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Nathan SD, Chandel A, Wang Y, Xu J, Shao L, Watkins TR, Diviney J, King CS, Han L. Derivation and validation of a noninvasive prediction tool to identify pulmonary hypertension in patients with IPF: Evolution of the model FORD. J Heart Lung Transplant 2024; 43:547-553. [PMID: 37979926 DOI: 10.1016/j.healun.2023.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND The administration of inhaled prostanoids to patients with pulmonary hypertension (PH) related to idiopathic pulmonary fibrosis (IPF) and other fibrotic lung diseases improves functional outcomes. Selection of patients with IPF at risk for concomitant PH to undergo right heart catheterization (RHC) remains challenging. We sought to develop a clinical prediction tool based on common noninvasive parameters to identify PH in patients with IPF. METHODS A prediction model based on noninvasive parameters was derived from patients enrolled in the ARTEMIS-IPF randomized, placebo-controlled clinical trial. Predictor variables were tested for association with the presence of PH diagnosed based on RHC. The derived multivariable logistic regression model and associated point-score index were then externally validated in a real-world cohort of patients with IPF. RESULTS Of the 481 patients included in the ARTEMIS-IPF study, 9.8% (N = 47) were diagnosed with PH related to IPF. Four variables were associated with PH and were included in the final model: forced vital capacity/diffusing capacity for carbon monoxide ratio (F), oxygen saturation nadir during 6-minute walk test (6MWT) (O), race (R), and distance ambulated during 6MWT (D). A model containing continuous predictors (FORD calculator) and a simple point-score system (FORD index) performed similarly well in the derivation cohort (area under the curve [AUC]: 0.75 and 0.75, respectively) and validation cohort (AUC: 0.69 and 0.69, respectively). CONCLUSIONS The FORD models are simple, validated tools incorporating noninvasive parameters that can be applied to identify patients at risk of PH related to IPF who may benefit from invasive testing.
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Affiliation(s)
- Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia.
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ya Wang
- Gilead Sciences Inc, Foster City, California
| | - Jiawei Xu
- Gilead Sciences Inc, Foster City, California
| | - Lixin Shao
- Gilead Sciences Inc, Foster City, California
| | | | - Jack Diviney
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Christopher S King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Ling Han
- Gilead Sciences Inc, Foster City, California
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Panagiotidou E, Βoutou A, Fouka E, Papakosta D, Chatzopoulos E, Sourla E, Markopoulou A, Kioumis I, Stanopoulos I, Pitsiou G. Phenotyping exercise limitation of patients with Interstitial Fibrosing Lung Disease: the importance of exercise hemodynamics. Pulmonology 2024; 30:104-112. [PMID: 35568651 DOI: 10.1016/j.pulmoe.2022.03.012] [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: 08/18/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Left-heart dysfunction and pulmonary vasculopathy are increasingly recognized as contributing factors of exercise capacity limitation in interstitial fibrosing lung disease (IFLD). Moreover, the clinical significance of exercise pulmonary hypertension (ePH) in pulmonary and cardiac diseases has been documented, representing a risk factor for decreased exercise capacity and survival, progression to resting pulmonary hypertension (PH) and overall clinical worsening. We conducted a prospective study aiming at: (a) assessing the prevalence of PH and ePH in a cohort of 40 functionally limited patients with IFLD, (b) determining the post-capillary (postC) or pre-capillary (preC) etiology of either PH or ePH in this cohort, and (c) examining the correlations between invasively and non-invasively measured exercise variables among hemodynamic groups. PATIENTS AND METHODS 40 IFLD patients underwent cardiopulmonary evaluation, including: clinical examination, lung function tests, 6-minute walking test, heart ultrasonography, cardiopulmonary exercise test and, finally, right heart catheterization (RHC). Resting hemodynamic evaluation was followed by the exercise protocol proposed by Herve et al, using a bedside cycle ergometer in the supine position. Abnormal elevation of mean pulmonary artery pressure (mPAP) above 30mmHg during exercise, with respect to abnormal elevation of cardiac output (CO) below 10 L/min (mPAP-CO ratio ⩾3 mmHg·min·L-1) was used to define ePH (Herve et al, 2015). Secondary hemodynamic evaluation involved detection of abnormal pulmonary arterial wedge pressure (PAWP) increase at peak exercise in relation to CO. Specifically, ΔPAWP/ΔCO >2 mmHg/L per minute determined an abnormal PAWP elevation (Bentley et al, 2020). RESULTS Among the 40-patient cohort, 25% presented postC PH, 37.5% preC PH, 27.5% ePH, with the remaining 10% recording normal hemodynamics. PAWP evaluation during exercise revealed a postC etiology in 4 out of the 11 patients presenting ePH, and a postC etiology in 6 out of the 15 patients presenting resting preC PH. Mean values of non-invasive variables did not display statistically significant differences among hemodynamic groups, except for: diffusing capacity for carbon monoxide (DLCO), carbon monoxide transfer coefficient (KCO) and the ratio of functional vital capacity to DLCO (FVC%/DLCO%), which were lower in both ePH and PH groups (p < 0.05). Resting values of CO, cardiac index (CI), stroke volume (SV) and pulmonary vascular compliance (PVC) were significantly impaired in ePH, preC-PH and postC-PH groups when compared to the normal group. CONCLUSIONS Both PH and ePH were highly prevalent within the IFLD patient group, suggesting that RHC should be offered more frequently in functionally limited patients. Diffusion capacity markers must thus guide decision making, in parallel to clinical evaluation. ePH was associated to lower resting CO and PVC, in a similar way to resting PH, indicating the relevance of cardiopulmonary function to exercise limitation. Finally, the use of the ΔPAWP/ΔCO>2 criterion further uncovered PH of postcapillary etiology, highlighting the complexity of hemodynamics in IFLD. CLINICALTRIALS gov ID: NCT03706820.
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Affiliation(s)
- E Panagiotidou
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - A Βoutou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - E Fouka
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Papakosta
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Chatzopoulos
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Sourla
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Markopoulou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - I Kioumis
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - I Stanopoulos
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - G Pitsiou
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kacprzak A, Tomkowski W, Szturmowicz M. Pulmonary Hypertension in the Course of Interstitial Lung Diseases-A Personalised Approach Is Needed to Identify a Dominant Cause and Provide an Effective Therapy. Diagnostics (Basel) 2023; 13:2354. [PMID: 37510098 PMCID: PMC10378268 DOI: 10.3390/diagnostics13142354] [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: 05/31/2023] [Revised: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
The prevalence of pulmonary hypertension (PH) complicating interstitial lung diseases (ILDs) is 3.5-15% at an early stage, and up to 90% in ILD patients listed for lung transplantation. In addition, other types of PH may occur in patients with ILDs due to concomitant conditions. Therefore, any significant PH occurring in the setting of ILD requires a proper differential workup. PH increases morbidity and mortality in ILDs. The pathomechanisms underlying PH due to ILD (PH-ILD) are not fully known, and there is no straightforward correlation between the presence or severity of PH-ILD and the severity of ILD. Severe PH in mild ILD without other explanatory causes constitutes a dilemma of differentiating between PH due to ILD and pulmonary arterial hypertension coexisting with ILDs. The heterogeneity and poor prognosis of patients with ILDs coexisting with PH necessitate an individualised approach to the management of this condition. This review presents recent advances in understanding and treatment options in PH-ILD. It also addresses practical issues, such as when to suspect and how to screen for PH in ILD, what are the indications for right heart catheterisation, and how to approach an individual ILD patient to determine the dominant PH cause and apply adequate management.
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Affiliation(s)
- Aneta Kacprzak
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
| | - Witold Tomkowski
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
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Trushenko NV, Suvorova OA, Nekludova GV, Levina IA, Chikina SY, Nikolenko AM, Tsareva NA, Volkov AV, Yaroshetskiy AI, Merzhoeva ZM, Nuralieva GS, Avdeev SN. Predictors of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients with Hypersensitivity Pneumonitis. Life (Basel) 2023; 13:1348. [PMID: 37374130 PMCID: PMC10302253 DOI: 10.3390/life13061348] [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: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) that occurs in susceptible individuals in response to various inhaled antigens. The fibrotic phenotype of HP is characterized by disease progression and can lead to pulmonary hypertension (PH). The aim of this study was to estimate the prevalence of PH and to identify predictors of PH in patients with chronic HP. METHODS We conducted an observational longitudinal study that included 85 patients with an established diagnosis of HP. Clinical examination, quality of life questionnaires, high-resolution computed tomography (HRCT) of the chest, arterial blood gases analyses, six-minute walking test (6-MWT), pulmonary function tests, and echocardiography were performed. RESULTS Patients were divided into groups with fibrotic (71.8%) and nonfibrotic phenotype (28.2%). PH was detected in 41 (48.2%) patients. Patients with PH had the predominant fibrotic phenotype of HP, were older, more symptomatic, and had a higher FVC/DLco ratio. The most significant predictors of PH were CT signs of fibrosis, finger clubbing, FVC/DLco, decreased distance, and SpO2 at the end of 6-MWT, as well as the presence of cardiovascular diseases. CONCLUSIONS PH is a common condition in patients with chronic HP, especially with the fibrotic phenotype. Early detection of the PH predictors is necessary for the timely diagnosis of this complication of HP.
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Affiliation(s)
- Natalia V. Trushenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Olga A. Suvorova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Galina V. Nekludova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Iuliia A. Levina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Svetlana Y. Chikina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Alexandra M. Nikolenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Natalia A. Tsareva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Alexandr V. Volkov
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Federal State Budgetary Scientific Institution, V. A. Nasonova Research Institute of Rheumatology, Kashirskoye Highway 34A, 115522 Moscow, Russia
| | - Andrey I. Yaroshetskiy
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Zamira M. Merzhoeva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Galiya S. Nuralieva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Sergey N. Avdeev
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
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Parikh R, Farber HW. Response to "Noninvasive determinants of pulmonary hypertension (PH) in interstitial lung disease (ILD)" by Joseph et al. Pulm Circ 2023; 13:e12239. [PMID: 37205150 PMCID: PMC10186004 DOI: 10.1002/pul2.12239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/15/2023] [Indexed: 05/21/2023] Open
Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep MedicineHartford HospitalHartfordConnecticutUSA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care MedicineTufts Medical CenterBostonMassachusettsUSA
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Piccari L, Allwood B, Antoniou K, Chung JH, Hassoun PM, Nikkho SM, Saggar R, Shlobin OA, Vitulo P, Nathan SD, Wort SJ. Pathogenesis, clinical features, and phenotypes of pulmonary hypertension associated with interstitial lung disease: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative - Group 3 Pulmonary Hypertension. Pulm Circ 2023; 13:e12213. [PMID: 37025209 PMCID: PMC10071306 DOI: 10.1002/pul2.12213] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a frequent complication of interstitial lung disease (ILD). Although PH has mostly been described in idiopathic pulmonary fibrosis, it can manifest in association with many other forms of ILD. Associated pathogenetic mechanisms are complex and incompletely understood but there is evidence of disruption of molecular and genetic pathways, with panvascular histopathologic changes, multiple pathophysiologic sequelae, and profound clinical ramifications. While there are some recognized clinical phenotypes such as combined pulmonary fibrosis and emphysema and some possible phenotypes such as connective tissue disease associated with ILD and PH, the identification of further phenotypes of PH in ILD has thus far proven elusive. This statement reviews the current evidence on the pathogenesis, recognized patterns, and useful diagnostic tools to detect phenotypes of PH in ILD. Distinct phenotypes warrant recognition if they are characterized through either a distinct presentation, clinical course, or treatment response. Furthermore, we propose a set of recommendations for future studies that might enable the recognition of new phenotypes.
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Affiliation(s)
- Lucilla Piccari
- Department of Pulmonary MedicineHospital del MarBarcelonaSpain
| | - Brian Allwood
- Department of Medicine, Division of PulmonologyStellenbosch University & Tygerberg HospitalCape TownSouth Africa
| | - Katerina Antoniou
- Department of Thoracic MedicineUniversity of Crete School of MedicineHeraklionCreteGreece
| | - Jonathan H. Chung
- Department of RadiologyThe University of Chicago MedicineChicagoIllinoisUSA
| | - Paul M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Rajan Saggar
- Lung & Heart‐Lung Transplant and Pulmonary Hypertension ProgramsUniversity of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Patrizio Vitulo
- Department of Pulmonary MedicineIRCCS Mediterranean Institute for Transplantation and Advanced Specialized TherapiesPalermoSiciliaItaly
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Stephen John Wort
- National Pulmonary Hypertension Service at the Royal Brompton HospitalLondonUK
- National Heart and Lung Institute, Imperial CollegeLondonUK
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Parikh R, Konstantinidis I, O'Sullivan DM, Farber HW. Pulmonary hypertension in patients with interstitial lung disease: a tool for early detection. Pulm Circ 2022; 12:e12141. [PMID: 36225536 PMCID: PMC9531548 DOI: 10.1002/pul2.12141] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension (PH) complicates the treatment of interstitial lung disease (ILD) patients resulting in poor functional status and worse outcomes. Early recognition of PH in ILD is important for initiating therapy and considering lung transplantation. However, no standard exists regarding which patients to screen for PH-ILD or the optimal method to do so. The aim of this study was to create a risk assessment tool that could reliably predict PH in ILD patients. We developed a PH-ILD Detection tool that incorporated history, exam, 6-min walk distance, diffusion capacity for carbon monoxide, chest imaging, and cardiac biomarkers to create an eight-component score. This tool was analyzed retrospectively in 154 ILD patients where each patient was given a score ranging from 0 to 12. The sensitivity (SN) and specificity (SP) of the PH-ILD Detection tool and an area-under-the-curve (AUC) were calculated. In this cohort, 74 patients (48.1%) had PH-ILD. A score of ≥6 on the PH-ILD Detection tool was associated with a diagnosis of PH-ILD (SN: 86.5%; SP: 86.3%; area-under-the-curve: 0.920, p < 0.001). The PH-ILD Detection tool provides high SN and SP for detecting PH in ILD patients. With confirmation in larger cohorts, this tool could improve the diagnosis of PH in ILD and may suggest further testing with right heart catheterization and earlier intervention with inhaled treprostinil and/or lung transplant evaluation.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care, and SleepHartford HospitalHartfordConnecticutUSA
| | | | - David M. O'Sullivan
- Department of Research AdministrationHartford HealthCareHartfordConnecticutUSA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care MedicineTufts Medical CenterBostonMassachusettsUSA
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8
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Rahaghi FF, Kolaitis NA, Adegunsoye A, de Andrade JA, Flaherty KR, Lancaster LH, Lee JS, Levine DJ, Preston IR, Safdar Z, Saggar R, Sahay S, Scholand MB, Shlobin OA, Zisman DA, Nathan SD. Screening Strategies for Pulmonary Hypertension in Patients With Interstitial Lung Disease: A Multidisciplinary Delphi Study. Chest 2022; 162:145-155. [PMID: 35176276 PMCID: PMC9993339 DOI: 10.1016/j.chest.2022.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication of interstitial lung disease (ILD) and is associated with worse outcomes and increased mortality. Evaluation of PH is recommended in lung transplant candidates, but there are currently no standardized screening approaches. Trials have identified therapies that are effective in this setting, providing another rationale to routinely screen patients with ILD for PH. RESEARCH QUESTION What screening strategies for identifying PH in patients with ILD are supported by expert consensus? STUDY DESIGN AND METHODS The study convened a panel of 16 pulmonologists with expertise in PH and ILD, and used a modified Delphi consensus process with three surveys to identify PH screening strategies. Survey 1 consisted primarily of open-ended questions. Surveys 2 and 3 were developed from responses to survey 1 and contained statements about PH screening that panelists rated from -5 (strongly disagree) to 5 (strongly agree). RESULTS Panelists reached consensus on several triggers for suspicion of PH including the following: symptoms, clinical signs, findings on chest CT scan or other imaging, abnormalities in pulse oximetry, elevations in brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP), and unexplained worsening in pulmonary function tests or 6-min walk distance. Echocardiography and BNP/NT-proBNP were identified as screening tools for PH. Right heart catheterization was deemed essential for confirming PH. INTERPRETATION Many patients with ILD may benefit from early evaluation of PH now that an approved therapy is available. Protocols to evaluate patients with ILD often overlap with evaluations for pulmonary hypertension-interstitial lung disease and can be used to assess the risk of PH. Because standardized approaches are lacking, this consensus statement is intended to aid physicians in the identification of patients with ILD and possible PH, and provide guidance for timely right heart catheterization.
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Affiliation(s)
- Franck F Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida, Weston, FL
| | | | - Ayodeji Adegunsoye
- Section of Pulmonary & Critical Care, The University of Chicago School of Medicine, Chicago, IL
| | - Joao A de Andrade
- Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Kevin R Flaherty
- Michigan Medicine Interstitial Lung Disease Program, University of Michigan, Ann Arbor, MI
| | | | - Joyce S Lee
- Pulmonary Sciences & Critical Care, University of Colorado School of Medicine, Aurora, CO
| | - Deborah J Levine
- Pulmonary Hypertension Center, UT Health San Antonio, San Antonio, TX
| | - Ioana R Preston
- Pulmonary Hypertension Center, Tufts Medical Center, Boston, MA
| | | | - Rajan Saggar
- Pulmonary and Critical Care Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA
| | | | | | - Oksana A Shlobin
- Inova Fairfax Heart & Lung Transplant Program, Inova Medical Group, Falls Church, VA
| | | | - Steven D Nathan
- Advanced Lung Disease Program, Lung Transplant Program, Inova Fairfax Hospital, Falls Church, VA.
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9
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Soliveres E, Mc Entee K, Couvreur T, Fastrès A, Roels E, Merveille AC, Tutunaru AC, Clercx C, Bolen G. Utility of Computed Tomographic Angiography for Pulmonary Hypertension Assessment in a Cohort of West Highland White Terriers With or Without Canine Idiopathic Pulmonary Fibrosis. Front Vet Sci 2021; 8:732133. [PMID: 34631858 PMCID: PMC8495013 DOI: 10.3389/fvets.2021.732133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
Abstract
West Highland white terriers (WHWTs) affected with canine idiopathic pulmonary fibrosis (CIPF) are at risk of developing precapillary pulmonary hypertension (PH). In humans, thoracic computed tomography angiography (CTA) is commonly used to diagnose and monitor patients with lower airway diseases. In such patients, CTA helps to identify comorbidities, such as PH, that could negatively impact prognosis. Diameter of the pulmonary trunk (PT), pulmonary trunk-to-aorta ratio (PT/Ao), and right ventricle-to-left ventricle ratio (RV/LV) are CTA parameters commonly used to assess the presence of PH. Pulmonary vein-to-right pulmonary artery ratio (PV/PA) is a new echocardiographic parameter that can be used in dogs to diagnose PH. The primary aim of this study was to evaluate the use of various CTA parameters to diagnose PH. An additional aim was to evaluate the correlation of RV/LV measurements between different CTA planes. CTA and echocardiography were prospectively performed on a total of 47 WHWTs; 22 affected with CIPF and 25 presumed healthy control dogs. Dogs were considered to have PH if pulmonary vein-to-right pulmonary artery ratio (PV/PA) measured on 2D-mode echocardiography was less than to 0.7. WHWTs affected with CIPF had higher PT/Ao compared with control patients. In WHWTs affected with CIPF, PT size was larger in dogs with PH (15.4 mm) compared with dogs without PH (13 mm, p = 0.003). A cutoff value of 13.8 mm predicted PH in WHWTs affected with CIPF with a sensitivity of 90% and a specificity of 87% (AUC = 0.93). High correlations were observed between the different CTA planes of RV/LV. Results suggest that diameter of the PT measured by CTA can be used to diagnose PH in WHWTs with CIPF.
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Affiliation(s)
- Eugénie Soliveres
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Kathleen Mc Entee
- Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Couvreur
- Department of Radiology, Christian Hospital Center Liège, Liège, Belgium
| | - Aline Fastrès
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Elodie Roels
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Anne-Christine Merveille
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Alexandru-Cosmin Tutunaru
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Cécile Clercx
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
| | - Géraldine Bolen
- Department of Clinical Sciences, Companion Animals, Faculty of Veterinary Medicine, Fundamental and Applied Research for Animals & Health (FARAH), University of Liège, Liège, Belgium
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Wernhart S, Hedderich J. Prediction of pulmonary hypertension in older adults based on vital capacity and systolic pulmonary artery pressure. JRSM Cardiovasc Dis 2020; 9:2048004020973834. [PMID: 33240494 PMCID: PMC7672752 DOI: 10.1177/2048004020973834] [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] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/25/2020] [Indexed: 11/20/2022] Open
Abstract
Objective Right heart catheterization (RHC) is associated with a higher procedural risk in older adults, but non-invasive estimation of pulmonary hypertension (PH) is a challenge. We aimed to elaborate a non-invasive prediction model to estimate PH. Methods and design We retrospectively analysed 134 older adults (70.0 years ±12.3; 44.9% males) who reported to our clinic with unclear dyspnea between 01/2015 and 01/2020 and had received RHC as a part of their diagnostic workup. Lung function testing, analysis of blood gas samples, 6 min walk distance and echocardiography were performed within 24 hours of RHC. Main outcome measures In a stepwise statistical approach by using an in/exclusion algorithm (using the AIC criterion) we analysed non-invasive parameters to test their value in predicting PH (defined as mean pulmonary artery pressure, PAmean, >25mmHg). Discrimination capability of the final model was measured by the AUC (area under curve) from an ROC (receiver operating characteristics) analysis. Results We yielded a sensitivity of 87.2% and a specificity of 62.5% in a combinatorial logistical model with systolic pulmonary artery pressure (sPAP) and forced vital capacity (VCmax), the discrimination index was 86.7%. The odds ratios for an increase of 10 mmHg of sPAP were 2.99 (2.08–4.65) and 1.86 (1.11–3.21) for a 1 l decrease in VCmax. On their own, VCmax proved to be specific (83.3%), while sPAP was a sensitive (79.1%) predictor for PH. Conclusions We provide a combinatorial model to predict PH from sPAP and VCmax in older adults, which may help to avoid invasive procedures.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany.,West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jürgen Hedderich
- Medistat-Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
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11
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King CS, Shlobin OA. The Trouble With Group 3 Pulmonary Hypertension in Interstitial Lung Disease: Dilemmas in Diagnosis and the Conundrum of Treatment. Chest 2020; 158:1651-1664. [PMID: 32387520 DOI: 10.1016/j.chest.2020.04.046] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022] Open
Abstract
Pulmonary hypertension (PH) due to interstitial lung disease (ILD; PH-ILD) can complicate a multitude of ILDs, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis, and nonspecific interstitial pneumonia. Development of PH-ILD is associated with increased need for supplemental oxygen, reduced mobility, and decreased survival. A high index of suspicion is required to make the diagnosis, given the substantial overlap in symptoms with those of ILD without PH. Severely reduced diffusing capacity or 6-min walk test distance, prominent exertional desaturation, and impaired heart rate recovery after exercise are all suggestive of the development of PH-ILD. Traditional transthoracic echocardiography is the most commonly used screening test for PH-ILD, but it lacks sensitivity and specificity. Newer echocardiographic tools involving 3-dimensional assessment of the right ventricle may have a role in both prognosis and the monitoring of patients with PH-ILD. Right-sided heart catheterization remains the gold standard for confirming a diagnosis of PH-ILD. Although there is little debate about the use of supplemental oxygen and diuretic therapy in the treatment of PH-ILD, treatment with pulmonary vasodilator therapy remains controversial. Although several studies have been terminated prematurely for harm, the recently completed INCREASE trial of inhaled treprostinil appears to validate the concept of treating PH-ILD with pulmonary vasodilators and, we hope, will serve as a foundation from which future studies can be developed.
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Affiliation(s)
- Christopher S King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Pulmonary Hypertension Program, Inova Fairfax Hospital, Falls Church, VA.
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12
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Kishaba T. Clinical staging of idiopathic pulmonary fibrosis. Respir Investig 2020; 58:81-82. [PMID: 31892464 DOI: 10.1016/j.resinv.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/14/2019] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Tomoo Kishaba
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Miyazato 281, Uruma, Okinawa, Japan.
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