1
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Budhram B, Weatherald J, Humbert M. Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:419-434. [PMID: 38499196 DOI: 10.1055/s-0044-1782217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.
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Affiliation(s)
- Brandon Budhram
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, European Reference Network for Rare Respiratory Diseases (ERN-LUNG), Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Le Kremlin-Bicêtre, France
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2
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Toma M, Savonitto G, Lombardi CM, Airò E, Driussi M, Gentile P, Howard L, Moschella M, Di Poi E, Pagnesi M, Monti S, Collini V, D'Angelo L, Vecchiato V, Giannoni A, Adamo M, Barbisan D, Bauleo C, Garascia A, Metra M, Sinagra G, Giudice FL, Stolfo D, Ameri P. Frequency, characteristics and risk assessment of pulmonary arterial hypertension with a left heart disease phenotype. Clin Res Cardiol 2024:10.1007/s00392-024-02448-9. [PMID: 38619580 DOI: 10.1007/s00392-024-02448-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
AIM To obtain real-world evidence about the features and risk stratification of pulmonary arterial hypertension (PAH) with a left heart disease (LHD) phenotype (PAH-LHD). METHODS AND RESULTS By reviewing the records of consecutive incident PAH patients at 7 tertiary centers from 2001 to 2021, we selected 286 subjects with all parameters needed to determine risk of death at baseline and at first follow-up with COMPERA and COMPERA 2.0 scores. Fifty seven (20%) had PAH-LHD according to the AMBITION definition. Compared with no-LHD ones, they were older, had higher BMI, more cardiovascular comorbidities, higher E/e' ratio and left atrial area, but lower BNP concentrations and better right ventricular function and pulmonary hemodynamics. Survival was comparable between PAH-LHD and no-LHD patients, although the former were less commonly treated with dual PAH therapy. Both COMPERA and COMPERA 2.0 discriminated all-cause mortality risk of PAH-LHD at follow-up, but not at baseline. Risk profile significantly improved during follow-up only when assessed by COMPERA 2.0. At multivariable analysis with low-risk status as reference, intermediate-high and high-risk, but not LHD phenotype, were associated with higher hazard of all-cause mortality. Results were comparable in secondary analyses including patients in the last 10 years and atrial fibrillation and echocardiographic abnormalities as additional criteria for PAH-LHD. CONCLUSIONS In real life, PAH-LHD patients are frequent, have less severe disease and are less likely treated with PAH drug combinations than no-LHD. The COMPERA 2.0 model may be more appropriate to evaluate their mortality risk during follow-up and how it is modulated by therapy.
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Affiliation(s)
- Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Giulio Savonitto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Carlo Maria Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Edoardo Airò
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Mauro Driussi
- Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Piero Gentile
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Luke Howard
- Faculty of Medicine, Imperial College London, National Heart & Lung Institute, London, UK
- Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Martina Moschella
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Emma Di Poi
- Department of Medicine, Rheumatology Clinic, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Matteo Pagnesi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Simonetta Monti
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Valentino Collini
- Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | | | - Veronica Vecchiato
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Alberto Giannoni
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Davide Barbisan
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Carolina Bauleo
- Cardiology and Pneumology Division, Fondazione Toscana G. Monasterio, Pisa, Italy
| | | | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy
| | - Francesco Lo Giudice
- Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Via Valdoni 7, 34149, Trieste, Italy.
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiovascular Network, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy.
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3
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Weatherald J, Sitbon O. Rebuttal From Drs Weatherald and Sitbon. Chest 2024; 165:496-498. [PMID: 38461013 DOI: 10.1016/j.chest.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine University of Alberta, Edmonton, AB, Canada
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
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4
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Blette BS, Moutchia J, Al-Naamani N, Ventetuolo CE, Cheng C, Appleby D, Urbanowicz RJ, Fritz J, Mazurek JA, Li F, Kawut SM, Harhay MO. Is low-risk status a surrogate outcome in pulmonary arterial hypertension? An analysis of three randomised trials. THE LANCET. RESPIRATORY MEDICINE 2023; 11:873-882. [PMID: 37230098 PMCID: PMC10592525 DOI: 10.1016/s2213-2600(23)00155-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Targeting short-term improvements in multicomponent risk scores for mortality in patients with pulmonary arterial hypertension (PAH) could result in improved long-term outcomes. We aimed to determine whether PAH risk scores were adequate surrogates for clinical worsening or mortality outcomes in PAH randomised clinical trials (RCTs). METHODS We performed an individual participant data meta-analysis of RCTs selected from PAH trials provided by the US Food and Drug Administration (FDA). We calculated predicted risk using the COMPERA, COMPERA 2.0, non-invasive FPHR, REVEAL 2.0, and REVEAL Lite 2 risk scores. The primary outcome of interest was time to clinical worsening, a composite endpoint composed of any of the following events: all-cause death, hospitalisation for worsening PAH, lung transplantation, atrial septostomy, discontinuation of study treatment (or study withdrawal) for worsening PAH, initiation of parenteral prostacyclin analogue therapy, or decrease of at least 15% in 6-min walk distance from baseline, combined with either worsening of WHO functional class from baseline or the addition of an approved PAH treatment. The secondary outcome of interest was time to all-cause mortality. We assessed the surrogacy of these risk scores, parameterised as attainment of low-risk status by 16 weeks, for improvement in long-term clinical worsening and survival using mediation and meta-analysis frameworks. FINDINGS Of 28 trials received from the FDA, three RCTs (AMBITION, GRIPHON, and SERAPHIN; n=2508) had the data necessary to assess long-term surrogacy. The mean age was 49 years (SD 16), 1956 (78%) participants were women, 1704 (68%) were classified as White, and 280 (11%) were Hispanic or Latino. 1388 (55%) of 2503 participants with available data had idiopathic PAH and 776 (31%) of 2503 had PAH associated with connective tissue disease. In a mediation analysis, the proportions of treatment effects explained by attainment of low-risk status ranged only from 7% to 13%. In a meta-analysis of trial-regions, the treatment effects on low-risk status were not predictive of the treatment effects on time to clinical worsening (R2 values 0·01-0·19) nor the treatment effects on time to all-cause mortality (R2 values 0-0·2). A leave-one-out analysis suggested that the use of these risk scores as surrogates might lead to biased inferences regarding the effect of therapies on clinical outcomes in PAH RCTs. Results were similar when using absolute risk scores at 16 weeks as the potential surrogates. INTERPRETATION Multicomponent risk scores have utility for the prediction of outcomes in patients with PAH. Clinical surrogacy for long-term outcomes cannot be inferred from observational studies of outcomes. Our analyses of three PAH trials with long-term follow-up suggest that further study is necessary before using these or other scores as surrogate outcomes in PAH RCTs or clinical care. FUNDING Cardiovascular Medical Research and Education Fund, US National Institutes of Health.
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Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E Ventetuolo
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Chao Cheng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Dina Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jason Fritz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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5
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Humbert M, Sitbon O, Guignabert C, Savale L, Boucly A, Gallant-Dewavrin M, McLaughlin V, Hoeper MM, Weatherald J. Treatment of pulmonary arterial hypertension: recent progress and a look to the future. THE LANCET. RESPIRATORY MEDICINE 2023; 11:804-819. [PMID: 37591298 DOI: 10.1016/s2213-2600(23)00264-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe but treatable form of pre-capillary pulmonary hypertension caused by pulmonary vascular remodelling. As a result of basic science discoveries, randomised controlled trials, studies of real-world data, and the development of clinical practice guidelines, considerable progress has been made in the treatment options and outcomes for patients with PAH, underscoring the importance of seamless translation of information from bench to bedside and, ultimately, to patients. However, PAH still carries a high mortality rate, which emphasises the urgent need for transformative innovations in the field. In this Series paper, written by a group of clinicians, researchers, and a patient with PAH, we review therapeutic approaches and treatment options for PAH. We summarise current knowledge of the cellular and molecular mechanisms of PAH, with an emphasis on emerging treatable pathways and optimisation of current management strategies. In considering future directions for the field, our ambition is to identify therapies with the potential to stall or reverse pulmonary vascular remodelling. We highlight novel therapeutic approaches, the important role of patients as partners in research, and innovative approaches to PAH clinical trials.
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Affiliation(s)
- Marc Humbert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France.
| | - Olivier Sitbon
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | | | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), Hannover, Germany
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
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6
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Wang A, Chen M, Zhuang Q, Guan L, Xie W, Wang L, Huang W, Cheng Z, Yu S, Zhou H, Shen J. Time to clinical improvement: an appropriate surrogate endpoint for pulmonary arterial hypertension medication trials. Front Cardiovasc Med 2023; 10:1142721. [PMID: 37378404 PMCID: PMC10291317 DOI: 10.3389/fcvm.2023.1142721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
Background Many retrospective studies suggest that risk improvement may be a suitable efficacy surrogate endpoint for pulmonary arterial hypertension (PAH) medication trials. This prospective multicenter study assessed the efficacy of domestic ambrisentan in Chinese PAH patients and observed risk improvement and time to clinical improvement (TTCI) under ambrisentan treatment. Methods Eligible patients with PAH were enrolled for a 24-week treatment with ambrisentan. The primary efficacy endpoint was 6-min walk distance (Δ6MWD). The exploratory endpoints were risk improvement and TTCI, defined as the time from initiation of treatment to the first occurrence of risk improvement. Results A total of 83 subjects were enrolled. After ambrisentan treatment, Δ6MWD was significantly increased at week 12 (42.2 m, P < 0.0001) and week 24 (53.4 m, P < 0.0001). Within 24 weeks, risk improvement was observed in 53 (64.6%) subjects (P < 0.0001), which is higher than WHO-FC (30.5%) and TAPSE/PASP (32.9%). Kaplan-Meier analysis of TTCI showed a median improvement time of 131 days and a cumulative improvement rate of 75.1%. Also, TTCI is consistent across different baseline risk status populations (log-rank P = 0.51). The naive group had more risk improvement (P = 0.043) and shorter TTCI (log-rank P = 0.008) than the add-on group, while Δ6MWD did not show significant differences between the two groups. Conclusions Domestic ambrisentan significantly improved the exercise capacity and risk status of Chinese PAH patients. TTCI has a relatively high positive event rate within 24-week treatment duration. Compared to Δ6MWD, TTCI is not affected by baseline risk status. Additionally, TTCI could identify better improvements in patients, which Δ6MWD does not detect. TTCI is an appropriate composite surrogate endpoint for PAH medication trials. Clinical Trial Registration NCT No. [ClinicalTrials.gov], identifier [NCT05437224].
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Affiliation(s)
- An Wang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mengqi Chen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Zhuang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lihua Guan
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiping Xie
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhaozhong Cheng
- Respiratory Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shiyong Yu
- Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongmei Zhou
- Congenital Heart Disease Center, Wuhan Asia Heart Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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7
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Deshwal H, Weinstein T, Salyer R, Thompson J, Cefali F, Fenton R, Bondarsky E, Sulica R. Long-term impact of add-on sequential triple combination therapy in pulmonary arterial hypertension: real world experience. Ther Adv Respir Dis 2023; 17:17534666231199693. [PMID: 37795626 PMCID: PMC10557422 DOI: 10.1177/17534666231199693] [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: 03/22/2023] [Accepted: 08/04/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sequential triple combination therapy is recommended for pulmonary arterial hypertension (PAH) patients who are not at therapeutic goal on dual therapy, but long-term data on efficacy and safety is scarce. OBJECTIVE To assess the long-term impact of sequential triple combination therapy in patients with PAH who are not at goal on dual combination therapy. STUDY DESIGN AND METHODS We performed a retrospective observational study in a racially/ethnically diverse cohort of consecutive PAH patients on a stable dual therapy regimen who remained in intermediate- or high-risk category and were subsequently initiated on sequential triple combination therapy. We studied interval change in functional, echocardiographic, and hemodynamic parameters, REVEAL 2.0 risk category and ERS/ESC 2022 simplified four-strata risk category. Multivariate logistic regression analysis was performed to identify independent predictors of successful risk reduction (achievement or maintenance of REVEAL 2.0 low-risk category). Kaplan-Meier survival curves were created to assess the effect of risk reduction on survival. RESULTS Out of 414 PAH patients seen in our program, 55 patients received add-on sequential triple combination regimen and had follow-up hemodynamic data. The mean age was 57 years, with 85% women. The most common etiology of PAH was idiopathic/heritable (41.8%). Most patients were WHO functional class III (76.4%), and 34.5% of patients were in high-risk category (REVEAL 2.0). On a median follow-up of 68 weeks, there was a significant improvement in WHO Functional Class (p < 0.001), six-minute walk distance (35 m) with 61.8% of patients achieving low-risk status by REVEAL 2.0, and a 28% of patients' improvement in pulmonary vascular resistance. Female gender was identified as a strong predictor of successful risk reduction, whereas Hispanic ethnicity estimated right atrial pressure on echocardiogram and pericardial effusion predicted lower probability of risk reduction. Patients who achieved or maintained low-risk status had significantly improved survival. CONCLUSION Add-on sequential triple combination therapy significantly increased functional, echocardiographic, and hemodynamic parameters with improvement in risk category and survival.
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Affiliation(s)
- Himanshu Deshwal
- Pulmonary Hypertension Clinic (Pulmonology), Division of Pulmonary, Sleep, and Critical Care Medicine, West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV 26505, USA
| | - Tatiana Weinstein
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Rachel Salyer
- Department of Medicine, West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, USA
| | - Jesse Thompson
- Department of Medicine, West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, USA
| | - Frank Cefali
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Rebecca Fenton
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Eric Bondarsky
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Roxana Sulica
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
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8
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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9
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Benza RL, Gomberg-Maitland M, Farber HW, Vizza CD, Broderick M, Holdstock L, Nelsen AC, Deng C, Rao Y, White RJ. Contemporary Risk Scores Predict Clinical Worsening in Pulmonary Arterial Hypertension - An Analysis of FREEDOM-EV. J Heart Lung Transplant 2022; 41:1572-1580. [DOI: 10.1016/j.healun.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 07/13/2022] [Accepted: 08/09/2022] [Indexed: 10/31/2022] Open
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10
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Pi H, Carlson SD, Barros LM, Hogl L, Kirkpatrick JN, Nolley S, Ralph DD, Rayner SG, Leary PJ. Risk Prediction and Right Ventricular Dilation in a Single-Institution Pulmonary Arterial Hypertension Cohort. J Am Heart Assoc 2022; 11:e025521. [PMID: 35861845 PMCID: PMC9707840 DOI: 10.1161/jaha.122.025521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Hongyang Pi
- Department of MedicineUniversity of WashingtonSeattleWA
| | - Selma D. Carlson
- Department of MedicineVeterans Administration MinneapolisMinneapolisMN
| | - Lia M. Barros
- Department of MedicineUniversity of WashingtonSeattleWA
| | - Laurie Hogl
- Department of MedicineUniversity of WashingtonSeattleWA
| | | | | | | | | | - Peter J. Leary
- Department of MedicineUniversity of WashingtonSeattleWA,Department of EpidemiologyUniversity of WashingtonSeattleWA
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11
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Arevalo C, White R, Lachant D. Transitioning selexipag to oral treprostinil in patients with pulmonary artery hypertension. Respir Med Case Rep 2022; 37:101646. [PMID: 35494550 PMCID: PMC9038566 DOI: 10.1016/j.rmcr.2022.101646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/30/2022] [Indexed: 10/31/2022] Open
Abstract
There are no prospective studies or guidelines describing transition between selexipag and oral treprostinil. We present two different transition strategies from selexipag to oral treprostinil, one started inpatient and then completed at home, and one completely under outpatient settings. Neither patient experienced worsening prostacyclin-type adverse effects; both were rigorous in their attention to a 7–8 hour administration schedule for oral treprostinil, and both experienced objective clinical benefit at follow-up. Prospective studies are needed to help guide clinical decisions when patients remain intermediate risk after a trial of either drug.
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12
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Sahay S, Balasubramanian V, Memon H, RRT AP, Bossone E, Highland K, Kay D, Levine DJ, Mullin CJ, Melendres‐Groves L, Mathai SC, Soto FJ, Shlobin O, Elwing JM. Utilization of Risk Assessment Tools in Management of PAH: A PAH Provider Survey. Pulm Circ 2022; 12:e12057. [PMID: 35514787 PMCID: PMC9063963 DOI: 10.1002/pul2.12057] [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: 10/16/2021] [Revised: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronically progressive fatal disease. A goal‐oriented approach to achieve low risk status has been associated with improved survival. A variety of risk stratification tools are available, but use is low. We conducted a survey to assess potential reasons for under‐utilization. We conducted a survey‐based study of global PAH disease specialists with a goal of assessing risk assessment utilization and identifying modifiable barriers to use. The survey was designed by the American College of Chest Physicians’ Pulmonary Vascular Diseases (PVD) NetWork. Respondents were global members of the PVD NetWork and Pulmonary Hypertension Association. Survey invitations were sent electronically to all members. Participation was anonymous and no provider or patient level data was collected. Participants from four countries responded with the majority (84%) being from the United States. Our survey found suboptimal use of any risk stratification tool with 71/112 (63%) reporting use. A total of 85% of the respondents had more than 5 years of experience in managing PAH. REVEAL 2.0 and European Society of Cardiology/European Respiratory Society risk tools were the most commonly used. A total of 44 (65%) surveyed felt that use of risk tools led to change in PAH therapies. Only 6 (9%) felt they prompted additional testing or changed the frequency of follow‐up. A total of 5 (7%) reported they prompted goals of care/palliative care discussions and 2 (3%) that they triggered lung transplant referral. The vast majority indicated that incorporation of risk tools into electronic medical records (EMR) would improve utilization. PAH risk assessment tools remain under‐utilized. Most respondents were experienced PAH clinicians. More than one‐third were not routinely using risk tools. Most felt that risk tools led to PAH therapy changes but few reported impacts on other aspects of care. The most commonly identified barriers to use were time constraints and lack of integration with EMR.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary Critical Care & Sleep Medicine Houston Methodist Hospital Houston Texas
| | | | | | | | | | | | - Dana Kay
- Division of Pulmonary & Critical Care Medicine University of Cincinnati College of Medicine Cincinnnati OH
| | - Deborah J Levine
- Division of Pulmonary & Critical Care Medicine University of Texas Health Science Center at San Antonio San Antonio Texas
| | - Christopher J Mullin
- Division of Pulmonary & Critical Care Medicine Warren Alpert Medical School of Brown University Rhode Island
| | - Lana Melendres‐Groves
- Division of Pulmonary & Critical Care Medicine University of New Mexico Health Science Center Albuquerque NM
| | - Stephen C Mathai
- Division of Pulmonary & Critical Care Medicine John Hopkins University Baltimore MD
| | - Francisco J Soto
- Division of Pulmonary & Critical Care Medicine University of Tennessee Medical Center Knoxville TN
| | - Oksana Shlobin
- Pulmonary Hypertension Program, Inova Fairfax Hospital Fairfax Virginia
| | - Jean M Elwing
- Division of Pulmonary & Critical Care Medicine University of Cincinnati College of Medicine Cincinnnati OH
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13
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Prognostic value of improvement endpoints in pulmonary arterial hypertension trials: A COMPERA analysis. J Heart Lung Transplant 2022; 41:971-981. [DOI: 10.1016/j.healun.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
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14
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Hwalek A, Rosenheck JP, Whitson BA. Lung transplantation for pulmonary hypertension. J Thorac Dis 2022; 13:6708-6716. [PMID: 34992846 PMCID: PMC8662488 DOI: 10.21037/jtd-2021-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/14/2021] [Indexed: 11/06/2022]
Abstract
From its identification as a distinct disease entity, understanding and management of pulmonary hypertension has continuously evolved. Diagnostic and therapeutic interventions have greatly improved the prognostic implications of this devastating disease, previously rapidly and uniformly fatal to one chronically managed by multi-disciplinary teams. Improved diagnostic algorithms and active research into biochemical signatures of pulmonary hypertension (PH) have led to earlier diagnosis of PH. Medical therapy has moved from upfront use of continuous intravenous prostaglandins to administration of combinations of oral medications targeting multiple pathways underlying this disease process. In addition to improved medical therapies, recently introduced interventions such as pulmonary endarterectomy and pulmonary artery balloon angioplasty for chronic thromboembolic pulmonary hypertension (CTEPH) give patients an increasing array of treatment options. Despite these many advances, lung transplantation remains the definitive treatment for patients with disease refractory to or progressing on best medical therapy. As our understanding of medical therapy has advanced, so to have best practices for lung transplantation. Recipient selection and approach to organ transplantation techniques have continuously evolved. Mechanical circulatory support has become increasingly employed to bridge patients through lung transplantation in the immediate post transplantation recovery. In this review, we give a history of lung transplantation for PH, an overview of PH, discuss current best practices and look to the future for insights into the care of these patients.
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Affiliation(s)
- Ann Hwalek
- Division of Cardiac Surgery, Columbus, Department of Surgery, The Ohio State University Wexner Medical Center, OH, USA
| | - Justin P Rosenheck
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Columbus, Department of Surgery, The Ohio State University Wexner Medical Center, OH, USA
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15
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Frantz RP, Benza RL, Channick RN, Chin K, Howard LS, McLaughlin VV, Sitbon O, Zamanian RT, Hemnes AR, Cravets M, Bruey JM, Roscigno R, Mottola D, Elman E, Zisman LS, Ghofrani HA. TORREY, a Phase 2 study to evaluate the efficacy and safety of inhaled seralutinib for the treatment of pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211057071. [PMID: 34790348 PMCID: PMC8591655 DOI: 10.1177/20458940211057071] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/12/2021] [Indexed: 12/14/2022] Open
Abstract
Aberrant kinase signaling that involves platelet-derived growth factor receptor (PDGFR) α/β, colony stimulating factor 1 receptor (CSF1R), and stem cell factor receptor (c-KIT) pathways may be responsible for vascular remodeling in pulmonary arterial hypertension. Targeting these specific pathways may potentially reverse the pathological inflammation, cellular proliferation, and fibrosis associated with pulmonary arterial hypertension progression. Seralutinib (formerly known as GB002) is a novel, potent, clinical stage inhibitor of PDGFRα/β, CSF1R, and c-KIT delivered via inhalation that is being developed for patients with pulmonary arterial hypertension. Here, we report on an ongoing Phase 2 randomized, double-blind, placebo-controlled trial (NCT04456998) evaluating the efficacy and safety of seralutinib in subjects with World Health Organization Group 1 Pulmonary Hypertension who are classified as Functional Class II or III. A total of 80 subjects will be enrolled and randomized to receive either study drug or placebo for 24 weeks followed by an optional 72-week open-label extension study. The primary endpoint is the change from baseline to Week 24 in pulmonary vascular resistance by right heart catheterization. The secondary endpoint is the change in distance from baseline to Week 24 achieved in the 6-min walk test. A computerized tomography sub-study will examine the effect of seralutinib on pulmonary vascular remodelling. A separate heart rate monitoring sub-study will examine the effect of seralutinib on cardiac effort during the 6-min walk test.
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Affiliation(s)
| | | | | | - Kelly Chin
- UT Southwestern Medical Center, Dallas, TX, USA
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16
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Boucly A, Weatherald J, Savale L, de Groote P, Cottin V, Prévot G, Chaouat A, Picard F, Horeau-Langlard D, Bourdin A, Jutant EM, Beurnier A, Jevnikar M, Jaïs X, Simonneau G, Montani D, Sitbon O, Humbert M. External validation of a refined 4-strata risk assessment score from the French pulmonary hypertension Registry. Eur Respir J 2021; 59:13993003.02419-2021. [PMID: 34737227 PMCID: PMC9245192 DOI: 10.1183/13993003.02419-2021] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/28/2021] [Indexed: 11/05/2022]
Abstract
Introduction Contemporary risk assessment tools categorise patients with pulmonary arterial hypertension (PAH) as low, intermediate or high risk. A minority of patients achieve low risk status with most remaining intermediate risk. Our aim was to validate a four-stratum risk assessment approach categorising patients as low, intermediate-low, intermediate-high or high risk, as proposed by the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) investigators. Methods We evaluated incident patients from the French PAH Registry and applied a four-stratum risk method at baseline and at first reassessment. We applied refined cut-points for three variables: World Health Organization functional class, 6-min walk distance and N-terminal pro-brain natriuretic peptide. We used Kaplan–Meier survival analyses and Cox proportional hazards regression to assess survival according to three-stratum and four-stratum risk approaches. Results At baseline (n=2879), the four-stratum approach identified four distinct risk groups and performed slightly better than a three-stratum method for predicting mortality. Four-stratum model discrimination was significantly higher than the three-stratum method when applied during follow-up and refined risk categories among subgroups with idiopathic PAH, connective tissue disease-associated PAH, congenital heart disease and portopulmonary hypertension. Using the four-stratum approach, 53% of patients changed risk category from baseline compared to 39% of patients when applying the three-stratum approach. Those who achieved or maintained a low risk status had the best survival, whereas there were more nuanced differences in survival for patients who were intermediate-low and intermediate-high risk. Conclusions The four-stratum risk assessment method refined risk prediction, especially within the intermediate risk category of patients, performed better at predicting survival and was more sensitive to change than the three-stratum approach. A four-stratum risk assessment method with low, intermediate-low, intermediate-high and high risk categories was better at discriminating survival in pulmonary arterial hypertension than a three-stratum method with low, intermediate and high risk groupshttps://bit.ly/3mA6kj7
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.,Both authors contributed equally
| | - Laurent Savale
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Pascal de Groote
- Université de Lille, Service de cardiologie, CHU Lille, Institut Pasteur de Lille, Inserm U1167, Lille, France
| | - Vincent Cottin
- Université Lyon 1, INRAE, UMR754, IVPC, National Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Lyon, France
| | - Grégoire Prévot
- CHU de Toulouse, Hôpital Larrey, Service de pneumologie, Toulouse, France
| | - Ari Chaouat
- Département de Pneumologie, Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, CHRU de Nancy, Vandoeuvre-lès-Nancy, France
| | - François Picard
- Université Bordeaux, Hôpital Cardiologique du Haut-Lévêque, Heart Failure Unit and Pulmonary Hypertension Expert Centre, Bordeaux, France
| | | | - Arnaud Bourdin
- Department of Respiratory Diseases, Université Montpellier, CHU Montpellier, Montpellier, France
| | - Etienne-Marie Jutant
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Service de pneumologie, CHU Poitiers, Poitiers, France
| | - Antoine Beurnier
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Mitja Jevnikar
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Xavier Jaïs
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Gérald Simonneau
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
| | - Marc Humbert
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France .,Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Both authors contributed equally
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17
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Dardi F, Manes A, Guarino D, Zuffa E, De Lorenzis A, Magnani I, Rotunno M, Ballerini A, Lo Russo GV, Nardi E, Galiè N, Palazzini M. A pragmatic approach to risk assessment in pulmonary arterial hypertension using the 2015 European Society of Cardiology/European Respiratory Society guidelines. Open Heart 2021; 8:e001725. [PMID: 34667092 PMCID: PMC8527122 DOI: 10.1136/openhrt-2021-001725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/07/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To optimise treatment of patients with pulmonary arterial hypertension (PAH), the 2015 European Society of Cardiology/European Respiratory Society guidelines recommend using risk stratification, with the aim of patients achieving low-risk status. Previous analyses of registries made progress in using risk stratification approaches, however, the focus is often on patients with a low-risk prognosis, whereas most PAH patients are in intermediate-risk or high-risk categories. Using only six parameters with high prognostic relevance, we aimed to demonstrate a pragmatic approach to individual patient risk assessment to discriminate between patients at low risk, intermediate risk and high risk of death. METHODS Risk assessment was performed combining six parameters in four criteria: (1) WHO functional class, (2) 6 min walk distance, (3) N-terminal pro-brain natriuretic peptide (BNP)/BNP plasma levels or right atrial pressure and (4) cardiac index or mixed venous oxygen saturation. Assessments were made at baseline and at first follow-up after 3-4 months. RESULTS 725 PAH treatment-naive patients were analysed. Survival estimates between risk groups were statistically significant at baseline and first follow-up (p<0.001), even when the analysis was performed within PAH etiological subgroups. Similar results were observed in 208 previously treated PAH patients. Furthermore, patients who remained at or improved to low risk had a significantly better estimated survival compared with patients who remained at or worsened to intermediate risk or high risk (p≤0.005). CONCLUSION The simplified risk-assessment method can discriminate idiopathic, connective-tissue-disease-associated and congenital-heart-disease-associated PAH patients into meaningful high-risk, intermediate-risk and low-risk groups at baseline and first follow-up. This pragmatic approach reinforces targeting a low-risk profile for PAH patients.
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Affiliation(s)
- Fabio Dardi
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Alessandra Manes
- Cardio-Thoracic-Vascular Department, IRCCS Sant'Orsola University Hospital, Bologna, Italy
| | - Daniele Guarino
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Elisa Zuffa
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Alessandro De Lorenzis
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Ilenia Magnani
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Mariangela Rotunno
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Alberto Ballerini
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Gerardo Vito Lo Russo
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Elena Nardi
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Massimiliano Palazzini
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
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18
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Deshwal H, Weinstein T, Sulica R. Advances in the management of pulmonary arterial hypertension. J Investig Med 2021; 69:1270-1280. [PMID: 34580123 PMCID: PMC8485135 DOI: 10.1136/jim-2021-002027] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
The management of pulmonary arterial hypertension (PAH) has significantly evolved over the last decades in the wake of more sensitive diagnostics and specialized clinical programs that can provide focused medical care. In the current era of PAH care, 1-year survival rates have increased to 86%–90% from 65% in the 1980s, and average long-term survival has increased to 6 years from 2.8 years. The heterogeneity in the etiology and disease course has opened doors to focusing research in phenotyping the disease and understanding the pathophysiology at a cellular and genetic level. This may eventually lead to precision medicine and the development of medications that may prevent or reverse pulmonary vascular remodeling. With more insight, clinical trial designs and primary end-points may change to identify the true survival benefit of pharmacotherapy. Identifying responders from non-responders to therapy may help provide individualized patient-centered care rather than an algorithm-based approach. The purpose of this review is to highlight the latest advances in screening, diagnosis, and management of PAH.
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Affiliation(s)
- Himanshu Deshwal
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Tatiana Weinstein
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Roxana Sulica
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
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19
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Grignola JC, Domingo E, López-Meseguer M, Trujillo P, Bravo C, Pérez-Hoyos S, Roman A. Pulmonary Arterial Remodeling Is Related to the Risk Stratification and Right Ventricular-Pulmonary Arterial Coupling in Patients With Pulmonary Arterial Hypertension. Front Physiol 2021; 12:631326. [PMID: 34012405 PMCID: PMC8126681 DOI: 10.3389/fphys.2021.631326] [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: 11/19/2020] [Accepted: 04/08/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Pulmonary arterial (PA) stiffness has an essential contribution to the right ventricular (RV) failure pathogenesis. A comprehensive and multiparameter risk assessment allows predicting mortality and guiding treatment decisions in PA hypertension (PAH). We characterize PA remodeling with intravascular ultrasound (IVUS) in prevalent and stable patients with PAH according to the ESC/ERS risk table and analyze the RV-PA coupling consequences. METHODS Ten control subjects and 20 prevalent PAH adult patients underwent right heart catheterization (RHC) with simultaneous IVUS study. We estimated cardiac index (CI), pulmonary vascular resistance, and compliance (PVR, PAC) by standard formulas. From IVUS and RHC data, PA diameter, wall thickness/luminal diameter ratio, and indexes of stiffness (pulsatility, compliance, distensibility, incremental elastic modulus - Einc-, and the stiffness index β) were measured. We evaluated RV-PA coupling by the ratio of tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP). The individual average risk was calculated by assigning a score of 1 (low-risk -LR-), 2 (intermediate-risk -IR-), and 3 (high-risk -HR-) for each of seven variables (functional class, six-minute walking test, brain natriuretic peptide, right atrial area and pressure, CI, and PA oxygen saturation) and rounding the average value to the nearest integer. RESULTS All PA segments interrogated showed increased vessel diameter, wall cross-sectional area (WCSA), and stiffness in patients with PAH compared to control subjects. 45% corresponded to LR, and 55% corresponded to IR PAH patients. The different measurements of PA stiffness showed significant correlations with TAPSE/sPAP (r = 0.6 to 0.76) in PAH patients. The IR group had higher PA stiffness and lower relative WCSA than LR patients (P < 0.05), and it is associated with a lower PAC and TAPSE/sPAP (P < 0.05). CONCLUSION In prevalent PAH patients, the severity of proximal PA remodeling is related to the risk stratification and associated with PAC and RV-PA coupling impairment beyond the indirect effect of the mean PA pressure. The concomitant assessment of IVUS and hemodynamic parameters at diagnosis and follow-up of PAH patients could be a feasible and safe tool for risk stratification and treatment response of the PA vasculopathy during serial hemodynamic measurements.
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Affiliation(s)
- Juan C. Grignola
- Pathophysiology Department, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Enric Domingo
- Area del Cor, Hospital Vall d’Hebron, Barcelona, Spain
- Physiology Department, School of Medicine, Universitat Autonoma, Barcelona, Spain
| | - Manuel López-Meseguer
- Department of Pneumology, Hospital Vall d’Hebron, Barcelona, Spain
- Ciberes, IS Carlos III, Madrid, Spain
| | - Pedro Trujillo
- Centro Cardiovascular Universitario, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Carlos Bravo
- Department of Pneumology, Hospital Vall d’Hebron, Barcelona, Spain
- Ciberes, IS Carlos III, Madrid, Spain
| | | | - Antonio Roman
- Department of Pneumology, Hospital Vall d’Hebron, Barcelona, Spain
- Ciberes, IS Carlos III, Madrid, Spain
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20
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Humbert M, Lau EMT. Risk Stratification in Pulmonary Arterial Hypertension: Do Not Forget the Patient Perspective. Am J Respir Crit Care Med 2021; 203:675-677. [PMID: 33357026 PMCID: PMC7958524 DOI: 10.1164/rccm.202012-4350ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris) Le Kremlin Bicêtre, France.,Faculté de Medicine Université Paris-Saclay Le Kremlin-Bicêtre, France
| | - Edmund M T Lau
- Department of Respiratory Medicine Royal Prince Alfred Hospital Camperdown, New South Wales, Australia and.,Faculty of Health and Medicine University of Sydney Camperdown, New South Wales, Australia
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21
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Badagliacca R, D'Alto M, Ghio S, Argiento P, Bellomo V, Brunetti ND, Casu G, Confalonieri M, Corda M, Correale M, D'Agostino C, De Michele L, Galgano G, Greco A, Lombardi C, Manzi G, Mercurio V, Mulè M, Paciocco G, Papa S, Romeo E, Scelsi L, Stolfo D, Vitulo P, Naeije R, Vizza CD. Risk Reduction and Hemodynamics with Initial Combination Therapy in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 203:484-492. [PMID: 32857597 DOI: 10.1164/rccm.202004-1006oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Rationale: An initial oral combination of drugs is being recommended in pulmonary arterial hypertension (PAH), but the effects of this approach on risk reduction and pulmonary vascular resistance (PVR) are not known.Objectives: To test the hypothesis that a low-risk status would be determined by the reduction of PVR in patients with PAH treated upfront with a combination of oral drugs.Methods: The study enrolled 181 treatment-naive patients with PAH (81% idiopathic) with a follow-up right heart catheterization at 6 months (interquartile range, 144-363 d) after the initial combination of endothelin receptor antagonist + phosphodiesterase-5 inhibitor drugs and clinical evaluation and risk assessments by European guidelines and Registry to Evaluate Early and Long-Term PAH Disease Management scores.Measurements and Main Results: Initial combination therapy improved functional class and 6-minute-walk distance and decreased PVR by an average of 35% (median, 40%). One-third of the patients had a decrease in PVR <25%. This poor hemodynamic response was independently predicted by age, male sex, pulmonary artery pressure and cardiac index, and at echocardiography, a right/left ventricular surface area ratio of greater than 1 associated with low tricuspid annular plane systolic excursion of less than 18 mm. A low-risk status at 6 months was achieved or maintained in only 34.8% (Registry to Evaluate Early and Long-Term PAH Disease Management score) to 43.1% (European score) of the patients. Adding criteria of poor hemodynamic response improved prediction of a low-risk status.Conclusions: A majority of patients with PAH still insufficiently improved after 6 months of initial combinations of oral drugs is identifiable at initial evaluation by hemodynamic response criteria added to risk scores.
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Affiliation(s)
- Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital, University L. Vanvitelli, Naples, Italy
| | - Stefano Ghio
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S Matteo, Pavia, Italy
| | - Paola Argiento
- Department of Cardiology, Monaldi Hospital, University L. Vanvitelli, Naples, Italy
| | - Vincenzo Bellomo
- Department of Cardiology, F.Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | - Gavino Casu
- Azienda per la Tutela della Salute Sardegna-Area Socio Sanitaria Locale Nuoro, San Francesco Hospital, Nuoro, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Heart-Thorax-Vessels Department, University Hospital of Cattinara, Trieste, Italy
| | - Marco Corda
- Azienda Ospedaliera G. Brotzu San Michele, Cagliari, Italy
| | - Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Carlo D'Agostino
- Cardiology Department, University Hospital Policlinico Consorziale Bari, Italy
| | - Lucrezia De Michele
- Cardiology Department, University Hospital Policlinico Consorziale Bari, Italy
| | - Giuseppe Galgano
- Department of Cardiology, F.Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alessandra Greco
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S Matteo, Pavia, Italy
| | - Carlo Lombardi
- Cardiologia, Università degli studi di Brescia, Brescia, Italy
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Giuseppe Paciocco
- Dipartimento Cardio-Toraco-Vascolare, Clinica Pneumologica, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital, University L. Vanvitelli, Naples, Italy
| | - Laura Scelsi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S Matteo, Pavia, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Patrizio Vitulo
- Pulmonology Unit, Istituti di Ricovero e Cura a Carattere Scientifico, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy; and
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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22
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Weatherald J, Boucly A, Savale L, Jaïs X, Montani D, Humbert M, Sitbon O. Pulmonary Vascular Resistance in Pulmonary Arterial Hypertension: La Pièce de Résistance? Am J Respir Crit Care Med 2021; 203:524-525. [PMID: 33105080 PMCID: PMC7885847 DOI: 10.1164/rccm.202009-3664le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jason Weatherald
- University of CalgaryCalgary Alberta, Canada.,Libin Cardiovascular Institute Calgary, Alberta, Canada
| | - Athénaïs Boucly
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
| | - David Montani
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Hôpital Marie Lannelongue Le Plessis-Robinson, France.,Université Paris-Saclay Le Kremlin-Bicêtre, France and.,Hôpital Bicêtre Le Kremlin-Bicêtre, France
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23
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Klinger JR, Chakinala MM, Langleben D, Rosenkranz S, Sitbon O. Riociguat: Clinical research and evolving role in therapy. Br J Clin Pharmacol 2020; 87:2645-2662. [PMID: 33242341 PMCID: PMC8359233 DOI: 10.1111/bcp.14676] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
Riociguat is a first-in-class soluble guanylate cyclase stimulator, approved for the treatment of adults with pulmonary arterial hypertension (PAH), inoperable chronic thromboembolic pulmonary hypertension (CTEPH), or persistent or recurrent CTEPH after pulmonary endarterectomy. Approval was based on the results of the phase III PATENT-1 (PAH) and CHEST-1 (CTEPH) studies, with significant improvements in the primary endpoint of 6-minute walk distance vs placebo of +36 m and +46 m, respectively, as well as improvements in secondary endpoints such as pulmonary vascular resistance and World Health Organization functional class. Riociguat acts as a stimulator of cyclic guanosine monophosphate synthesis rather than as an inhibitor of cGMP metabolism. As with other approved therapies for PAH, riociguat has antifibrotic, antiproliferative and anti-inflammatory effects, in addition to vasodilatory properties. This has led to further clinical studies in patients who do not achieve a satisfactory clinical response with phosphodiesterase type-5 inhibitors. Riociguat has also been evaluated in patients with World Health Organization group 2 and 3 pulmonary hypertension, and other conditions including diffuse cutaneous systemic sclerosis, Raynaud's phenomenon and cystic fibrosis. This review evaluates the results of the original clinical trials of riociguat for the treatment of PAH and CTEPH, and summarises the body of work that has examined the safety and efficacy of riociguat for the treatment of other types of pulmonary hypertension.
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Affiliation(s)
- James R Klinger
- Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology), and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - Olivier Sitbon
- Universite Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
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24
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Risk assessment in patients with functional class II pulmonary arterial hypertension: Comparison of physician gestalt with ESC/ERS and the REVEAL 2.0 risk score. PLoS One 2020; 15:e0241504. [PMID: 33175857 PMCID: PMC7657501 DOI: 10.1371/journal.pone.0241504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background Accurate and regular risk assessment is important for evaluation and treatment of pulmonary arterial hypertension (PAH) patients, including those with functional class (FC) II symptoms, a population considered at low risk for disease progression. Risk assessment methods include subjective and objective evaluations. Multiparametric assessments include tools based on the European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines (COMPERA and FPHR methods, respectively) and the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL; REVEAL 2.0 tool). To better understand risk status determination in FC II patients, we compared physician-reported risk assessments with objective multiparameter assessment tools. Methods This retrospective chart analysis included PAH patients with FC II symptoms receiving monotherapy or dual therapy. Physicians were surveyed (via telephone) to obtain an assessment of patient risk using their typical methodology, which might have been informed by objective risk assessment. Patient risk was then calculated independently using COMPERA, FPHR and REVEAL 2.0 tools. Factors associated with incongruent risk assessment were identified. Results Of the 153 patients, 41%, 46%, and 13% were classified as low, intermediate, and high risk, respectively, by physicians. Concordance between physician gestalt and objective methods ranged from 43%–54%. Among patients considered as low risk by physician gestalt, 4%–28% were categorized as high risk using objective methods. The most common physician factor associated with incongruent risk assessment was less frequent echocardiography during follow-up (every 7–12 months vs. every 3 months; p = 0.01). Conclusions More than half of FC II PAH patients were classified as intermediate/high risk using objective multiparameter assessments. Incorporating objective risk-assessment algorithms into clinical practice may better inform risk assessment and treatment strategies.
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25
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Wilson M, Keeley J, Kingman M, Wang J, Rogers F. Current clinical utilization of risk assessment tools in pulmonary arterial hypertension: a descriptive survey of facilitation strategies, patterns, and barriers to use in the United States. Pulm Circ 2020; 10:2045894020950186. [PMID: 33062258 PMCID: PMC7534093 DOI: 10.1177/2045894020950186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/27/2020] [Indexed: 11/17/2022] Open
Abstract
Practice guidelines suggest that treatment decisions in pulmonary arterial hypertension be informed by periodic assessment of patients' clinical risk. Several tools, well validated for risk discrimination, such as the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management calculator, were developed to assess pulmonary arterial hypertension patients' risk of death based on multiple parameters, including functional class, hemodynamics, biomarkers, comorbidities, and exercise capacity. Using an online survey, we investigated the use of risk assessment tools by pulmonary hypertension healthcare providers in the United States. Of 121 survey respondents who make treatment decisions, 59% reported using risk assessment tools. The use of these tools was lower for non-physicians (48% vs. 65% physicians) and for practitioners at centers with 1 to 100 pulmonary arterial hypertension patients compared with centers with >100 patients (47% vs. 64%). Risk was most frequently assessed by decision makers at the time of diagnosis (cited by 54%) and at the time of worsening symptoms (cited by 42%), suggesting that use of pulmonary arterial hypertension risk assessment tools remains low. In our survey, non-physicians compared with physicians cited two major barriers to increased tool use: lack of education and training (20% vs. 4%) and lack of clarity on the best tool to use (30% vs. 18%). Information technology tools, such as electronic medical record integration and web or phone-based risk calculating applications, were cited most frequently as ways to increase the use of risk assessment tools.
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Affiliation(s)
- Melisa Wilson
- AdventHealth Orlando, Cardiovascular Institute, Orlando, FL, USA
| | - Jennifer Keeley
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Martha Kingman
- Internal Medicine University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jiajing Wang
- AdventHealth Orlando, Cardiovascular Institute, Orlando, FL, USA
| | - Fran Rogers
- Temple University Hospital, Heart and Vascular Institute Philadelphia, PA, USA
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26
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Development and Validation of an Abridged Version of the REVEAL 2.0 Risk Score Calculator, REVEAL Lite 2, for Use in Patients With Pulmonary Arterial Hypertension. Chest 2020; 159:337-346. [PMID: 32882243 PMCID: PMC7462639 DOI: 10.1016/j.chest.2020.08.2069] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background Achievement of low-risk status is a treatment goal in pulmonary arterial hypertension (PAH). Risk assessment often is performed using multiparameter tools, such as the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk calculator. Risk calculators that assess fewer variables without compromising validity may expedite risk assessment in the routine clinic setting. We describe the development and validation of REVEAL Lite 2, an abridged version of REVEAL 2.0. Research Question Can a simplified version of the REVEAL 2.0 risk assessment calculator for patients with PAH be developed and validated? Study Design and Methods REVEAL Lite 2 includes six noninvasive variables—functional class (FC), vital signs (systolic BP [SBP] and heart rate), 6-min walk distance (6MWD), brain natriuretic peptide (BNP)/N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and renal insufficiency (by estimated glomerular filtration rate [eGFR])—and was validated in a series of analyses (Kaplan-Meier, concordance index, Cox proportional hazard model, and multivariate analysis). Results REVEAL Lite 2 approximates REVEAL 2.0 at discriminating low, intermediate, and high risk for 1-year mortality in patients in the REVEAL registry. The model indicated that the most highly predictive REVEAL Lite 2 parameter was BNP/NT-proBNP, followed by 6MWD and FC. Even if multiple, less predictive variables (heart rate, SBP, eGFR) were missing, REVEAL Lite 2 still discriminated among risk groups. Interpretation REVEAL Lite 2, an abridged version of REVEAL 2.0, provides a simplified method of risk assessment that can be implemented routinely in daily clinical practice. REVEAL Lite 2 is a robust tool that provides discrimination among patients at low, intermediate, and high risk of 1-year mortality. Trial Registry ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov;
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27
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White RJ, Jerjes-Sanchez C, Bohns Meyer GM, Pulido T, Sepulveda P, Wang KY, Grünig E, Hiremath S, Yu Z, Gangcheng Z, Yip WLJ, Zhang S, Khan A, Deng CQ, Grover R, Tapson VF. Combination Therapy with Oral Treprostinil for Pulmonary Arterial Hypertension. A Double-Blind Placebo-controlled Clinical Trial. Am J Respir Crit Care Med 2020; 201:707-717. [PMID: 31765604 PMCID: PMC7068822 DOI: 10.1164/rccm.201908-1640oc] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown. Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy. Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response. Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting. Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening. Clinical trial registered with www.clinicaltrials.gov (NCT01560624).
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Affiliation(s)
- R James White
- Division of Pulmonary and Critical Care Medicine and the Mary M. Parkes Center, University of Rochester Medical Center, Rochester, New York
| | | | | | - Tomas Pulido
- Departamento de Cardioneumología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Kuo Yang Wang
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ekkehard Grünig
- Thoraxclinic at University Hospital Heidelberg, Heidelberg, Germany
| | | | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital of Central South University, Changsha, China
| | | | - Wei Luen James Yip
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Shuyang Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Akram Khan
- Oregon Health and Science University, Portland, Oregon
| | - C Q Deng
- United Therapeutics, Research Triangle Park, North Carolina; and
| | - Rob Grover
- United Therapeutics, Research Triangle Park, North Carolina; and
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, California
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28
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Lewis RA, Johns CS, Cogliano M, Capener D, Tubman E, Elliot CA, Charalampopoulos A, Sabroe I, Thompson AAR, Billings CG, Hamilton N, Baster K, Laud PJ, Hickey PM, Middleton J, Armstrong IJ, Hurdman JA, Lawrie A, Rothman AMK, Wild JM, Condliffe R, Swift AJ, Kiely DG. Identification of Cardiac Magnetic Resonance Imaging Thresholds for Risk Stratification in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2020; 201:458-468. [PMID: 31647310 PMCID: PMC7049935 DOI: 10.1164/rccm.201909-1771oc] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Rationale: Pulmonary arterial hypertension (PAH) is a life-shortening condition. The European Society of Cardiology and European Respiratory Society and the REVEAL (North American Registry to Evaluate Early and Long-Term PAH Disease Management) risk score calculator (REVEAL 2.0) identify thresholds to predict 1-year mortality. Objectives: This study evaluates whether cardiac magnetic resonance imaging (MRI) thresholds can be identified and used to aid risk stratification and facilitate decision-making. Methods: Consecutive patients with PAH (n = 438) undergoing cardiac MRI were identified from the ASPIRE (Assessing the Spectrum of Pulmonary Hypertension Identified at a Referral Center) MRI database. Thresholds were identified from a discovery cohort and evaluated in a test cohort. Measurements and Main Results: A percentage-predicted right ventricular end-systolic volume index threshold of 227% or a left ventricular end-diastolic volume index of 58 ml/m2 identified patients at low (<5%) and high (>10%) risk of 1-year mortality. These metrics respectively identified 63% and 34% of patients as low risk. Right ventricular ejection fraction >54%, 37–54%, and <37% identified 21%, 43%, and 36% of patients at low, intermediate, and high risk, respectively, of 1-year mortality. At follow-up cardiac MRI, patients who improved to or were maintained in a low-risk group had a 1-year mortality <5%. Percentage-predicted right ventricular end-systolic volume index independently predicted outcome and, when used in conjunction with the REVEAL 2.0 risk score calculator or a modified French Pulmonary Hypertension Registry approach, improved risk stratification for 1-year mortality. Conclusions: Cardiac MRI can be used to risk stratify patients with PAH using a threshold approach. Percentage-predicted right ventricular end-systolic volume index can identify a high percentage of patients at low-risk of 1-year mortality and, when used in conjunction with current risk stratification approaches, can improve risk stratification. This study supports further evaluation of cardiac MRI in risk stratification in PAH.
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Affiliation(s)
- Robert A Lewis
- 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; and
| | - Christopher S Johns
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - Marcella Cogliano
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - David Capener
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - Euan Tubman
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - 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
- 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; and
| | - A A Roger Thompson
- 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; and
| | - Catherine G Billings
- 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; and
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Kathleen Baster
- Statistical Services Unit, School of Mathematics and Statistics and
| | - Peter J Laud
- Statistical Services Unit, School of Mathematics and Statistics and
| | - Peter M Hickey
- 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; and
| | - Jennifer Middleton
- 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; and
| | - 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
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - Alexander M K Rothman
- 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; and.,Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom; and.,Insigneo Institute for In Silico Medicine, University of Sheffield, 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; and.,Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
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Zelt JGE, Hossain A, Sun LY, Mehta S, Chandy G, Davies RA, Contreras-Dominguez V, Dunne R, Doyle-Cox C, Wells G, Stewart DJ, Mielniczuk LM. Incorporation of renal function in mortality risk assessment for pulmonary arterial hypertension. J Heart Lung Transplant 2020; 39:675-685. [PMID: 32336606 DOI: 10.1016/j.healun.2020.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Risk assessment is important for prognostication and individualized treatment decisions for patients with pulmonary arterial hypertension (PAH). The purpose was (1) to compare contemporary risk assessment tools and (2) to determine the prognostic significance of risk parameters of kidney function and whether they can further improve risk prediction for patients with PAH. METHODS We identified a cohort of treatment-naive patients (n = 211) who received an incident diagnosis of PAH at the University of Ottawa Heart Institute. Using demographics, disease characteristics, and hemodynamic data at diagnosis, we categorized patients as low, intermediate, or high risk according to current European guidelines (European Society of Cardiology [ESC]) and registry to evaluate early and long-term pulmonary arterial hypertension disease management (REVEAL) risk scores. The primary end-point was transplant-free survival (TFS). RESULTS Patients were predominantly women (64.6%) with World Health Organization function Class III symptoms (66.5%). The median TFS was 7.09 years. There was little agreement between ESC- and REVEAL-based risk estimates (weighted kappa = 0.21-0.34). Although both the ESC (log-rank, p = 0.0002) and REVEAL algorithms stratified TFS risk (p < 0.0001), the REVEAL score provided superior discrimination (C-statistic = 0.70 vs 0.59, p = 0.004). Renal function at diagnosis (p < 0.0001) and Δ renal function at 6 months (p < 0.0001) were identified as novel risk parameters and served to reclassify some patients in the intermediate-risk category to a lower or higher risk stratum (p < 0.0001). CONCLUSION REVEAL-based strategies provide superior TFS risk discrimination to ESC/European Respiratory Society-based approaches. However, the classification of intermediate-risk patients varied significantly across tools. We demonstrate the importance of renal function, which further improved the stratification of risk in patients with PAH, particularly in patients who are considered intermediate risk.
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Affiliation(s)
- Jason G E Zelt
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Alomgir Hossain
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Louise Y Sun
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sanjay Mehta
- Division of Respirology, Department of Medicine, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - George Chandy
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada; Division of Respirology and Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ross A Davies
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada
| | | | - Rosemary Dunne
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Caroyln Doyle-Cox
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - George Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Duncan J Stewart
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada; Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada.
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30
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The Role of Noninvasive Endpoints in Predicting Long-Term Outcomes in Pulmonary Arterial Hypertension. Lung 2019; 198:65-86. [PMID: 31722043 PMCID: PMC7012965 DOI: 10.1007/s00408-019-00289-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/29/2019] [Indexed: 12/26/2022]
Abstract
Background Until recently, many clinical trials in patients with pulmonary arterial hypertension (PAH) evaluated exercise capacity with 6-minute walk distance (6MWD) as the primary endpoint. Common secondary endpoints include PAH functional class (FC), which assesses symptoms, and either brain natriuretic peptide (BNP) or the inactive N-terminal cleavage product of its prohormone (NT-proBNP), which assesses cardiac function. Objective Examine the relationships among 6MWD, FC, and BNP/NT-proBNP measured at baseline or follow-up with long-term outcomes in PAH studies. Methods Relevant literature from January 1990 to April 2018 were obtained by searching PubMed, Embase, and Cochrane. Articles in English reporting on associations between 6MWD, FC, or BNP/NT-proBNP and outcomes in PAH were identified. Each endpoint was evaluated individually. Prespecified inclusion and exclusion criteria were applied at level 1 (titles/abstracts) and level 2 (full-text review). Results The database search yielded 836 unique records; 65 full-text articles were reviewed. Twenty-five studies were eligible for inclusion. Findings supported the importance of measuring PAH noninvasive endpoints in predicting long-term outcomes. Patients with shorter or decreased 6MWD, poor (III/IV) or declining FC (e.g., from II to III), or elevated or increasing BNP/NT-proBNP had a higher risk of death and costly events (e.g., hospitalization, lung transplant). FC also predicted health care resource utilization and costs. Collectively, these endpoints establish risk groups that predict likelihood of complications from PAH or death. Conclusion Assessment of 6MWD, FC, and BNP/NT-proBNP provides low-cost, efficient, and noninvasive means of predicting long-term health and economic outcomes in patients with PAH.
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Avdeev SN, Tsareva NA. [Risk stratification methods and their significance in pulmonary arterial hypertension]. TERAPEVT ARKH 2019; 91:150-157. [PMID: 32598827 DOI: 10.26442/00403660.2019.09.000192] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Despite significant advances in therapy, pulmonary arterial hypertension (PAH) remains a progressive disease with a poor prognosis. Immediately after establishing the diagnosis of PAH, urgent treatment with PAH-specific therapy is required. Due to the progressive nature of the disease, all patients should be closely monitored and their treatment regimen should be promptly changed according to clinical need. Risk stratification is an important method for informing the clinician and the patient about the prognosis of disease and the choice of therapy methods. The REVEAL scale and the ESC/ERS 2015 risk assessment table are important multifactorial tools for making decisions about the prescription and correction of PAH therapy, as well as for assessment of patients' response to therapy. Current guidelines for PAH indicate that the most important task of treatment of PAH is to achieve the low - risk status.
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Affiliation(s)
- S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Research Institute
| | - N A Tsareva
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Research Institute
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32
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Farber HW, Benza RL. Risk Assessment Tools in Pulmonary Arterial Hypertension. Prognosis for Prospective Trials? Am J Respir Crit Care Med 2019; 197:843-845. [PMID: 29373796 DOI: 10.1164/rccm.201801-0042ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Harrison W Farber
- 1 Pulmonary Center Boston University School of Medicine Boston, Massachusetts and
| | - Raymond L Benza
- 2 The Cardiovascular Institute Allegheny General Hospital Pittsburgh, Pennsylvania
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33
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Benza RL, Gomberg-Maitland M, Elliott CG, Farber HW, Foreman AJ, Frost AE, McGoon MD, Pasta DJ, Selej M, Burger CD, Frantz RP. Predicting Survival in Patients With Pulmonary Arterial Hypertension. Chest 2019; 156:323-337. [DOI: 10.1016/j.chest.2019.02.004] [Citation(s) in RCA: 266] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/16/2019] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
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Humbert M, Farber HW, Ghofrani HA, Benza RL, Busse D, Meier C, Hoeper MM. Risk assessment in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 53:13993003.02004-2018. [PMID: 30923187 PMCID: PMC6551213 DOI: 10.1183/13993003.02004-2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/12/2019] [Indexed: 12/21/2022]
Abstract
Background Current pulmonary hypertension treatment guidelines recommend use of a risk stratification model encompassing a range of parameters, allowing patients to be categorised as low, intermediate or high risk. Three abbreviated versions of this risk stratification model were previously evaluated in patients with pulmonary arterial hypertension (PAH) in the French, Swedish and COMPERA registries. Our objective was to investigate the three abbreviated risk stratification methods for patients with mostly prevalent PAH and chronic thromboembolic pulmonary hypertension (CTEPH), in patients from the PATENT-1/2 and CHEST-1/2 studies of riociguat. Methods Risk was assessed at baseline and at follow-up in PATENT-1 and CHEST-1. Survival and clinical worsening-free survival were assessed in patients in each risk group/strata. Results With all three methods, riociguat improved risk group/strata in patients with PAH after 12 weeks. The French non-invasive and Swedish/COMPERA methods discriminated prognosis for survival and clinical worsening-free survival at both baseline and follow-up. Furthermore, patients achieving one or more low-risk criteria or a low-risk stratum at follow-up had a significantly reduced risk of death and clinical worsening compared with patients achieving no low-risk criteria or an intermediate-risk stratum. Similar results were obtained in patients with inoperable or persistent/recurrent CTEPH. Conclusions This analysis confirms and extends the results of the registry analyses, supporting the value of goal-oriented treatment in PAH. Further assessment of these methods in patients with CTEPH is warranted. Riociguat improves risk group in patients with PAH and CTEPH according to three abbreviated versions of the ESC/ERS risk stratification model (results of a post hoc analysis)http://ow.ly/Herk30o8lKM
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Affiliation(s)
- Marc Humbert
- University Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM Unité 999, Le Kremlin-Bicêtre, France
| | - Harrison W Farber
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Raymond L Benza
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | | | - Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research (DZL), Hannover, Germany
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Kanwar M, Raina A, Lohmueller L, Kraisangka J, Benza R. The Use of Risk Assessment Tools and Prognostic Scores in Managing Patients with Pulmonary Arterial Hypertension. Curr Hypertens Rep 2019; 21:45. [PMID: 31025123 PMCID: PMC6756754 DOI: 10.1007/s11906-019-0950-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) is a chronic, progressive, and incurable disease with significant morbidity and mortality. Despite increasingly available treatment options, PAH patients continue to experience disease progression and increased rates of hospitalizations due to right heart failure. Physician's ability to comprehensively assess PAH patients, determine prognosis, and monitor disease progression and response to treatment remains critical in optimizing outcomes. RECENT FINDINGS Risk assessment in PAH should include a range of clinical, hemodynamic, and exercise parameters, performed in a serial fashion over the course of treatment. Approaches to risk assessment in PAH patients include the use of risk variables, scores, and equations that stratify the impact of both modifiable (e.g., 6-min walk distance, functional class, brain natriuretic peptide), and non-modifiable (e.g., age, gender, PAH etiology) risk factors. Such tools allow physicians to better determine prognosis, allocate treatment resources, and enhance the consistency of treatment approaches across providers. Comprehensive and accurate risk prediction is essential to make individualized treatment decisions and optimizing outcomes in PAH.
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Affiliation(s)
- Manreet Kanwar
- Department of Cardiovascular Disease, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Amresh Raina
- Department of Cardiovascular Disease, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | | | | | - Raymond Benza
- Department of Cardiovascular Disease, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA.
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Sitbon O, Gomberg-Maitland M, Granton J, Lewis MI, Mathai SC, Rainisio M, Stockbridge NL, Wilkins MR, Zamanian RT, Rubin LJ. Clinical trial design and new therapies for pulmonary arterial hypertension. Eur Respir J 2019; 53:13993003.01908-2018. [PMID: 30545975 PMCID: PMC6351342 DOI: 10.1183/13993003.01908-2018] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 12/20/2022]
Abstract
Until 20 years ago the treatment of pulmonary arterial hypertension (PAH) was based on case reports and small series, and was largely ineffectual. As a deeper understanding of the pathogenesis and pathophysiology of PAH evolved over the subsequent two decades, coupled with epidemiological studies defining the clinical and demographic characteristics of the condition, a renewed interest in treatment development emerged through collaborations between international experts, industry and regulatory agencies. These efforts led to the performance of robust, high-quality clinical trials of novel therapies that targeted putative pathogenic pathways, leading to the approval of more than 10 novel therapies that have beneficially impacted both the quality and duration of life. However, our understanding of PAH remains incomplete and there is no cure. Accordingly, efforts are now focused on identifying novel pathogenic pathways that may be targeted, and applying more rigorous clinical trial designs to better define the efficacy of these new potential treatments and their role in the management scheme. This article, prepared by a Task Force comprised of expert clinicians, trialists and regulators, summarises the current state of the art, and provides insight into the opportunities and challenges for identifying and assessing the efficacy and safety of new treatments for this challenging condition. State of the art and research perspectives in clinical trial design and new therapies for pulmonary arterial hypertensionhttp://ow.ly/VHQ030mfRxc
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Affiliation(s)
- Olivier Sitbon
- Université Paris-Sud, Hôpital Bicêtre, INSERM UMR_S999, Le Kremlin-Bicêtre, France
| | | | - John Granton
- University Health Network-General Division, University of Toronto, Toronto, ON, Canada
| | - Michael I Lewis
- Pulmonary/Critical Care Division and Smidt Heart Institute, Cedars Sinai Medical Center, UCLA, Los Angeles, CA, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care, Dept of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Martin R Wilkins
- Dept of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Roham T Zamanian
- Dept of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Lewis J Rubin
- San Diego School of Medicine, University of California, La Jolla, CA, USA
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38
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Howard LS. Is right heart catheterisation still a fundamental part of the follow-up assessment of pulmonary arterial hypertension? The argument against. Eur Respir J 2018; 52:52/1/1800996. [PMID: 29973359 DOI: 10.1183/13993003.00996-2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 05/30/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Kaymaz C, Akbal OY, Hakgor A, Tokgoz HC, Tanyeri S. Dart to the target: an alternative bull's eye parametric display for European Society of Cardiology / European Respiratory Society goal-orientated risk reduction strategy in pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018780522. [PMID: 29767575 PMCID: PMC6055270 DOI: 10.1177/2045894018780522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite the significant mortality and mobidity benefits being obtained with the targeted therapies in patients with pulmonary arterial hypertension (PAH), mid- to long-term survival of patients with this disease has remained unsatisfactory. For earlier and reliable risk stratification in PAH and tailoring the dynamic management strategies, various risk assessment models have been developed. Currently available risk reduction strategy recommended by the European Society of Cardiology (ESC)/European Respiratory Society (ERS) 2015 Pulmonary Hypertension Guidelines has been utilized in three recent registries. In this review, we evaluated the risk prediction models and management algorithms in this setting and propose an alternative parametric display, a bull's eye, dart table scheme for ESC/ERS goal-orientated risk reduction strategy in patients with PAH.
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Affiliation(s)
- Cihangir Kaymaz
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Ozgur Yasar Akbal
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Aykun Hakgor
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Hacer Ceren Tokgoz
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
| | - Seda Tanyeri
- University of Health Sciences, Kosuyolu Heart Education and Research Hospital Cevizli Mah., İstanbul, Turkey
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