential to enhance the performance of risk prediction models, but has its own limitations and remains unproved.
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Affiliation(s)
- Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA. https://twitter.com/ramseywehbemd
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA. https://twitter.com/HeartDocSadiya
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA. https://twitter.com/HFpEF
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 600, Chicago, IL 60611, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan Avenue, 15th Floor, Chicago, IL 60611, USA.
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20
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Ollivier C, Sun H, Amchin W, Beghetti M, Berger RMF, Breitenstein S, Garnett C, Gullberg N, Hassel P, Ivy D, Kawut SM, Klein A, Lesage C, Migdal M, Nije B, Odermarsky M, Strait J, de Graeff PA, Stockbridge N. New Strategies for the Conduct of Clinical Trials in Pediatric Pulmonary Arterial Hypertension: Outcome of a Multistakeholder Meeting With Patients, Academia, Industry, and Regulators, Held at the European Medicines Agency on Monday, June 12, 2017. J Am Heart Assoc 2020; 8:e011306. [PMID: 31088189 PMCID: PMC6585335 DOI: 10.1161/jaha.118.011306] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | - Haihao Sun
- 2 Food and Drug Administration Silver Spring MD
| | | | - Maurice Beghetti
- 3 Pediatric Cardiology Unit Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique University Hospitals of Geneva City of Geneva Switzerland
| | - Rolf M F Berger
- 4 Center for Congenital Heart Diseases Department of Pediatric Cardiology Beatrix Children's Hospital University Medical Center Groningen University of Groningen the Netherlands
| | | | | | | | | | - Dunbar Ivy
- 7 Heart Institute Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Steven M Kawut
- 8 Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | | | | | - Marek Migdal
- 11 Childrens Memorial Health Institute Warsaw Poland
| | | | - Michal Odermarsky
- 12 Department of Paediatric Cardiology Paediatric Heart Center Lund University and Skåne University Hospital Lund Sweden
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21
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Costa GOS, Ramos RP, Oliveira RKF, Cepêda A, Vieira EB, Ivanaga IT, Ferreira EVM, Ota-Arakaki JS. Prognostic value of six-minute walk distance at a South American pulmonary hypertension referral center. Pulm Circ 2020; 10:2045894019888422. [PMID: 32523683 PMCID: PMC7235667 DOI: 10.1177/2045894019888422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/22/2019] [Indexed: 12/27/2022] Open
Abstract
Six-minute walk distance (6MWD) assessment is recommended for pulmonary arterial hypertension multidimensional risk stratification. However, current 6MWD cut-off values were mainly derived from North American and European pulmonary arterial hypertension registries. Therefore, it is unknown if such cut-off values broadly apply to other geographical populations. In this study, we aimed to identify 6MWD cut-off values for Brazilian pulmonary arterial hypertension patients and to contrast our findings to current international Pulmonary Hypertension guidelines recommendations. One-hundred four consecutive pulmonary arterial hypertension patients were allocated in groups according to their 6MWD, considering 50 m as a clinically relevant 6MWD difference. Next, patients were categorized into different 6MWD ranges based on similar survival rates in each group: < 250 m, 250–400 m, and >400 m. The study outcome was all-cause mortality and transplantation according to the 6MWD range. Survival was truncated at five years. Median follow-up period was 4.35 years (0.48–5.00). Survival rates at 1, 2, 3, and 5 years were 96%, 89%, 81%, and 73%, respectively. Cox analyses adjusted for age, sex, and pulmonary arterial hypertension etiology showed that 6MWD < 250 m and >400 m were associated with higher and lower risk of all-cause mortality and transplantation. According to Harrell's c-statistic, the prognostic discrimination of the 6MWD cut-off value identified by the current study was 0.70 while international Pulmonary Hypertension guidelines 6MWD cut-offs value was 0.61. In conclusion, our findings suggest that 6MWD geographical variations should be considered when assessing risk stratification in pulmonary arterial hypertension.
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Affiliation(s)
- Gabriela O S Costa
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Roberta P Ramos
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Rudolf K F Oliveira
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Angelo Cepêda
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Elaine B Vieira
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Ivan T Ivanaga
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Eloara V M Ferreira
- Department of Medicine, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
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22
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Xanthouli P, Koegler M, Marra AM, Benjamin N, Fischer L, Eichstaedt CA, Harutyunova S, Nagel C, Grünig E, Egenlauf B. Risk stratification and prognostic factors in patients with pulmonary arterial hypertension and comorbidities a cross-sectional cohort study with survival follow-up. Respir Res 2020; 21:127. [PMID: 32448256 PMCID: PMC7245826 DOI: 10.1186/s12931-020-01393-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The objective of this study was to analyze prognostic factors and risk stratification in patients with pulmonary arterial hypertension (PAH) and comorbidities. METHODS Patients with invasively diagnosed PAH were included in the analysis. Comorbidities were clinically diagnosed as proposed in the 6th World Symposium of pulmonary hypertension. Uni- and multivariate analysis were employed for identification of factors predicting survival and time to first clinical worsening (TTCW). Risk stratification was based on parameters from ESC/ERS-guidelines 2015. RESULTS In total 142 patients were enrolled in the study, 90 of them were diagnosed as PAH without and 52 with comorbidities. All patients received targeted PAH therapy and were followed for 3.3 ± 2.4 years. In PAH patients without comorbidities survival and TTCW were significantly associated with reduced 6-min walking distance (6MWD), elevated N-terminal pro brain natriuretic peptide (NT-proBNP), WHO-functional class (WHO-FC) and right atrial (RA) area. In the multivariate analysis, 6MWD was an independent predictor for survival (p = 0.002) and WHO-FC for TTCW (p = 0.001). In patients with PAH and comorbidities these parameters had no significant association with survival and TTCW. Average risk score was significantly associated with survival (p = 0.001) and TTCW (p = 0.013) in PAH but not in PAH with comorbidities (both p > 0.05; figure 1). CONCLUSION Risk stratification based on ESC/ERS-guidelines could only be confirmed in patients without comorbidities, but not in patients with PAH and comorbidities. The data of this study suggest, that a different risk stratification needs to be applied to PAH patients with comorbidities. Further studies are needed to confirm these results. TRIAL REGISTRATION Not applicable, retrospective registry.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Maria Koegler
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | | | - Nicola Benjamin
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Lukas Fischer
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Christian Nagel
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.,Lung Centre, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension at Thoraxklinik gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), Heidelberg, Germany.
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23
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Han QY, Hu ZD. Clinical prediction model construction and evaluation: a challenge for clinical researchers. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:74. [PMID: 32175367 PMCID: PMC7048993 DOI: 10.21037/atm.2019.11.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 08/30/2023]
Affiliation(s)
- Qiu-Yan Han
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
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24
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McLaughlin VV, Channick R, De Marco T, Farber HW, Gaine S, Galié N, Krasuski RA, Preston I, Souza R, Coghlan JG, Frantz RP, Hemnes A, Kim NH, Lang IM, Langleben D, Li M, Sitbon O, Tapson V, Frost A. Results of an Expert Consensus Survey on the Treatment of Pulmonary Arterial Hypertension With Oral Prostacyclin Pathway Agents. Chest 2019; 157:955-965. [PMID: 31738929 DOI: 10.1016/j.chest.2019.10.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/11/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Treatment of pulmonary arterial hypertension (PAH) has evolved substantially over the past two decades and varies according to etiology, functional class (FC), hemodynamic parameters, and other clinical factors. Current guidelines do not provide definitive recommendations regarding the use of oral prostacyclin pathway agents (PPAs) in PAH. To provide guidance on the use of these agents, an expert panel was convened to develop consensus statements for the initiation of oral PPAs in adults with PAH. METHODS A systematic literature search was conducted using MEDLINE. The established RAND/University of California Los Angeles appropriateness method, which incorporates the Delphi method and the nominal group technique, was used to create consensus statements. Idiopathic, heritable, repaired congenital heart defect, and drug- or toxin-induced PAH (IPAH+) was considered as one etiologic grouping. The process was focused on the use of oral treprostinil or selexipag in patients with IPAH+ or connective tissue disease-associated PAH and FC II or III symptoms receiving background dual endothelin receptor antagonist/phosphodiesterase type 5 inhibitor therapy. RESULTS The panel developed 14 consensus statements regarding the appropriate use of oral PPAs in the target population. The panel identified 13 clinical scenarios in which selexipag may be considered as a treatment option. CONCLUSIONS The paucity of clinical evidence overall, and particularly from randomized trials in this setting, creates a gap in knowledge. These consensus statements are intended to aid physicians in navigating treatment options and using oral PPAs in the most appropriate manner in patients with PAH.
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Affiliation(s)
| | - Richard Channick
- Department of Medicine, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Teresa De Marco
- Department of Cardiology, University of California, San Francisco, CA
| | - Harrison W Farber
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | | | - Nazzareno Galié
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | | | - Ioana Preston
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Rogerio Souza
- Pulmonary Department, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - J Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London, England
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Anna Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nick H Kim
- Department of Cardiothoracic Surgery, University of California San Diego Medical Center, San Diego, CA
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | - David Langleben
- Center for Pulmonary Vascular Disease, Cardiology Division, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Olivier Sitbon
- Université Paris-Saclay, APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France
| | - Victor Tapson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Adaani Frost
- Department of Medicine, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX
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25
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Zhu S, Zhou M, Wei D, Yang H, Fan L, Wu B, Chen J. Risk Analysis of Perioperative Death in Lung Transplant Patients With Severe Idiopathic Pulmonary Hypertension. Transplant Proc 2019; 51:875-879. [DOI: 10.1016/j.transproceed.2019.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
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Wang S, Yu M, Zheng X, Dong S. A Bayesian network meta-analysis on the efficacy and safety of eighteen targeted drugs or drug combinations for pulmonary arterial hypertension. Drug Deliv 2019; 25:1898-1909. [PMID: 30442035 PMCID: PMC6249551 DOI: 10.1080/10717544.2018.1523257] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) can be relieved by pharmacological interventions, especially the targeted drug, which is classified into endothelin receptor antagonist, phosphodiesterase 5 inhibitor, prostaglandin I2, soluble guanylate cyclase stimulator and selective non-prostanoid prostacyclin receptor agonist. To solve the contradictions existing in reported trials and provide a comprehensive guideline for clinical practice. PubMed, Embase, Cochrane library, and clinicaltrials.gov were searched. The basic information about the article, trial, arm, intervention, and the detailed data of outcome, including 6 minutes walking distance (6MWD) change, WHO functional class (FC) improvement, Borg dyspnea score (BDS) change, cardiac index (CI) change, mean pulmonary arterial pressure (mPAP) change, mean right arterial pressure (mRAP) change, pulmonary vascular resistance (PVR) change, clinical worsening, hospitalization, death, severe adverse events (SAEs), and withdrawal were extracted. The rank of treatments was estimated. 10,230 cases provided the firsthand comparison data about targeted drugs for treating PAH. For 6MWD, ambrisentan + tadalafil, vardenafil, and sildenafil + bosentan were better than others. Epoprostenol, macitentan, and sildenafil represented a greater WHO FC improvement. Vardenafil and treprostinil were better for BDS. So were bosentan + epoprostenol and bosentan alone for CI. Iloprost plus bosentan, bosentan + epoprostenol, and epoprostenol were better for mPAP. Iloprost plus bosentan, bosentan alone, and selexipag could reduce PVR. Sildenafil, epoprostenol, and vardenafil had the highest probability to reduce the incidence of death and withdrawal. To conclude, vardenafil and iloprost + bosentan showed relatively better performance in both efficacy and safety. However, the therapeutic choice should be made according to both the feature of each therapy and the individual condition.
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Affiliation(s)
- Sumei Wang
- a Department of Emergency , Dongfang Hospital Beijing University of Chinese Medicine , Beijing , China
| | - Miao Yu
- b Department of Emergency , Beijing University of Chinese Medicine Third Affiliated Hospital , Beijing , China
| | - Xiangchun Zheng
- a Department of Emergency , Dongfang Hospital Beijing University of Chinese Medicine , Beijing , China
| | - Shangjuan Dong
- c Department Respiration , Dongfang Hospital Beijing University of Chinese Medicine , Beijing , China
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Huang G, Liu J, Yang C, Xiang Y, Wang Y, Wang J, Cao M, Yang W. RNA sequencing discloses the genome‑wide profile of long noncoding RNAs in dilated cardiomyopathy. Mol Med Rep 2019; 19:2569-2580. [PMID: 30720098 PMCID: PMC6423559 DOI: 10.3892/mmr.2019.9937] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/17/2019] [Indexed: 12/13/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is a common type of non‑ischemic cardiomyopathy, of which the underlying mechanisms have not yet been fully elucidated. Long noncoding RNAs (lncRNAs) have been reported to serve crucial physiological roles in various cardiac diseases. However, the genome‑wide expression profile of lncRNAs remains to be elucidated in DCM. In the present study, a case‑control study was performed to identify expression deviations in circulating lncRNAs between patients with DCM and controls by RNA sequencing. Partial dysregulated lncRNAs were validated by reverse transcription‑polymerase chain reaction. Gene Ontology, Kyoto Encyclopedia of Genes and Genomes pathway, and lncRNA‑messenger RNA (mRNA) co‑expression network analyses were employed to probe potential functions of these dysregulated lncRNAs in DCM. Comparison between 8 DCM and 8 control samples demonstrated that there were alterations in the expression levels of 988 lncRNAs and 1,418 mRNAs in total. The dysregulated lncRNAs were found to be mainly associated with system development, organ morphogenesis and metabolic regulation in terms of 'biological processes'. Furthermore, the analysis revealed that the gap junction pathway, phagosome, and dilated and hypertrophic cardiomyopathy pathways may serve crucial roles in the development of DCM. The lncRNA‑mRNA co‑expression network also suggested that the target genes of the lncRNAs were different in patients with DCM as compared with those in the controls. In conclusion, the present study revealed the genome‑wide profile of circulating lncRNAs in DCM by RNA sequencing, and explored the potential functions of these lncRNAs in DCM using bioinformatics analysis. These findings provide a theoretical foundation for future studies of lncRNAs in DCM.
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Affiliation(s)
- Guangyong Huang
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, Shandong 252000, P.R. China
| | - Jingwen Liu
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, Shandong 252000, P.R. China
| | - Chuansheng Yang
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, Shandong 252000, P.R. China
| | - Youzhang Xiang
- Shandong Institute for Endemic Disease Control, Jinan, Shandong 250014, P.R. China
| | - Yuehai Wang
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, Shandong 252000, P.R. China
| | - Jing Wang
- Shandong Institute for Endemic Disease Control, Jinan, Shandong 250014, P.R. China
| | - Miaomiao Cao
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, Shandong 252000, P.R. China
| | - Wenbo Yang
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, P.R. China
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Karauzum K, Karauzum I, Kilic T, Sahin T, Baydemir C, Baris Argun S, Celikyurt U, Bildirici U, Agir A. Bendopnea and Its Clinical Importance in Outpatient Patients with Pulmonary Arterial Hypertension. ACTA CARDIOLOGICA SINICA 2018; 34:518-525. [PMID: 30449993 DOI: 10.6515/acs.201811_34(6).20180528a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Bendopnea is a recently reported novel symptom in patients with heart failure (HF) defined as shortness of breath when bending forward. It has been demonstrated that bendopnea is associated with advanced symptoms and worse outcomes. The aim of this study was to assess the presence of bendopnea and its clinical importance with regards to functional status, hemodynamic and echocardiographic characteristics in outpatient pulmonary arterial hypertension (PAH) patients. Methods We conducted this prospective observational study of 53 patients who were admitted to our PAH clinic for routine control visits. We determined the presence of bendopnea and analyzed hemodynamic parameters, World Heart Organization (WHO) functional class, transcutaneous oxygen saturation, 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) and right ventricular (RV) function indicators in patients with and without bendopnea. Results Bendopnea was present 33.9% of the PAH patients. The mean age was higher in the patients with bendopnea than in those without bendopnea, but the difference was not significant (p = 0.201). The patients with bendopnea had a lower 6-MWD and higher NT-proBNP level (p < 0.001), and worse WHO functional class symptoms (p = 0.010). Mean right atrial pressure, pulmonary artery pressure, and pulmonary vascular resistance were higher in the patients with bendopnea. The patients with bendopnea had a more dilated RV end-diastolic diameter and lower tricuspid annular plane systolic excursion value (p < 0.001 and p = 0.001, respectively). Conclusions Bendopnea was associated with worse functional capacity status, hemodynamic characteristics and RV function in our outpatient PAH patients.
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Affiliation(s)
| | | | | | | | | | - Serap Baris Argun
- Department of Pulmonary Diseases, Medical Faculty, Kocaeli University, Kocaeli, Turkey
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Xiong W, Zhao Y, Xu M, Pudasaini B, Guo X, Liu J. A modified risk score in one-year survival rate assessment of group 1 pulmonary arterial hypertension. BMC Pulm Med 2018; 18:161. [PMID: 30326867 PMCID: PMC6192332 DOI: 10.1186/s12890-018-0712-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 08/21/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Risk assessment of pulmonary arterial hypertension (PAH) contributes to its management. Unfortunately, the existing risk assessment approaches are defective for clinicians to practice in daily clinical settings to some extent. METHODS We designed a modified Risk Assessment Score of PAH (mRASP) comprising four non-invasive variables which were World Health Organization functional class(WHO FC), 6-min walk distance (6MWD), N-terminal of the pro-hormone brain natriuretic peptide(NT-pro BNP), and right atrial area(RAA), then validated it in the prediction of one-year survival rate for patients with PAH by contrast with the REVEAL risk score. RESULTS For the validation cohort(n = 216), the predicted one-year survival rate were 95-100%, 90-95%, and < 90% in the mRASP risk score strata of 0-2, 3-5, and 6-8, respectively; meanwhile, the observed one-year survival rates were 97.1, 92.6, and 52.2%, in each corresponding stratum, respectively. The mRASP (c-index = 0.727) demonstrated similar predictive power in contrast with the REVEAL risk assessment score (c-index = 0.715) in the prediction of one-year survival rate. CONCLUSION The mRASP is an eligible risk assessment tool for the prognostic assessment of PAH. In contrast with the REVEAL score, it demonstrated similar predictive power and accuracy, with extra simplicity and convenience.
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Affiliation(s)
- Wei Xiong
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092 China
- Department of Cardiopulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Yunfeng Zhao
- Department of Respiratory Medicine, Punan Hospital, Pudong New District, Shanghai, China
| | - Mei Xu
- Department of Pediatrics, Kongjiang Hospital, Yangpu District, Shanghai, China
- Department of Pediatrics, Shanghai Dinghai Community Health Service Center, Tongji University School of Medicine, Yangpu District, Shanghai, China
| | - Bigyan Pudasaini
- Department of Cardiopulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092 China
| | - Jinming Liu
- Department of Cardiopulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
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30
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Risk stratification strategy and assessment of disease progression in patients with pulmonary arterial hypertension: Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:20-29. [PMID: 30266353 DOI: 10.1016/j.ijcard.2018.08.084] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 11/22/2022]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available, and were last updated in the spring of 2018. This article focusses on the proposed risk stratification and assessment of disease progression in patients with pulmonary arterial hypertension (PAH), covering 3 parts: In part 1, methods and markers that are recommended to assess severity and progression of PAH are discussed and commented. These updated comments incorporate most recent data as well as challenges arising from the variability of phenotypes of PAH patients with increasing cardiopulmonary comorbidities. In part 2, the proposed ESC/ERS risk stratification strategy is discussed, together with a review of the recent validation studies from different European registries. Finally, in part 3, the working group of the Cologne Consensus Conference provides recommendations on how risk assessment may be implemented in routine clinical practice and may serve clinical decision making.
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31
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Halliday SJ, Xu M, Thayer TE, Mosley JD, Sheng Q, Ye F, Farber-Eger EH, Pugh ME, Robbins IR, Assad TR, West JD, Brittain EL, Hemnes AR. Clinical and genetic associations with prostacyclin response in pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018800544. [PMID: 30142026 PMCID: PMC6134494 DOI: 10.1177/2045894018800544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Parenteral prostacyclin therapy is the most efficacious pharmacologic treatment for pulmonary arterial hypertension (PAH), but clinical response is variable. We sought to identify clinical, hemodynamic, and genetic associations with response to prostacyclin therapy. We performed a retrospective analysis of patients within a de-identified electronic health record and associated DNA biobank. Patients with PAH and a right heart catheterization (RHC) in the six months before initiation of a parenteral prostacyclin were included. Responders were defined a priori by attainment of World Health Organization (WHO) functional class (FC) 2 or better at the time of repeat RHC within two years. We performed exploratory analyses to identify genomic associations with prostacyclin response. Of 129 patients identified, 54 met our criteria for “responders.” These patients were younger, more likely to be male, and were less likely to have connective tissue disease-related PAH. At follow-up, responders had improved hemodynamics, 6-min walk distance, and long-term survival. Baseline PA oxygen saturation (hazard ratio [HR] 0.568 [0.34–0.95]) and follow-up FC (HR = 2.57 [1.22–5.43]) were associated with survival. Prostacyclin responders were enriched in alleles related to cell development and circulatory system development and pathways related to aldosterone metabolism, cAMP signaling, and vascular smooth muscle contraction (P < 0.001). Age at treatment initiation, WHO FC at short-term follow-up, and PA O2% are associated with survival in patients with PAH exposed to parenteral prostacyclins. Exploratory genetic analysis yielded associations in biologically relevant pathways in the pathogenesis of PAH.
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Affiliation(s)
- Stephen J Halliday
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meng Xu
- 2 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy E Thayer
- 3 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D Mosley
- 4 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Quanhu Sheng
- 5 Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fei Ye
- 2 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric H Farber-Eger
- 6 Center for Translational and Clinical Cardiovascular Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith E Pugh
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ivan R Robbins
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tufik R Assad
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James D West
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan L Brittain
- 3 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,6 Center for Translational and Clinical Cardiovascular Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna R Hemnes
- 1 Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Shah AC, Ma K, Faraoni D, Oh DCS, Rooke GA, Van Norman GA. Self-reported functional status predicts post-operative outcomes in non-cardiac surgery patients with pulmonary hypertension. PLoS One 2018; 13:e0201914. [PMID: 30114222 PMCID: PMC6095504 DOI: 10.1371/journal.pone.0201914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/30/2018] [Indexed: 01/26/2023] Open
Abstract
Background Pulmonary hypertension (PHTN) is associated with increased post-procedure morbidity and mortality. Pre-procedure echocardiography (ECHO) is a widely used tool for evaluation of these patients, but its accuracy in predicting post-procedure outcomes is unproven. Self-reported exercise tolerance has not been evaluated for operative risk stratification of PHTN patients. Objective We analyzed whether self-reported exercise tolerance predicts outcomes (hospital length-of-stay [LOS], mortality and morbidity) in PHTN patients (WHO Class I–V) undergoing anesthesia and surgery. Methods and findings We reviewed 550 non-cardiac, non-obstetric procedures performed on 370 PHTN patients at a single institution between 2007 and 2013. All patients had cardiac ECHO documented within 1 year prior to the procedure. Pre-procedure comorbidities and ECHO data were collected. Functional status (< or ≥ 4 metabolic equivalents of task [METs]) was assigned based on responses to standard patient interview questions during the pre-anesthesia clinic visit. Multiple logistic regression was used to develop a risk score model (Pulmonary Hypertension Outcome Risk Score; PHORS) and determine its value in predicting post-procedure outcomes. In an adjusted model, functional status <4 METs was independently associated with a LOS >7 days (p < .003), as were higher ASA class (p < .002), open surgical approach (p < .002), procedure duration > 2 hours (p < .001), and the absence of systemic hypertension (p = .012). PHORS Score ≥2 was associated with an increased 30-day major complication rate (28.7% vs. 19.2%; p < 0.001) and ICU admission rate (8.6% s 2.8%; p = .007), but no statistical difference in hospital readmissions rate (17.6% vs. 14.0%; p = .29), or mortality (3.5% vs. 1.4%; p = .75). Similar ECHO findings did not further improve outcome prediction. Conclusions Poor functional status is associated with severe PHTN and predicts increased LOS and post-procedure complications in patients with moderate to severe pulmonary hypertension with different etiologies. A risk assessment model predicts increased LOS with fair accuracy. A thorough evaluation of underlying etiologies of PHTN should be undertaken in every patient.
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Affiliation(s)
- Aalap C. Shah
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
- * E-mail:
| | - Kevin Ma
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Daniel C. S. Oh
- School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - G. Alec Rooke
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
| | - Gail A. Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
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Scott TE, Kemp-Harper BK, Hobbs AJ. Inflammasomes: a novel therapeutic target in pulmonary hypertension? Br J Pharmacol 2018; 176:1880-1896. [PMID: 29847700 DOI: 10.1111/bph.14375] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/26/2018] [Accepted: 05/18/2018] [Indexed: 01/01/2023] Open
Abstract
Pulmonary hypertension (PH) is a rare, progressive pulmonary vasculopathy characterized by increased mean pulmonary arterial pressure, pulmonary vascular remodelling and right ventricular failure. Current treatments are not curative, and new therapeutic strategies are urgently required. Clinical and preclinical evidence has established that inflammation plays a key role in PH pathogenesis, and recently, inflammasomes have been suggested to be central to this process. Inflammasomes are important regulators of inflammation, releasing the pro-inflammatory cytokines IL-1β and IL-18 in response to exogenous pathogen- and endogenous damage-associated molecular patterns. These cytokines are elevated in PH patients, but whether this is a consequence of inflammasome activation remains to be determined. This review will briefly summarize current PH therapies and their pitfalls, introduce inflammasomes and the mechanisms by which they promote inflammation and, finally, highlight the preclinical and clinical evidence for the potential involvement of inflammasomes in PH pathobiology and how they may be targeted therapeutically. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.
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Affiliation(s)
- Tara Elizabeth Scott
- William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UK.,Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Pharmacology, Monash University, Clayton, VIC, Australia
| | - Barbara K Kemp-Harper
- Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Pharmacology, Monash University, Clayton, VIC, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UK
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34
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Billings CG, Lewis R, Armstrong IJ, Hurdman JA, Smith IA, Austin M, Elliot CA, Charalampopoulos A, Sabroe I, Lawrie A, Thompson AAR, Condliffe R, Kiely DG. Incremental Shuttle Walking Test Distance Is Reduced in Patients With Pulmonary Hypertension in World Health Organisation Functional Class I. Front Med (Lausanne) 2018; 5:172. [PMID: 29977892 PMCID: PMC6022155 DOI: 10.3389/fmed.2018.00172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background: There is increasing interest in screening for and diagnosing pulmonary hypertension earlier in the course of disease. However, there is limited data on cardiopulmonary abnormalities in patients with pulmonary hypertension newly diagnosed in World Health Organization Function Class (WHO FC) I. Methods: Data were retrieved from the ASPIRE registry (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral center) for consecutive treatment naïve patients diagnosed with pulmonary hypertension by cardiac catheterization between 2001 and 2010 who underwent incremental shuttle walk exercise testing. Results: Eight hundred and ninety-five patients were diagnosed with Group 1-5 pulmonary hypertension. Despite the absence of symptoms, patients in WHO FC I (n = 9) had a significant reduction in exercise capacity (Incremental shuttle walk distance percent predicted (ISWD%pred) 65 ± 13%, Z score -1.77 ± 1.05), and modest pulmonary hypertension with a median (interquartile range) pulmonary artery pressure 31(20) mmHg and pulmonary vascular resistance 2.1(8.2) Wood Units, despite a normal diffusion of carbon monoxide adjusted for age and sex (DLco)%pred 99 ± 40%. Compared to patients in WHO FC I, patients in WHO FC II (n = 162) had a lower ISWD%pred 43 ± 22 and lower DLco%pred 65 ± 21%. Conclusion: Our results demonstrate that patients with newly diagnosed pulmonary hypertension with no or minimal symptomatic limitation have a significant reduction of exercise capacity.
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Affiliation(s)
- Catherine G Billings
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Iain J Armstrong
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Judith A Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ian A Smith
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Matthew Austin
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ian Sabroe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, United Kingdom
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, United Kingdom
| | - A A Roger Thompson
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, United Kingdom.,Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
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35
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Benza RL, Lohmueller LC, Kraisangka J, Kanwar M. Risk Assessment in Pulmonary Arterial Hypertension Patients: The Long and Short of it. ACTA ACUST UNITED AC 2018. [DOI: 10.21693/1933-088x-16.3.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a chronic and rapidly progressive disease that is characterized by extensive narrowing of the pulmonary vasculature, leading to increases in pulmonary vascular resistance, subsequent right ventricular dysfunction, and eventual death. There are currently multiple approved drugs—developed as single or combination therapies in the last few years—that have improved outcome and functionality in PAH. However, despite improvement in short-term survival with these new effective therapies, PAH remains an incurable disease with a median survival of 7 years (Figure 1).1 This chronic disease state may be characterized by morbid events such as hospitalizations that herald rapid disease progression and account for a significant disease burden (Figure 2).23 Physician ability to predict PAH disease progression is critical for determining optimal care of patients. Accurate risk assessment allows clinicians to determine the patient's prognosis, identify treatment goals, and monitor disease progression and the patient's response to treatment. Risk assessment for PAH patients should include a range of clinical, hemodynamic, and exercise parameters, performed in a serial fashion over the treatment course. Patient risk stratification can also help physicians better allocate treatment resources in settings where they are scarce. If widely adopted, risk prediction can enhance the consistency of treatment approaches across PAH practitioners and improve the timeliness of referral for lung transplantation. Hence, along with advancing PAH treatment options, comprehensive risk prediction is essential to make individualized treatment decisions in the current treatment era.
Several tools are currently available for assessing risk in PAH (Figure 3). These include the 2015 European Society of Cardiology/European Respiratory Society pulmonary hypertension guidelines' risk variables,4 the French registry equation,5 the National Institutes of Health risk equation,6 or a risk score such as the one derived from the Registry to Evaluate Early And Long-term PAH Disease Management.1 These registries and evaluations of clinical trial sets have provided important insights into the importance of both modifiable (eg, 6-minute walk distance, functional class, brain natriuretic peptide, and nonmodifiable (eg, age, gender, PAH etiology) risk factors that predict survival. The following review explores commonly cited risk factors, both modifiable and nonmodifiable, and their implications for patient outcomes.
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Jung JY, Lee CH, Kim HA, Choi ST, Lee JH, Yoon BY, Kang DR, Suh CH. Pulmonary Hypertension in Connective Tissue Disease is Associated with the New York Heart Association Functional Class and Forced Vital Capacity, But Not with Interstitial Lung Disease. JOURNAL OF RHEUMATIC DISEASES 2018; 25:179. [DOI: 10.4078/jrd.2018.25.3.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/14/2018] [Accepted: 03/28/2018] [Indexed: 08/30/2023]
Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chan Hee Lee
- Department of Rheumatology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Sang Tae Choi
- Department of Rheumatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Joo-Hyun Lee
- Division of Rheumatology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Bo-Young Yoon
- Division of Rheumatology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dae-Ryong Kang
- Department of Medical Humanities and Social Medicine, Office of Biostatistics, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Schneider M, Pistritto AM, Gerges C, Gerges M, Binder C, Lang I, Maurer G, Binder T, Goliasch G. Multi-view approach for the diagnosis of pulmonary hypertension using transthoracic echocardiography. Int J Cardiovasc Imaging 2017; 34:695-700. [PMID: 29230598 PMCID: PMC5889411 DOI: 10.1007/s10554-017-1279-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/15/2017] [Indexed: 11/30/2022]
Abstract
Pulmonary hypertension (PH) is a disease with severe morbidity and mortality. Echocardiography plays an essential role in the screening of PH. The quality of the acquired continuous wave Doppler signal is the major limitation of the method and can greatly affect the accuracy of estimated pulmonary pressures. The aim of this study was to evaluate the clinical need to image from multiple ultrasound windows in patients with suspected pulmonary hypertension. We prospectively evaluated 65 patients (43% male, mean age 67.2 years) with echocardiography and right heart catheterization. 17% had invasively normal pulmonary pressures, 83% had pulmonary hypertension. Peak tricuspid regurgitation (TR) velocity was imaged in five echocardiographic views. Sufficient Doppler signal was recorded in 94% of the patients. Correlation for overall peak TR velocity with invasively measured systolic pulmonary artery pressure was r = 0.83 (p < 0.001). Considering all five imaging windows resulted in a sensitivity of 87%, and a specificity of 91% for correct diagnosis of PH with an AUC of 0.89, which was significantly better as compared to sole imaging from the right ventricular modified apical four-chamber view (AUC 0.85, p = 0.0395). Additional imaging from atypical views changed the overall peak TR velocity in 32% of the patients. A multiple-view approach changed the echocardiographic diagnosis of PH in 11% of the patients as opposed to sole imaging from an apical four-chamber view. This study comprehensively assessed the impact on clinical decision making when evaluating patients with an echocardiographic multiplane approach for suspected PH. This approach substantially increased sensitivity without a decrease in specificity.
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Affiliation(s)
- Matthias Schneider
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anna Maria Pistritto
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.,Emergency Department, Division of Cardiology, San Paolo Hospital, Savona, Italy
| | - Christian Gerges
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Mario Gerges
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Irene Lang
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Gerald Maurer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Humbert M, Singh M, Furst DE, Khanna D, Seibold JR. Pulmonary hypertension related to systemic sclerosis: points to consider for clinical trials. Rheumatology (Oxford) 2017; 56:v33-v37. [PMID: 28992168 DOI: 10.1093/rheumatology/kex197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Indexed: 01/05/2023] Open
Abstract
There are proven successful approaches to clinical trial design in pulmonary arterial hypertension (PAH), which in turn have led to the licensing of a number of effective therapies. SSc has been included in trials of World Health Organization Group 1 PAH but has been under-represented. Responses in outcomes as diverse as exercise capacity, quality of life, durability of drug effect and survival have been reduced in comparison with those seen in idiopathic PAH. The PAH community has achieved international and interdisciplinary consensus guidelines for future studies. We consider the diverse outcome measures used in trials in the context of the complexities of scleroderma. An argument is advanced in favour of future trials focused exclusively on SSc but with adaptations of the core outcome measures and trial design templates applicable to more general studies of PAH.
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Affiliation(s)
- Marc Humbert
- Faculté de Médecine, Université Paris-Sud.,Service de Pneumologie, DHU Thorax Innovation, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre.,Inserm U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Manjit Singh
- Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Daniel E Furst
- Department of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
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Banerjee D, Kamuren J, Baird GL, Palmisciano A, Krishnan I, Whittenhall M, Klinger JR, Ventetuolo CE. The Modified Borg Dyspnea Scale does not predict hospitalization in pulmonary arterial hypertension. Pulm Circ 2017; 7:384-390. [PMID: 28597751 PMCID: PMC5467923 DOI: 10.1177/2045893217695568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Breathlessness is the most common symptom reported by patients with pulmonary arterial hypertension (PAH). The Modified Borg Dyspnea Scale (MBS) is routinely obtained during the six-minute walk test in the assessment of PAH patients, but it is not known whether the MBS predicts clinical outcomes such as hospitalizations in PAH. Methods We performed a retrospective study of World Health Organization (WHO) Group 1 PAH patients followed at our center. The dates of the first three MBS and hospitalizations that occurred within three months of a documented MBS were collected. Marginal Cox hazard regression modeling was used to assess for a relationship between MBS and all-cause as well as PAH-related hospitalization. Results A total of 50 patients were included; most (92%) were functional class III/IV, 44% and 65% were treatment-naïve prior to their first MBS and hospitalization, respectively. The first recorded MBS was inversely correlated with the first recorded six-minute walk distance (6MWD) (r = –0.41, P < 0.01) but did not track with WHO functional class (r = 0.07, P = 0.63). MBS did not predict all-cause (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.76–1.08; P = 0.28) or PAH-related hospitalization (HR, 1.04; 95% CI, 0.89–1.23; P = 0.61), though there was a strong relationship between 6MWD and PAH-related hospitalization (P = 0.01). These findings persisted after multivariable adjustment. Conclusions Breathlessness as assessed by MBS does not predict all-cause or PAH-related hospitalization. Robust and validated patient-reported outcomes are needed in pulmonary vascular disease.
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Affiliation(s)
- Debasree Banerjee
- 1 Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Jane Kamuren
- 1 Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | | | - Mary Whittenhall
- 1 Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - James R Klinger
- 1 Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- 1 Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.,3 Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
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Divers C, Platt D, Wang E, Lin J, Lingohr-Smith M, Mathai SC. A Review of Clinical Trial Endpoints of Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension and How They Relate to Patient Outcomes in the United States. J Manag Care Spec Pharm 2017; 23:92-104. [PMID: 28025931 PMCID: PMC10398058 DOI: 10.18553/jmcp.2017.23.1.92] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are subgroups of pulmonary hypertension and are considered rare diseases. Understanding how endpoints of clinical trials (and patient registry studies) of patients with PAH and CTEPH are associated with patient outcomes is important in order to address the concerns of patients, health care providers, decision makers, and payers. The purpose of this review was to examine how endpoints used in clinical trials and patient registry studies are associated with outcomes of patients with PAH and CTEPH. A PubMed literature search was conducted to retrieve published studies, including randomized phase III clinical trials and observational studies, from years 2000 to May 2015 that evaluated the associations between change in 6-minute walking distance (6MWD), 6MWD thresholds, change in World Health Organization functional class (WHO-FC), and time to clinical worsening with outcomes of patients with PAH and CTEPH. Based on this review of published literature, a reduction in 6MWD as a criterion for PAH worsening, a deterioration in WHO-FC, and delay in the time to clinical worsening are clinically meaningful trial endpoints and are associated with outcomes of patients with PAH and CTEPH. Utilization and standardization of these endpoints will be useful for comparing interventions of clinical trials and therapies. Hospitalizations are frequent among patients with PAH and CTEPH, and total health care costs are high. From a U.S. payer perspective, clinical worsening is an important composite endpoint in that it includes hospitalization, which can be transformed into a preventative cost value associated with efficacious treatment of patients with PAH and CTEPH. In view of the greater number of medications available to treat PAH, the introduction of the first approved therapy to treat CTEPH, and the increasing use of combination pharmacotherapy, reliable prognostic markers of treatment responsiveness are important to help guide appropriate management. As new clinical trials and observational studies are conducted, it will be important to maintain universal endpoints so that health care providers, decision makers, and payers can better understand the value of targeted pharmacotherapies and combination therapies for the treatment of patients with PAH and CTEPH. DISCLOSURES Sponsorship for this review and article processing charges were funded by Bayer HealthCare Pharmaceuticals. Divers and Platt are employees of Bayer HealthCare Pharmaceuticals. Wang is an employee of Bayer HealthCare Pharmaceuticals and owns stock in the company. Lin and Lingohr-Smith are employees of Novosys Health, which received research funds from Bayer HealthCare Pharmaceuticals in connection with conducting this review and developing this manuscript. Mathai is a consultant to Bayer HealthCare Pharmaceuticals and also reports consulting fees from Actelion and Gilead. Study concept and design were contributed by Divers, Platt, Lin, and Mathai. Lin and Lingohr-Smith collected the data, and data interpretation was performed by Divers, Platt, Wang, and Matthai. The manuscript was written primarily by Lingohr-Smith, with assistance from the other authors, and revised by Divers, Platt, Wang, and Mathai.
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Affiliation(s)
| | - David Platt
- 1 Bayer HealthCare Pharmaceuticals, Whippany, New Jersey
| | - Edward Wang
- 1 Bayer HealthCare Pharmaceuticals, Whippany, New Jersey
| | - Jay Lin
- 2 Novosys Health, Green Brook, New Jersey
| | | | - Stephen C Mathai
- 3 Johns Hopkins University School of Medicine, Baltimore, Maryland
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Affiliation(s)
- Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John J Ryan
- University Hospital, University of Utah, Salt Lake City, Utah, USA
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Abstract
RATIONALE Pulmonary arterial hypertension is a progressive disease with high morbidity and mortality despite advances in medical therapy. The relationship between patient-related outcomes, such as health-related quality of life (HRQOL), and survival is not well described. OBJECTIVE To assess the relationship between HRQOL and outcomes in patients with pulmonary arterial hypertension. METHODS Consecutive patients with right heart catheterization-proven pulmonary arterial hypertension who completed the Medical Outcomes Survey Short Form-36 survey (SF-36) were included. Demographic, clinical, physiological, and hemodynamic data were collected at baseline. Survival was assessed from the time of diagnosis of pulmonary arterial hypertension. Cox proportional hazard models were constructed to assess the relationship between HRQOL and transplant-free survival. MEASUREMENTS AND MAIN RESULTS Eighty-seven patients with pulmonary arterial hypertension were enrolled and followed prospectively for a median of 3.8 years. At baseline, HRQOL was significantly worse than U.S. normal values for six of eight domains of the SF-36. Several domains demonstrated moderate correlation (r value ≥ 0.40) with 6-minute-walk distance and World Health Organization functional class; there were no significant associations with hemodynamics. In univariable Cox proportional hazard models, six of eight domains and both summary scores were significantly associated with survival. In multivariable models, adjusted for age, disease type, and cardiac function, these relationships largely persisted. CONCLUSIONS In this cohort of patients with pulmonary arterial hypertension, HRQOL, as assessed by the SF-36, was strongly associated with transplant-free survival. These relationships persisted when controlling for potential confounders such as disease type and disease severity. These findings suggest that HRQOL may be an important predictor of outcomes in pulmonary arterial hypertension and therefore a target for future therapeutic interventions.
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Persistent right ventricular dysfunction, functional capacity limitation, exercise intolerance, and quality of life impairment following pulmonary embolism: Systematic review with meta-analysis. Vasc Med 2016; 22:37-43. [DOI: 10.1177/1358863x16670250] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Long-term right ventricular (RV) function, functional capacity, exercise capacity, and quality of life following pulmonary embolism (PE), and the impact of thrombolysis, are unclear. A systematic review of studies that evaluated these outcomes with ⩾ 3-month mean follow-up after PE diagnosis was performed. For each outcome, random effects meta-analyses were performed. Twenty-six studies (3671 patients) with 18-month median follow-up were included. The pooled prevalence of RV dysfunction was 18.1%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of RV dysfunction versus those treated with anticoagulation (odds ratio: 0.51, 95% CI: 0.24 to 1.13, p=0.10). Pooled prevalence of at least mild functional impairment (NYHA II–IV) was 33.2%, and at least moderate functional impairment (NYHA III–IV) was 11.3%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of at least moderate functional impairment versus those treated with anticoagulation (odds ratio: 0.48, 95% CI: 0.15 to 1.49, p=0.20). Pooled 6-minute walk distance was 415 m (95% CI: 372 to 458 m), SF-36 Physical Component Score was 44.8 (95% CI: 43 to 46), and Pulmonary Embolism Quality of Life (QoL) Questionnaire total score was 9.1. Main limitations included heterogeneity among studies for many outcomes, variation in the completeness of data reported, and inclusion of data from non-randomized, non-controlled, and retrospective studies. Persistent RV dysfunction, impaired functional status, diminished exercise capacity, and reduced QoL are common in PE survivors. The effect of thrombolysis on RV function and functional status remains unclear.
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Patients', relatives', and practitioners' views of pulmonary arterial hypertension: A qualitative study. Presse Med 2016; 45:e11-27. [PMID: 26775203 DOI: 10.1016/j.lpm.2015.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 05/26/2015] [Accepted: 06/11/2015] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION To study practitioners', patients' with PAH, and relatives' views regarding pulmonary arterial hypertension (PAH) and identify potential improvements in medical care strategies. METHODS A qualitative study based on semi-structured interviews involving 16 patients, 4 relatives, and 9 practitioners. RESULTS Patients with PAH, their relatives, and physicians who treat persons with PAH had divergent perspectives on PAH. The discrepancies identified concerned their perceptions of the illness and its impact on patients' with PAH daily lives. Patients with PAH had a broader view, including social, identity, financial, and functional dimensions of PAH's impact on their lives, whereas practitioners were more focused on functional aspects. The study also pointed out divergent approaches among physicians to assessing patients' New York Heart Association functional class. The expectations of patients with PAH, relatives, and physicians also differed. Patients with PAH expected improvement in PAH diagnosis and better coordination between primary care physicians and PAH medical centers. They also valued reducing side effects, less restrictive medications, and greater consideration of their views in the medical decision making process. Physicians' expectations focused more on identifying and validating therapeutic strategies. CONCLUSION Our results suggest several potential improvements in patient management, especially in order to better tailor treatment to patients' needs and to achieve a more uniform approach to the PAH functional impact assessment process. The findings may also be useful in enhancing therapeutic education for patients and their relatives, and in enabling practitioners to better interpret dyspnea in patients with PAH. Finally, this qualitative database will help in developing patient-reported outcome measures with better content validity. It lays the groundwork for developing new instruments to investigate the impact of PAH on patients' daily lives in terms of symptom assessment and functional impact.
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Abstract
Conducting clinical trials on pulmonary hypertension in the US and Western Europe has become increasingly difficult and costly because of many challenges. These include a limited patient population that makes recruitment difficult. Recruiting internationally has helped, but can add variability. The choice of end points is important but ideal end points that reflect pathogenesis of the disease are not available. The 6-min walk distance has been used in most trials to date, but recent trials have used an 'event-driven' design, in which combined outcomes are used to reflect progression of the disease. This design has advantages but requires many hundreds of patients and may take up to several years. Thus, there is still a role for functional or hemodynamic end points to enable testing of more new agents. Assuring the safety and scientific integrity of clinical trials without excessive regulation will also help facilitate the evaluation of additional therapies for this devastating disease.
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Affiliation(s)
- Nicholas S Hill
- a 1 Tufts Medical Center, Medicine, 800 Washington St #257, Boston 02111, USA
| | - Kari Roberts
- a 1 Tufts Medical Center, Medicine, 800 Washington St #257, Boston 02111, USA
| | - Ioana Preston
- b 2 Tufts Medical Center, 800 Washington St #257, Boston 01770, USA
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Kang KY, Jeon CH, Choi SJ, Yoon BY, Choi CB, Lee CH, Suh CH, Lee CW, Cho CS, Nam EJ, Koh EM, Kim HY, Choi HJ, Kim HA, Jun JB, Lee J, Kim J, Ji JD, Min JK, Kim KJ, Shin K, So MW, Kwon SR, Kim SK, Nah SS, Kwok SK, Lee SK, Lee SW, Park SH, Park W, Park YB, Lee YH, Lee SS, Yoo DH. Survival and prognostic factors in patients with connective tissue disease-associated pulmonary hypertension diagnosed by echocardiography: results from a Korean nationwide registry. Int J Rheum Dis 2015. [PMID: 26214170 DOI: 10.1111/1756-185x.12645] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). The survival rates and mortality-predictive factors of a nationwide registry of Korean patients with CTD-PH measured by echocardiography were determined. METHODS Patients with CTD-PH were enrolled between April 2008 and December 2012. Hemodynamic parameters and clinical data (WHO-functional class [FC], organ involvement, laboratory tests and treatment agents) were recorded. Survival rates were calculated by using the Kaplan-Meier method. Mortality-associated factors were examined by Cox proportional hazards regression analysis. RESULTS In total, 174 incident PH cases (61 with systemic lupus erythematosus, 50 with systemic sclerosis, 10 with mixed CTD, 22 with rheumatoid arthritis (RA) and 31 with other CTDs) were diagnosed by Doppler echocardiography. Of these, 25 (14%) died during the 3.8 ± 2.7 year follow-up period after PH diagnosis. The 1- and 3-year survival rates were 90.7% and 87.3%, respectively. Compared to the other CTD-PHs, RA-PH had the lowest survival rates (56% 3 year survival; P = 0.022). Multiple regression analysis revealed that low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were poor prognostic factors (P = 0.008, 0.04 and 0.009, respectively). Anti-UI-RNP (ribonucleoprotein) antibody positivity was protective (P = 0.022). In patients with WHO-FC III/IV, patients who received vasodilators had lower mortality than those who did not (P = 0.038). CONCLUSIONS In Korean patients with CTD-PH, the 3-year survival rate was 87%. Low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were independent poor prognostic factors. Anti-UI-RNP antibody was protective. Prompt PAH-specific vasodilator therapy may improve the survival of patients with severe CTD-PH.
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Affiliation(s)
- Kwi Young Kang
- Department of Internal Medicine, Incheon Saint Mary's Hospital, Catholic University of Korea, Incheon, Korea
| | - Chan Hong Jeon
- Department of Internal Medicine, Hospital Bucheon, Soonchunhyang University, Bucheon, Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Bo Young Yoon
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chan-Bum Choi
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Chang Hoon Lee
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Choong Won Lee
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Chul Soo Cho
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eon Jeong Nam
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eun-Mi Koh
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Ho-Youn Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Bum Jun
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jaejoon Lee
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jinseok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Dae Ji
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Jun Ki Min
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Jo Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kichul Shin
- Department of Internal Medicine, Borame Hospital, Seoul National University, Seoul, Korea
| | - Min Wook So
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Ryul Kwon
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Seong-Kyu Kim
- Department of Internal Medicine, Catholic University of Daegu, Daegu, Korea
| | - Seong-Su Nah
- Department of Internal Medicine, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Kon Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, Dong-A University, Pusan, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Park
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Yong-Beom Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School, Kwangju, Korea
| | - Dae Hyun Yoo
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
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MacKenzie AM, Peacock AJ. Medical Therapies for the Treatment of Pulmonary Arterial Hypertension: How Do We Choose? Curr Hypertens Rep 2015; 17:56. [DOI: 10.1007/s11906-015-0560-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Jardim C, Souza R. Biomarkers and Prognostic Indicators in Pulmonary Arterial Hypertension. Curr Hypertens Rep 2015; 17:556. [DOI: 10.1007/s11906-015-0556-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Ryan JJ, Butrous G, Maron BA. The heterogeneity of clinical practice patterns among an international cohort of pulmonary arterial hypertension experts. Pulm Circ 2015; 4:441-51. [PMID: 25621157 DOI: 10.1086/677357] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/16/2014] [Indexed: 11/03/2022] Open
Abstract
The extent to which pulmonary arterial hypertension (PAH) experts share common practice patterns that are in alignment with published expert consensus recommendations is unknown. Our objective was to characterize the clinical management strategies used by an international cohort of self-identified PAH experts. A 32-item questionnaire composed mainly of rank order or Likert scale questions was distributed via the Internet (August 5, 2013, through January 20, 2014) to four international pulmonary vascular disease organizations. The survey respondents (N = 105) were field experts reporting 11.6 ± 8.7 years of PAH experience. Likert scale responses (1 = disagree, 7 = agree) were 3.0-5.0, indicating a disparity in opinions, for 78% of questions. Respondent (dis)agreement scores were 4.4 ± 2.2 for use of expert recommendations to determine catheterization timing in PAH. For PAH patients without cardiogenic shock or known vasoreactivity status, the most and least preferred first-line therapies (1 = most preferred, 5 = least preferred) were phosphodiesterase type 5 inhibitors (PDE-Vi) and subcutaneous prostacyclin analogues, respectively (1.4 ± 0.8 vs. 4.0 ± 1.1; P < 0.05). Compared with US-practicing clinicians (N = 46), non-US-practicing clinicians (N = 57) favored collaboration between cardiology and pulmonary medicine for clinical decision making (1 = disagree, 7 = agree; 3.1 ± 2.2 vs. 4.8 ± 2.2; P < 0.0001) and PDE-Vi (6.5% vs. 22.4%) as first-line therapy for PAH patients with cardiogenic shock but were less likely to perform vasoreactivity testing in patients with lung disease-induced pulmonary hypertension (4.3 ± 2.1 vs. 2.2 ± 1.6; P < 0.0001). In conclusion, practice patterns among PAH experts diverge from consensus recommendations and differ by practice location, suggesting that opportunity may exist to improve care quality for this highly morbid cardiopulmonary disease.
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Affiliation(s)
- John J Ryan
- Division of Cardiology, University Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Ghazwan Butrous
- School of Pharmacy, University of Kent, Kent, United Kingdom
| | - Bradley A Maron
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; and Department of Cardiology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
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Taichman DB, Ornelas J, Chung L, Klinger JR, Lewis S, Mandel J, Palevsky HI, Rich S, Sood N, Rosenzweig EB, Trow TK, Yung R, Elliott CG, Badesch DB. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest 2014; 146:449-475. [PMID: 24937180 PMCID: PMC4137591 DOI: 10.1378/chest.14-0793] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/05/2014] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Choices of pharmacologic therapies for pulmonary arterial hypertension (PAH) are ideally guided by high-level evidence. The objective of this guideline is to provide clinicians advice regarding pharmacologic therapy for adult patients with PAH as informed by available evidence. METHODS This guideline was based on systematic reviews of English language evidence published between 1990 and November 2013, identified using the MEDLINE and Cochrane Library databases. The strength of available evidence was graded using the Grades of Recommendations, Assessment, Development, and Evaluation methodology. Guideline recommendations, or consensus statements when available evidence was insufficient to support recommendations, were developed using a modified Delphi technique to achieve consensus. RESULTS Available evidence is limited in its ability to support high-level recommendations. Therefore, we drafted consensus statements to address many clinical questions regarding pharmacotherapy for patients with PAH. A total of 79 recommendations or consensus statements were adopted and graded. CONCLUSIONS Clinical decisions regarding pharmacotherapy for PAH should be guided by high-level recommendations when sufficient evidence is available. Absent higher level evidence, consensus statements based upon available information must be used. Further studies are needed to address the gaps in available knowledge regarding optimal pharmacotherapy for PAH.
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Affiliation(s)
| | | | - Lorinda Chung
- Stanford University and Palo Alto VA Health Care System, Palo Alto, CA
| | | | | | | | | | | | | | | | | | - Rex Yung
- Johns Hopkins University, Baltimore, MD
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