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Lokhorst C, van der Werf S, Berger RMF, Douwes JM. Prognostic Value of Serial Risk Stratification in Adult and Pediatric Pulmonary Arterial Hypertension: A Systematic Review. J Am Heart Assoc 2024; 13:e034151. [PMID: 38904230 PMCID: PMC11255703 DOI: 10.1161/jaha.123.034151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/10/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND In pulmonary arterial hypertension, it is recommended to base therapeutic decisions on risk stratification. This systematic review aims to report the prognostic value of serial risk stratification in adult and pediatric pulmonary arterial hypertension and to explore the usability of serial risk stratification as treatment target. METHODS AND RESULTS Electronic databases PubMed, Embase, and Web of Science were searched up to January 30, 2023, using terms associated with pulmonary arterial hypertension, pediatric pulmonary hypertension, and risk stratification. Observational studies and clinical trials describing risk stratification at both baseline and follow-up were included. Sixty five studies were eligible for inclusion, including only 2 studies in a pediatric population. C-statistic range at baseline was 0.31 to 0.77 and improved to 0.30 to 0.91 at follow-up. In 53% of patients, risk status changed (42% improved, 12% worsened) over 168 days (interquartile range, 137-327 days; n=22 studies). The average proportion of low-risk patients increased from 18% at baseline to 36% at a median follow-up of 244 days (interquartile range, 140-365 days; n=40 studies). In placebo-controlled drug studies, risk statuses of the intervention groups improved more and worsened less compared with the placebo groups. Furthermore, a low-risk status, but also an improved risk status, at follow-up was associated with a better outcome. Similar results were found in the 2 pediatric studies. CONCLUSIONS Follow-up risk stratification has improved prognostic value compared with baseline risk stratification, and change in risk status between baseline and follow-up corresponded to a change in survival. These data support the use of serial risk stratification as treatment target in pulmonary arterial hypertension.
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Affiliation(s)
- Chantal Lokhorst
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Sjoukje van der Werf
- Central Medical LibraryUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Rolf M. F. Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Johannes M. Douwes
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
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2
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Zhang S, Li Y, Yang Y, Gong S, Yang Z, Hong C, Cui X, Wan J, Ji Y, Chen H, Zhu L, Li C, Cheng Z, Zhang Y, Wang Q, Luo Q, Guo L, Ma G, Han B, Liu Z, Xiong C, Wang L, Ji Q, Li F, Wang S, Zhang Z, Zhang Y, Wang D, Gao Q, Huang Q, Xie W, Zhai Z, Wang C. The management pattern and outcomes of chronic thromboembolic pulmonary hypertension: rationale and design for a Chinese real-world study. BMC Pulm Med 2024; 24:265. [PMID: 38825688 PMCID: PMC11145764 DOI: 10.1186/s12890-024-03042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disorder with substantial morbidity and mortality, also a disease underdiagnosed and undertreated. It is potentially curable by pulmonary endarterectomy (PEA) in patients with surgically accessible thrombi. Balloon pulmonary angioplasty (BPA) and targeted medical therapy are options for patients with distal lesions or persistent/recurrent pulmonary hypertension after PEA. There is an urgent need to increase the awareness of CTEPH. Qualified CTEPH centers are still quite limited. Baseline characteristics, management pattern and clinical outcome of CTEPH in China needs to be reported. METHODS AND DESIGN The CHinese reAl-world study to iNvestigate the manaGEment pattern and outcomes of chronic thromboembolic pulmonary hypertension (CHANGE) study is designed to provide the multimodality treatment pattern and clinical outcomes of CTEPH in China. Consecutive patients who are ≥ 14 year-old and diagnosed with CTEPH are enrolled. The diagnosis of CTEPH is confirmed in right heart catheterization and imaging examinations. The multimodality therapeutic strategy, which consists of PEA, BPA and targeted medical therapy, is made by a multidisciplinary team. The blood sample and tissue from PEA are stored in the central biobank for further research. The patients receive regular follow-up every 3 or 6 months for at least 3 years. The primary outcomes include all-cause mortality and changes in functional and hemodynamic parameters from baseline. The secondary outcomes include the proportion of patients experiencing lung transplantation, the proportion of patients experiencing heart and lung transplantation, and changes in health-related quality of life. Up to 31 December 2023, the study has enrolled 1500 eligible patients from 18 expert centers. CONCLUSIONS As a real-world study, the CHANGE study is expected to increase our understanding of CTEPH, and to fill the gap between guidelines and the clinical practice in the diagnosis, assessment and treatment of patients with CTEPH. REGISTRATION NUMBER IN CLINICALTRIALS.GOV: NCT05311072.
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Affiliation(s)
- Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yishan Li
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Sugang Gong
- Dpartments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Cheng Hong
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, P.R. China
| | - Xiaopei Cui
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, P.R. China
| | - Chenghong Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Zhaozhong Cheng
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, P.R. China
| | - Yunhui Zhang
- Department of Respiratory Medicine, The First People's Hospital of Yunnan Province, Kunming, P.R. China
| | - Qiguang Wang
- Division of Pulmonary Vascular Disease, General Hospital of Northern Theater of Command, Shenyang, P.R. China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lu Guo
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, P.R. China
| | - Guofeng Ma
- Department of Respiratory Diseases, Sir Run Run ShawHospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Baoshi Han
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, P.R. China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lan Wang
- Departments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Qiushang Ji
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Fajiu Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, P.R. China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiang Huang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Chen Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
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Yogeswaran A, da Rocha BB, Rako ZA, Kaufmann SJ, Schäfer S, Kremer N, Ghofrani HA, Seeger W, Tello K. Physiological mechanisms behind respiratory variations in right atrial pressure in pulmonary hypertension. Sci Rep 2024; 14:12547. [PMID: 38822042 PMCID: PMC11143365 DOI: 10.1038/s41598-024-61825-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/10/2024] [Indexed: 06/02/2024] Open
Abstract
Impaired respiratory variation of right atrial pressure (RAP) in severe pulmonary hypertension (PH) suggests difficulty tolerating increased preload during inspiration. Our study explores whether this impairment links to specific factors: right ventricular (RV) diastolic function, elevated RV afterload, systolic RV function, or RV-pulmonary arterial (PA) coupling. We retrospectively evaluated respiratory RAP variation in all participants enrolled in the EXERTION study. Impaired respiratory variation was defined as end-expiratory RAP - end-inspiratory RAP ≤ 2 mm Hg. RV function and afterload were evaluated using conductance catheterization. Impaired diastolic RV function was defined as end-diastolic elastance (Eed) ≥ median (0.19 mm Hg/mL). Seventy-five patients were included; PH was diagnosed in 57 patients and invasively excluded in 18 patients. Of the 75 patients, 31 (41%) had impaired RAP variation, which was linked with impaired RV systolic function and RV-PA coupling and increased tricuspid regurgitation and Eed as compared to patients with preserved RAP variation. In backward regression, RAP variation associated only with Eed. RAP variation but not simple RAP identified impaired diastolic RV function (area under the receiver operating characteristic curve [95% confidence interval]: 0.712 [0.592, 0.832] and 0.496 [0.358, 0.634], respectively). During exercise, patients with impaired RAP variation experienced greater RV dilatation and reduced diastolic reserve and cardiac output/index compared with patients with preserved RAP variation. Preserved RAP variation was associated with a better prognosis than impaired RAP variation based on the 2022 European Society of Cardiology/European Respiratory Society risk score (chi-square P = 0.025) and survival free from clinical worsening (91% vs 71% at 1 year and 79% vs 50% at 2 years [log-rank P = 0.020]; hazard ratio: 0.397 [95% confidence interval: 0.178, 0.884]). Subgroup analyses in patients with group 1 and group 4 PH demonstrated consistent findings with those observed in the overall study cohort. Respiratory RAP variations reflect RV diastolic function, are independent of RV-PA coupling or tricuspid regurgitation, are associated with exercise-induced haemodynamic changes, and are prognostic in PH.Trial registration. NCT04663217.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Bruno Brito da Rocha
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Zvonimir A Rako
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Samuel J Kaufmann
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Simon Schäfer
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Nils Kremer
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany.
- Department of Internal Medicine, Justus-Liebig-University Giessen, Klinikstrasse 32, 35392, Giessen, Germany.
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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Yogeswaran A, Gall H, Fünderich M, Wilkins MR, Howard L, Kiely DG, Lawrie A, Hassoun PM, Sirenklo Y, Torbas O, Sweatt AJ, Zamanian RT, Williams PG, Frauendorf M, Arvanitaki A, Giannakoulas G, Saleh K, Sabbour H, Cajigas HR, Frantz R, Al Ghouleh I, Chan SY, Brittain E, Annis JS, Pepe A, Ghio S, Orfanos S, Anthi A, Majeed RW, Wilhelm J, Ghofrani HA, Richter MJ, Grimminger F, Sahay S, Tello K, Seeger W. Comparison of Contemporary Risk Scores in All Groups of Pulmonary Hypertension: A Pulmonary Vascular Research Institute GoDeep Meta-Registry Analysis. Chest 2024:S0012-3692(24)00309-X. [PMID: 38508334 DOI: 10.1016/j.chest.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/22/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a heterogeneous disease with a poor prognosis. Accurate risk stratification is essential for guiding treatment decisions in pulmonary arterial hypertension (PAH). Although various risk models have been developed for PAH, their comparative prognostic potential requires further exploration. Additionally, the applicability of risk scores in PH groups beyond group 1 remains to be investigated. RESEARCH QUESTION Are risk scores originally developed for PAH predictive in PH groups 1 through 4? STUDY DESIGN AND METHODS We conducted a comprehensive analysis of outcomes among patients with incident PH enrolled in the multicenter worldwide Pulmonary Vascular Research Institute GoDeep meta-registry. Analyses were performed across PH groups 1 through 4 and further subgroups to evaluate the predictive value of PAH risk scores, including Registry to Evaluate Early and Long-Term PAH Disease Mangement (REVEAL) Lite 2, REVEAL 2.0, ESC/ERS 2022, Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) 3-strata, and COMPERA 4-strata. RESULTS Eight thousand five hundred sixty-five patients were included in the study, of whom 3,537 patients were assigned to group 1 PH, whereas 1,807 patients, 1,635 patients, and 1,586 patients were assigned to group 2 PH, group 3 PH, and group 4 PH, respectively. Pulmonary hemodynamics were impaired with median mean pulmonary arterial pressure of 42 mm Hg (interquartile range, 33-52 mm Hg) and pulmonary vascular resistance of 7 Wood units (WU) (interquartile range, 4-11 WU). All risk scores were prognostic in the entire PH population and in each of the PH groups 1 through 4. The REVEAL scores, when used as continuous prediction models, demonstrated the highest statistical prognostic power and granularity; the COMPERA 4-strata risk score provided subdifferentiation of the intermediate-risk group. Similar results were obtained when separately analyzing various subgroups (PH subgroups 1.1, 1.4.1, and 1.4.4; PH subgroups 3.1 and 3.2; group 2 with isolated postcapillary PH vs combined precapillary and postcapillary PH; patients of all groups with concomitant cardiac comorbidities; and severe [> 5 WU] vs nonsevere PH). INTERPRETATION This comprehensive study with real-world data from 15 PH centers showed that PAH-designed risk scores possess predictive power in a large PH cohort, whether considered as common to the group or calculated separately for each PH group (1-4) and various subgroups. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT05329714; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Meike Fünderich
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London
| | - Luke Howard
- National Heart and Lung Institute, Imperial College London, London
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, University of Sheffield and National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, England
| | - Allan Lawrie
- National Heart and Lung Institute, Imperial College London, London; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, University of Sheffield and National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, England
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yuriy Sirenklo
- National Scientific Center M.D. Strazhesko Institute of Cardiology, Clinical and Regenerative Medicine, The National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Olena Torbas
- National Scientific Center M.D. Strazhesko Institute of Cardiology, Clinical and Regenerative Medicine, The National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy, and Critical Care and the Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Palo Alto, CA
| | - Roham T Zamanian
- Division of Pulmonary, Allergy, and Critical Care and the Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Palo Alto, CA
| | | | | | - Alexandra Arvanitaki
- First Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Khaled Saleh
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Hani Sabbour
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Hector R Cajigas
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Robert Frantz
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | - Stefano Ghio
- Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | | | - Raphael W Majeed
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute of Medical Informatics, RWTH Aachen University, Aachen, Germany
| | - Jochen Wilhelm
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | | | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute (CPI), Giessen, Germany.
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6
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Kiely DG, Hamilton N, Wood S, Durrington C, Exposto F, Muzwidzwa R, Raiteri L, Beaudet A, Muller A, Sauter R, Pillai N, Lawrie A. Risk assessment and real-world outcomes in chronic thromboembolic pulmonary hypertension: insights from a UK pulmonary hypertension referral service. BMJ Open 2024; 14:e080068. [PMID: 38176861 PMCID: PMC10773408 DOI: 10.1136/bmjopen-2023-080068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES This study was conducted to evaluate the ability of risk assessment to predict healthcare resource utilisation (HCRU), costs, treatments, health-related quality of life (HRQoL) and survival in patients diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH). DESIGN Retrospective observational study. SETTING Pulmonary hypertension referral centre in the UK. PARTICIPANTS Adults diagnosed with CTEPH between 1 January 2012 and 30 June 2019 were included. Cohorts were retrospectively defined for operated patients (received pulmonary endarterectomy (PEA)) and not operated; further subgroups were defined based on risk score (low, intermediate or high risk for 1-year mortality) at diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES Demographics, clinical characteristics, comorbidities, treatment patterns, HRQoL, HCRU, costs and survival outcomes were analysed. RESULTS Overall, 683 patients were analysed (268 (39%) operated; 415 (61%) not operated). Most patients in the operated and not-operated cohorts were intermediate risk (63%; 53%) or high risk (23%; 31%) at diagnosis. Intermediate-risk and high-risk patients had higher HCRU and costs than low-risk patients. Outpatient and accident and emergency visits were lower postdiagnosis for both cohorts and all risk groups versus prediagnosis. HRQoL scores noticeably improved in the operated cohort post-PEA, and less so in the not-operated cohort at 6-18 months postdiagnosis. Survival at 5 years was 83% (operated) and 49% (not operated) and was lower for intermediate-risk and high-risk patients compared with low-risk patients. CONCLUSIONS Findings from this study support that risk assessment at diagnosis is prognostic for mortality in patients with CTEPH. Low-risk patients have better survival and HRQoL and lower HCRU and costs compared with intermediate-risk and high-risk patients.
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Affiliation(s)
- David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Biomedical Research Centre Sheffield, Sheffield, UK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Steven Wood
- NIHR Biomedical Research Centre Sheffield, Sheffield, UK
- Scientific Computing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | | | | | | | | | - Audrey Muller
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Rafael Sauter
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Nadia Pillai
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Allan Lawrie
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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7
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Pienn M, Gertz RJ, Gerhardt F, Kröger JR, Zaytoun H, Reimer RP, Kaplan A, Wissmüller M, Kovacs G, Rosenkranz S, Olschewski H, Bunck AC. CT-derived lung vessel morphology correlates with prognostic markers in precapillary pulmonary hypertension. J Heart Lung Transplant 2024; 43:54-65. [PMID: 37619642 DOI: 10.1016/j.healun.2023.08.013] [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: 02/19/2023] [Revised: 07/30/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND While computed tomography pulmonary angiography (CTPA) is an integral part of the work-up in patients with suspected pulmonary hypertension (PH), there is no established CTPA-derived prognostic marker. We aimed to assess whether quantitative readouts of lung vessel morphology correlate with established prognostic indicators in PH. METHODS We applied a fully-automatic in-house developed algorithm for segmentation of arteries and veins to determine lung vessel morphology in patients with precapillary PH who underwent right heart catheterization and CTPA between May 2016 and May 2019. Primary endpoint of this retrospective study was the calculation of receiver operating characteristics for identifying low and high mortality risk according to the 3-strata risk assessment model presented in the current guidelines. RESULTS We analyzed 73 patients, median age 65 years (interquartile range (IQR): 54-76), female/male ratio 35/38, median mean pulmonary arterial pressure 37 mm Hg (IQR: 30-46), and found significant correlations with important prognostic factors in pulmonary arterial hypertension. N-terminal pro-brain natriuretic peptide, cardiac index, mixed venous oxygen saturation, and 6-minute walking distance were correlated with the ratio of the number of arteries over veins with vessel diameters of 6-10 mm (Spearman correlation coefficients ρ = 0.64, p < 0.001; ρ = -0.60, p < 0.001; ρ = -0.47, p = 0.005; ρ = -0.45, p = 0.001, respectively). This ratio predicted a low- and high-risk score with an area under the curve of 0.73 (95% confidence interval (CI): 0.56-0.90) and 0.86 (95% CI: 0.74-0.97), respectively. CONCLUSIONS The ratio of the number of arteries over veins with diameters between 6 and 10 mm is significantly correlated with prognostic markers in pulmonary hypertension and predicts low and high mortality risk.
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Affiliation(s)
- Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Roman J Gertz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Felix Gerhardt
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan R Kröger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Hasan Zaytoun
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Robert P Reimer
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anil Kaplan
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Wissmüller
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander C Bunck
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [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: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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9
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Lichtblau M, Titz A, Bahrampoori B, Schmiedeskamp M, Ulrich S. What changed after the 2022 guidelines for pulmonary hypertension? Eur J Intern Med 2023; 118:1-5. [PMID: 37673774 DOI: 10.1016/j.ejim.2023.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
With an estimated prevalence of around 1%, pulmonary hypertension (PH) presents a relevant burden worldwide. In this review, we aim to give an overview of the novelties from the revised European Society of Cardiology (ESC) /European Respiratory Society (ERS) guidelines for the diagnosis and treatment of PH and their implication for the everyday clinical practice.
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Affiliation(s)
- Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | | | - Mark Schmiedeskamp
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
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10
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Lowery MM, Hill NS, Wang L, Rosenzweig EB, Bhat A, Erzurum S, Finet JE, Jellis CL, Kaur S, Kwon DH, Nawabit R, Radeva M, Beck GJ, Frantz RP, Hassoun PM, Hemnes AR, Horn EM, Leopold JA, Rischard FP, Mehra R. Sleep-Related Hypoxia, Right Ventricular Dysfunction, and Survival in Patients With Group 1 Pulmonary Arterial Hypertension. J Am Coll Cardiol 2023; 82:1989-2005. [PMID: 37968017 PMCID: PMC11060475 DOI: 10.1016/j.jacc.2023.09.806] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Group 1 pulmonary arterial hypertension (PAH) is a progressive fatal condition characterized by right ventricular (RV) failure with worse outcomes in connective tissue disease (CTD). Obstructive sleep apnea and sleep-related hypoxia may contribute to RV dysfunction, though the relationship remains unclear. OBJECTIVES The aim of this study was to prospectively evaluate the association of the apnea-hypopnea index (AHI) and sleep-related hypoxia with RV function and survival. METHODS Pulmonary Vascular Disease Phenomics (National Heart, Lung, and Blood Institute) cohort participants (patients with group 1 PAH, comparators, and healthy control participants) with sleep studies were included. Multimodal RV functional measures were examined in association with AHI and percentage of recording time with oxygen saturation <90% (T90) per 10-unit increment. Linear models, adjusted for demographics, oxygen, diffusing capacity of the lungs for carbon monoxide, pulmonary hypertension medications, assessed AHI and T90, and RV measures. Log-rank test/Cox proportional hazards models adjusted for demographics, oxygen, and positive airway pressure were constructed for transplantation-free survival analyses. RESULTS Analysis included 186 participants with group 1 PAH with a mean age of 52.6 ± 14.1 years; 71.5% were women, 80.8% were Caucasian, and there were 43 events (transplantation or death). AHI and T90 were associated with decreased RV ejection fraction (on magnetic resonance imaging), by 2.18% (-2.18; 95% CI: -4.00 to -0.36; P = 0.019) and 0.93% (-0.93; 95% CI: -1.47 to -0.40; P < 0.001), respectively. T90 was associated with increased RV systolic pressure (on echocardiography), by 2.52 mm Hg (2.52; 95% CI: 1.61 to 3.43; P < 0.001); increased mean pulmonary artery pressure (on right heart catheterization), by 0.27 mm Hg (0.27; 95% CI: 0.05 to 0.49; P = 0.019); and RV hypertrophy (on electrocardiography), 1.24 mm (1.24; 95% CI: 1.10 to 1.40; P < 0.001). T90, but not AHI, was associated with a 17% increased 5-year risk for transplantation or death (HR: 1.17; 95% CI: 1.07 to 1.28). In non-CTD-associated PAH, T90 was associated with a 21% increased risk for transplantation or death (HR: 1.21; 95% CI: 1.08 to 1.34). In CTD-associated PAH, T90 was associated with RV dysfunction, but not death or transplantation. CONCLUSIONS Sleep-related hypoxia was more strongly associated than AHI with measures of RV dysfunction, death, or transplantation overall and in group 1 non-CTD-associated PAH but only with RV dysfunction in CTD-associated PAH. (Pulmonary Vascular Disease Phenomics Program [PVDOMICS]; NCT02980887).
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Affiliation(s)
- Megan M Lowery
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Lu Wang
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Department of Pediatrics and Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Aparna Bhat
- Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serpil Erzurum
- Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J Emanuel Finet
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine L Jellis
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sunjeet Kaur
- Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah H Kwon
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rawan Nawabit
- Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Milena Radeva
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Franz P Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, Arizona, USA
| | - Reena Mehra
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA; Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA; Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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11
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Guth S, Wilkens H, Halank M, Held M, Hobohm L, Konstantinides S, Omlor A, Seyfarth HJ, Schäfers HJ, Mayer E, Wiedenroth CB. [Chronic thromboembolic pulmonary hypertension]. Pneumologie 2023; 77:937-946. [PMID: 37963483 DOI: 10.1055/a-2145-4807] [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: 11/16/2023]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is an important late complication of acute pulmonary embolism, in which the thrombi transform into fibrous tissue, become integrated into the vessel wall, and lead to chronic obstructions. CTEPD is differentiated into cases without pulmonary hypertension (PH), characterized by a mean pulmonary arterial pressure up to 20 mmHg and a form with PH. Then, it is still referred to as chronic thromboembolic pulmonary hypertension (CTEPH).When there is suspicion of CTEPH, initial diagnostic tests should include echocardiography and ventilation/perfusion scan to detect perfusion defects. Subsequently, referral to a CTEPH center is recommended, where further imaging diagnostics and right heart catheterization are performed to determine the appropriate treatment.Currently, three treatment modalities are available. The treatment of choice is pulmonary endarterectomy (PEA). For non-operable patients or patients with residual PH after PEA, PH-targeted medical therapy, and the interventional procedure of balloon pulmonary angioplasty (BPA) are available. Increasingly, PEA, BPA, and pharmacological therapy are combined in multimodal concepts.Patients require post-treatment follow-up, preferably at (CTE)PH centers. These centers are required to perform a minimum number of PEA surgeries (50/year) and BPA interventions (100/year).
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Affiliation(s)
- Stefan Guth
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Heinrike Wilkens
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin, Missionsärztliche Klinik Würzburg, Würzburg, Deutschland
| | - Lukas Hobohm
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Albert Omlor
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Hans-Jürgen Seyfarth
- Bereich Pneumologie, Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Eckhard Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
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12
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Lin J, Lin S, Zhang Y, Liu W. Identification of Ferroptosis-related potential biomarkers and immunocyte characteristics in Chronic Thromboembolic Pulmonary Hypertension via bioinformatics analysis. BMC Cardiovasc Disord 2023; 23:504. [PMID: 37821869 PMCID: PMC10566044 DOI: 10.1186/s12872-023-03511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a form of pulmonary hypertension with a high mortality rate. A new type of iron-mediated cell death is Ferroptosis, which is characterized by the accumulation of lethal iron ions and lipid peroxidation leading to mitochondrial atrophy and increased mitochondrial membrane density. Now, there is a lack of Ferroptosis-related biomarkers (FRBs) associated with pathogenic process of CTEPH. METHODS The differentially expressed genes (DEGs) of CTEPH were obtained by GEO2R. Genes related to Ferroptosis were obtained from FerrDb database. The intersection of Ferroptosis and DEGs results in FRBs. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were performed in Database for Annotation, Visualization and Integrated Discovery (DAVID) database. The optimal potential biomarkers for CTEPH were analyzed by least absolute shrinkage and selection operator (LASSO) and support vector machine-recursive feature elimination (SVM-RFE) machine learning. The four hub genes were verified from the Gene Expression Omnibus (GEO) dataset GSE188938. Immune infiltration was analyzed by CIBERSORT. SPSS software was used to analyze the Spearman rank correlation between FRBs identified and infiltration-related immune cells, and p < 0.05 was considered as statistically significant. RESULTS In this study, potential genetic biomarkers associated with Ferroptosis in CTEPH were investigated and explored their role in immune infiltration. In total, we identified 17 differentially expressed Ferroptosis-associated genes by GEOquery package. The key FRBs including ARRDC3, HMOX1, BRD4, and YWHAE were screened using Lasso and SVM-RFE machine learning methods.Through gene set GSE188938 verification, only upregulation of gene ARRDC3 showed statistical difference. In addition, immune infiltration analysis using the CIBERSORT algorithm revealed the infiltration of Eosinophils and Neutrophils in CTEPH samples was less than that in the control group. And correlation analysis revealed that ARRDC3 was positively correlated with T cells follicular helper (r = 0.554, p = 0.017) and negatively correlated with Neutrophils (r = -0.47, p = 0.049). CONCLUSIONS In conclusion, ARRDC3 upregulation with different immune cell infiltration were involved in the development of CTEPH. ARRDC3 might a potential Ferroptosis-related biomarker for CTEPH treatment. This study provided a new insight into pathogenesis CTEPH.
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Affiliation(s)
- Jiangpeng Lin
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510260, China
| | - Shuangfeng Lin
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yuzhuo Zhang
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510260, China
| | - Weihua Liu
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510260, China.
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Ahmed MS, Ghallab M, Ostrow T, Nashawi M, Alagha Z, Levine A, Aronow WS, Lanier GM. Pharmacotherapy of refractory pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:1861-1874. [PMID: 37698041 DOI: 10.1080/14656566.2023.2257134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.
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Affiliation(s)
- Mahmoud Samy Ahmed
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Muhammad Ghallab
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Talia Ostrow
- Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mouhamed Nashawi
- Department of Medicine, Baylor Scott & White Health, Dallas, TX, USA
| | - Zakaria Alagha
- Department of Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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15
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Sonnweber T, Tymoszuk P, Steringer-Mascherbauer R, Sigmund E, Porod-Schneiderbauer S, Kohlbacher L, Theurl I, Lang I, Weiss G, Löffler-Ragg J. The combination of supervised and unsupervised learning based risk stratification and phenotyping in pulmonary arterial hypertension-a long-term retrospective multicenter trial. BMC Pulm Med 2023; 23:143. [PMID: 37098543 PMCID: PMC10131314 DOI: 10.1186/s12890-023-02427-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/06/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Accurate risk stratification in pulmonary arterial hypertension (PAH), a devastating cardiopulmonary disease, is essential to guide successful therapy. Machine learning may improve risk management and harness clinical variability in PAH. METHODS We conducted a long-term retrospective observational study (median follow-up: 67 months) including 183 PAH patients from three Austrian PAH expert centers. Clinical, cardiopulmonary function, laboratory, imaging, and hemodynamic parameters were assessed. Cox proportional hazard Elastic Net and partitioning around medoid clustering were applied to establish a multi-parameter PAH mortality risk signature and investigate PAH phenotypes. RESULTS Seven parameters identified by Elastic Net modeling, namely age, six-minute walking distance, red blood cell distribution width, cardiac index, pulmonary vascular resistance, N-terminal pro-brain natriuretic peptide and right atrial area, constituted a highly predictive mortality risk signature (training cohort: concordance index = 0.82 [95%CI: 0.75 - 0.89], test cohort: 0.77 [0.66 - 0.88]). The Elastic Net signature demonstrated superior prognostic accuracy as compared with five established risk scores. The signature factors defined two clusters of PAH patients with distinct risk profiles. The high-risk/poor prognosis cluster was characterized by advanced age at diagnosis, poor cardiac output, increased red cell distribution width, higher pulmonary vascular resistance, and a poor six-minute walking test performance. CONCLUSION Supervised and unsupervised learning algorithms such as Elastic Net regression and medoid clustering are powerful tools for automated mortality risk prediction and clinical phenotyping in PAH.
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Affiliation(s)
- Thomas Sonnweber
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Piotr Tymoszuk
- Data Analytics As a Service Tirol, Daas.Tirol, Innsbruck, Austria
| | | | | | | | - Lisa Kohlbacher
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Igor Theurl
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Irene Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Judith Löffler-Ragg
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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16
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Si-Mohamed SA, Zumbihl L, Turquier S, Boccalini S, Mornex JF, Douek P, Cottin V, Boussel L. Lung Dual-Energy CT Perfusion Blood Volume as a Marker of Severity in Chronic Thromboembolic Pulmonary Hypertension. Diagnostics (Basel) 2023; 13:diagnostics13040769. [PMID: 36832256 PMCID: PMC9955200 DOI: 10.3390/diagnostics13040769] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
In chronic thromboembolic pulmonary hypertension (CTEPH), assessment of severity requires right heart catheterization (RHC) through cardiac index (CI). Previous studies have shown that dual-energy CT allows a quantitative assessment of the lung perfusion blood volume (PBV). Therefore, the objective was to evaluate the quantitative PBV as a marker of severity in CTEPH. In the present study, thirty-three patients with CTEPH (22 women, 68.2 ± 14.8 years) were included from May 2017 to September 2021. Mean quantitative PBV was 7.6% ± 3.1 and correlated with CI (r = 0.519, p = 0.002). Mean qualitative PBV was 41.1 ± 13.4 and did not correlate with CI. Quantitative PBV AUC values were 0.795 (95% CI: 0.637-0.953, p = 0.013) for a CI ≥ 2 L/min/m2 and 0.752 (95% CI: 0.575-0.929, p = 0.020) for a CI ≥ 2.5 L/min/m2. In conclusion, quantitative lung PBV outperformed qualitative PBV for its correlation with the cardiac index and may be used as a non-invasive marker of severity in CTPEH patients.
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Affiliation(s)
- Salim A. Si-Mohamed
- Radiology Department, Louis Pradel Hospital, 59 Boulevard Pinel, 69500 Bron, France
- INSA-Lyon, University of Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, 69621 Lyon, France
- Correspondence: ; Tel.: +33-04-7235-7335
| | - Léa Zumbihl
- Radiology Department, Louis Pradel Hospital, 59 Boulevard Pinel, 69500 Bron, France
| | - Ségolène Turquier
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, 69677 Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon, 69007 Lyon, France
- ERN-LUNG, 69500 Bron, France
| | - Sara Boccalini
- Radiology Department, Louis Pradel Hospital, 59 Boulevard Pinel, 69500 Bron, France
- INSA-Lyon, University of Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, 69621 Lyon, France
| | - Jean-Francois Mornex
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, 69677 Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon, 69007 Lyon, France
- ERN-LUNG, 69500 Bron, France
| | - Philippe Douek
- Radiology Department, Louis Pradel Hospital, 59 Boulevard Pinel, 69500 Bron, France
- INSA-Lyon, University of Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, 69621 Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, 69677 Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon, 69007 Lyon, France
- ERN-LUNG, 69500 Bron, France
| | - Loic Boussel
- Radiology Department, Louis Pradel Hospital, 59 Boulevard Pinel, 69500 Bron, France
- INSA-Lyon, University of Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, 69621 Lyon, France
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17
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Hirsch K, Nolley S, Ralph DD, Zheng Y, Altemeier WA, Rhodes CJ, Morrell NW, Wilkins MR, Leary PJ, Rayner SG. Circulating markers of inflammation and angiogenesis and clinical outcomes across subtypes of pulmonary arterial hypertension. J Heart Lung Transplant 2023; 42:173-182. [PMID: 36470771 PMCID: PMC9840657 DOI: 10.1016/j.healun.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Subtypes of pulmonary arterial hypertension (PAH) differ in both fundamental disease features and clinical outcomes. Angiogenesis and inflammation represent disease features that may differ across subtypes and are of special interest in connective tissue disease-associated PAH (CTD-PAH). We compared inflammatory and angiogenic biomarker profiles across different etiologies of PAH and related them to clinical outcomes. METHODS Participants with idiopathic PAH, CTD-PAH, toxin-associated PAH (tox-PAH), or congenital heart disease-associated PAH (CHD-PAH) were enrolled into a prospective observational cohort. Baseline serum concentrations of 33 biomarkers were related to 3-year mortality, echocardiogram, REVEAL score, and 6-minute walk distance (6MWD). Findings were validated using plasma proteomic data from the UK PAH Cohort Study. RESULTS One hundred twelve patients were enrolled: 45 idiopathic, 27 CTD-PAH, 20 tox-PAH, and 20 CHD-PAH. Angiogenic and inflammatory biomarkers were distinctly elevated within the CTD-PAH cohort. Six biomarkers were associated with mortality within the entire PAH cohort: interleukin-6 (IL-6, HR:1.6, 95% CI:1.18-2.18), soluble fms-like tyrosine kinase 1 (sFlt-1, HR:1.35, 95% CI:1.02-1.80), placental growth factor (PlGF, HR:1.55, 95% CI:1.07-2.25), interferon gamma-induced protein 10 (IP-10, HR:1.44, 95% CI:1.04-1.99), tumor necrosis factor-beta (TNF-β, HR:1.81, 95% CI:1.11-2.95), and NT-proBNP (HR:2.19, 95% CI:1.52-3.14). Only IL-6 and NT-proBNP remained significant after controlling for multiple comparisons. IL-6, IP-10, and sFlt-1 significantly associated with mortality in CTD-PAH, but not non-CTD-PAH subgroups. In the UK cohort, IP-10, PlGF, TNF-β, and NT-proBNP significantly associated with 5-year survival. CONCLUSION Levels of angiogenic and inflammatory biomarkers are elevated in CTD-PAH, compared with other etiologies of PAH, and may correlate with clinical outcomes including mortality.
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Affiliation(s)
- Kellen Hirsch
- Department of Medicine, University of Washington, Seattle, Washington
| | - Stephanie Nolley
- Department of Medicine, University of Washington, Seattle, Washington
| | - David D Ralph
- Department of Medicine, University of Washington, Seattle, Washington
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, Washington
| | - William A Altemeier
- Department of Medicine, University of Washington, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington
| | - Christopher J Rhodes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Peter J Leary
- Department of Medicine, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Samuel G Rayner
- Department of Medicine, University of Washington, Seattle, Washington; Department of Bioengineering, University of Washington, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington.
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18
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 461] [Impact Index Per Article: 461.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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19
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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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20
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1082] [Impact Index Per Article: 541.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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21
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Hendriks PM, van de Groep LD, Veen KM, van Thor MCJ, Meertens S, Boersma E, Boomars KA, Post MC, van den Bosch AE. Prognostic value of brain natriuretic peptides in patients with pulmonary arterial hypertension: A systematic review and meta-analysis. Am Heart J 2022; 250:34-44. [PMID: 35533723 DOI: 10.1016/j.ahj.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Multiple biomarkers have been investigated in the risk stratification of patients with pulmonary arterial hypertension (PAH). This systematic review and meta-analysis is the first to investigate the prognostic value of (NT-pro)BNP in patients with PAH. METHODS A systematic literature search was performed using MEDLINE, Embase, Web of Science, the Cochrane Library and Google scholar to identify studies on the prognostic value of baseline (NT-pro)BNP levels in PAH. Studies reporting hazard ratios (HR) for the endpoints mortality or lung transplant were included. A random effects meta-analysis was performed to calculate the pooled HR of (NT-pro)BNP levels at the time of diagnosis. To account for different transformations applied to (NT-pro)BNP, the HR was calculated for a 2-fold difference of the weighted mean (NT-pro)BNP level of 247 pmol/L, for studies reporting a HR based on a continuous (NT-pro)BNP measurement. RESULTS Sixteen studies were included, representing 6999 patients (mean age 45.2-65.0 years, 97.3% PAH). Overall, 1460 patients reached the endpoint during a mean follow-up period between 1 and 10 years. Nine studies reported HRs based on cut-off values. The risk of mortality or lung transplant was increased for both elevated NT-proBNP and BNP with a pooled HR based on unadjusted HRs of 2.75 (95%-CI: 1.86-4.07) and 3.87 (95% CI 2.69-5.57) respectively. Six studies reported HRs for (NT-pro)BNP on a continues scale. A 2-fold difference of the weighted mean NT-proBNP resulted in an increased risk of mortality or lung transplant with a pooled HR of 1.17 (95%-CI: 1.03-1.32). CONCLUSIONS Increased levels of (NT-pro)BNP are associated with a significantly increased risk of mortality or lung transplant in PAH patients.
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Affiliation(s)
- Paul M Hendriks
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Liza D van de Groep
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Kevin M Veen
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mitch C J van Thor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sabrina Meertens
- Medical Library, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Clinical epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin A Boomars
- Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Utrecht University Medical Center, Utrecht, The Netherlands
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22
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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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23
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Kjellström B, Bouzina H, Björklund E, Beaudet A, Edwards SC, Hesselstrand R, Jansson K, Nisell M, Rådegran G, Sandqvist A, Wåhlander H, Hjalmarsson C, Söderberg S. Five year risk assessment and treatment patterns in patients with chronic thromboembolic pulmonary hypertension. ESC Heart Fail 2022; 9:3264-3274. [PMID: 35789127 DOI: 10.1002/ehf2.14033] [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: 01/26/2022] [Revised: 04/20/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Repeated risk assessments and treatment patterns over long time are sparsely studied in chronic thromboembolic pulmonary hypertension (CTEPH); thus, we aimed to investigate changes in risk status and treatment patterns in incident patients with CTEPH over a 5 year period. METHODS AND RESULTS Descriptive and explorative study including 311 patients diagnosed with CTEPH 2008-2019 from the Swedish pulmonary hypertension registry, stratified by pulmonary endarterectomy surgery (PEA). Risk and PH-specific treatment were assessed in surgically treated (PEA) and medically treated (non-PEA) patients at diagnosis and up to 5 years follow-up. Data are presented as median (Q1-Q3), count or per cent. Prior to surgery, 63% in the PEA-group [n = 98, age 64 (51-71) years, 37% female] used PH-specific treatment and 20, 69, and 10% were assessed as low, intermediate or high risk, respectively. After 1 year post-surgery, 34% had no PH-specific treatment or follow-up visit registered despite being alive at 5 years. Of patients with a 5 year visit (n = 23), 46% were at low and 54% at intermediate risk, while 91% used PH-specific treatment. In the non-PEA group [n = 213, age 72 (65-77) years, 56% female], 28% were assessed as low, 61% as intermediate and 11% as high risk. All patients at high risk versus 50% at low risk used PH-specific treatment. The 1 year mortality was 6%, while the risk was unchanged in 57% of the patients; 14% improved from intermediate to low risk, and 1% from high to low risk. At 5 years, 27% had a registered visit and 28% had died. Of patients with a 5 year visit (n = 58), 38% were at low, 59% at intermediate and 1% at high risk, and 86% used PH-specific treatment. CONCLUSIONS Risk status assessed pre-surgery did not foresee long-term post-PEA risk and pre-surgery PH-specific treatment did not foresee long-term post-PEA treatment. Medically treated CTEPH patients tend to remain at the same risk over time, suggesting a need for improved treatment strategies in this group.
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Affiliation(s)
- Barbro Kjellström
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology and Skåne University Hospital, Lund, Sweden.,Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Habib Bouzina
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Erik Björklund
- Department of Cardiology, University Hospital, Uppsala, Sweden
| | | | | | - Roger Hesselstrand
- Department of Clinical Sciences Lund, Section for Rheumatology, Lund University and Skåne university hospital, Lund, Sweden
| | - Kjell Jansson
- Department of Cardiology and Department of Clinical Physiology Institution of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Magnus Nisell
- Lung Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | | | - Håkan Wåhlander
- Pediatric Heart Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, and Department of Pediatrics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clara Hjalmarsson
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Medicine Unit, Umeå University, Umeå, Sweden
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24
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Liu CM, Shih ES, Chen JY, Huang CH, Wu IC, Chen PF, Higa S, Yagi N, Hu YF, Hwang MJ, Chen SA. Artificial Intelligence-Enabled Electrocardiogram Improves the Diagnosis and Prediction of Mortality in Patients With Pulmonary Hypertension. JACC. ASIA 2022; 2:258-270. [PMID: 36338407 PMCID: PMC9627911 DOI: 10.1016/j.jacasi.2022.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND Pulmonary hypertension is a disabling and life-threatening cardiovascular disease. Early detection of elevated pulmonary artery pressure (ePAP) is needed for prompt diagnosis and treatment to avoid detrimental consequences of pulmonary hypertension. OBJECTIVES This study sought to develop an artificial intelligence (AI)-enabled electrocardiogram (ECG) model to identify patients with ePAP and related prognostic implications. METHODS From a hospital-based ECG database, the authors extracted the first pairs of ECG and transthoracic echocardiography taken within 2 weeks of each other from 41,097 patients to develop an AI model for detecting ePAP (PAP > 50 mm Hg by transthoracic echocardiography). The model was evaluated on independent data sets, including an external cohort of patients from Japan. RESULTS Tests of 10-fold cross-validation neural-network deep learning showed that the area under the receiver-operating characteristic curve of the AI model was 0.88 (sensitivity 81.0%; specificity 79.6%) for detecting ePAP. The diagnostic performance was consistent across age, sex, and various comorbidities (diagnostic odds ratio >8 for most factors examined). At 6-year follow-up, the patients predicted by the AI model to have ePAP were independently associated with higher cardiovascular mortality (HR: 3.69). Similar diagnostic performance and prediction for cardiovascular mortality could be replicated in the external cohort. CONCLUSIONS The ECG-based AI model identified patients with ePAP and predicted their future risk for cardiovascular mortality. This model could serve as a useful clinical test to identify patients with pulmonary hypertension so that treatment can be initiated early to improve their survival prognosis.
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Affiliation(s)
- Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine and Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Edward S.C. Shih
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Jhih-Yu Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Chih-Han Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Genome and Systems Biology Degree Program, Academia Sinica and National Taiwan University, Taipei, Taiwan
| | - I-Chien Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Pei-Fen Chen
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa, Japan
| | - Nobumori Yagi
- Division of Cardiovascular Medicine, Nakagami Hospital, Okinawa, Japan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine and Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Address for correspondence: Dr Yu-Feng Hu, Taipei Veterans General Hospital, 201 Sec. 2, Shih-Pai Road, Taipei, Taiwan.
| | - Ming-Jing Hwang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Genome and Systems Biology Degree Program, Academia Sinica and National Taiwan University, Taipei, Taiwan
- Dr Ming-Jing Hwang, Institute of Biomedical Sciences, Academia Sinica, 128 Sec. 2, Academia Road, Nankang, Taipei, Taiwan.
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine and Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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25
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Abstract
RATIONALE Pulmonary hypertension encompasses progressive disorders leading to right ventricular dysfunction and early death. Late detection is an important cause of poor clinical outcomes. However, biomarkers that accurately predict the presence of pulmonary hypertension are currently lacking. OBJECTIVES In this study we provide evidence that blood platelets contain a distinctive RNA profile that may be exploited for detection of pulmonary hypertension. METHODS Blood platelet RNA was isolated prospectively from 177 prevalent patients with different subtypes of pulmonary hypertension as well as 195 controls clinically not suspected of pulmonary hypertension. Sequencing libraries were created using SMARTer cDNA amplification, and sequenced on the Illumina HiSeq platform. RNA-sequencing reads were mapped to the human reference genome, and intron-spanning spliced RNA reads were selected. Differential spliced RNA panels were calculated by ANOVA-statistics. A particle swarm optimisation (PSO)-enhanced classification algorithm was built employing a development (n=213 samples) and independent validation series (n=159 samples). RESULTS We detected a total of 4014 different RNAs in blood platelets from pulmonary hypertension patients (n=177) and asymptomatic controls (n=195). GSEA gene ontology analysis revealed enriched RNA levels for genes related to RNA-processing, translation and mitochondrial function. A PSO-selected RNA panel of 408 distinctive differentially spliced RNAs mediated detection of pulmonary hypertension with 93% sensitivity, 62% specificity, 77% accuracy, 0.89 (95%CI 0.83-0.93) area under the curve and a negative predictive value of 91% in the independent validation series. Prediction score was independent of age, sex, smoking, pulmonary hypertension subtype, and the use of pulmonary hypertension-specific medication or anti-coagulants. CONCLUSION A platelet RNA-panel may accurately discriminate patients with pulmonary hypertension from asymptomatic controls. In the light of current diagnostic delays, this study is the starting point for further development and evaluation of a platelet RNA-based blood test, to ultimately improve early diagnosis and clinical outcomes in patients with pulmonary hypertension.
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26
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Sanna L, Todea A. Risk assessment tools for survival prognosis: An era of new surrogacy endpoints for clinical outcome measurement in pulmonary arterial hypertension clinical trials? Respir Med Res 2022; 81:100893. [PMID: 35523041 DOI: 10.1016/j.resmer.2022.100893] [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: 10/19/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 11/19/2022]
Abstract
Developing a new medication in a rare disease indication like pulmonary arterial hypertension (PAH) is very challenging. This is especially true now that clinical trials often employ time to clinical worsening (TTCW) as an endpoint (thus requiring a relatively large and lengthy trial) and since patients are more frequently prescribed combination therapy. During the last few decades, several tools have been developed to predict mortality in PAH and have demonstrated generally good discrimination. The objective of this review article is to assess the available data on the different tools and methods described in the literature and identify potential candidates that could be used as surrogate endpoints in pivotal randomized clinical trials in future. Some of these tools have been validated in various registries and in post-hoc analyses of clinical trial data, but none have been assessed in a prospective clinical trial and we still lack the evidence necessary for endorsement by health authorities. In this review, we identify several promising options that warrant further investigation as potential surrogate endpoints in clinical trials to replace TTCW or 6-minute walk distance. Prospective inclusion of such tools in new clinical trials may help build a stronger surrogacy for prognosis of disease progression and mortality.
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Affiliation(s)
- Lilian Sanna
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland.
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27
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Stubbe B, Halank M, Seyfarth HJ, Obst A, Desole S, Opitz CF, Ewert R. [Risk Stratification in Patients with Pulmonary Arterial Hypertension under Treatment - Results of Four German Centers]. Pneumologie 2022; 76:330-339. [PMID: 35373311 DOI: 10.1055/a-1740-3377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). According to the current European guidelines the expected 1-year risk of mortality for PAH patients can be categorized as low, intermediate, or high, based on clinical, non-invasive and hemodynamic data.Data from 131 patients with incident PAH (age 64 ± 14) and frequent comorbidities (in 66.4 %) treated between 2016 and 2018 at 4 German PH centers were analyzed. At baseline, most patients were classified as intermediate risk (76 %), 13.8 % as high risk and only 9.9 % as low risk.During follow-up while on treatment after 12 ± 3 months (range 9-16 months) 64.9 % were still classified as intermediate risk (76 %), 14.4 % as high risk and 20.7 % as low risk.Survival at 12 and 24 months was 96 % and 82 % in the intermediate risk group, while only 89 % and 51 % of the high risk patients were alive at these time points. In contrast, all patients in the low risk category were alive at 24 months.Despite the availability of various treatment options for patients with PAH even in specialized centers only a minority of patients can be stabilized in the low risk group associated with a good outcome.
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Affiliation(s)
- Beate Stubbe
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | | | - Anne Obst
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Susanna Desole
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | | | - Ralf Ewert
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
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28
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Sinkala E, Ahmed HY, Sibomana JP, Lee MH, Kassa B, Kumar R, Mazimba S, Binegdie AB, Mpisa S, Wamundila K, Graham BB, Hilton JF. Rationale and design of a screening study to detect schistosomiasis-associated pulmonary hypertension in Ethiopia and Zambia. Pulm Circ 2022; 12:e12072. [PMID: 35514775 PMCID: PMC9063961 DOI: 10.1002/pul2.12072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/28/2022] [Accepted: 03/27/2022] [Indexed: 11/05/2022] Open
Abstract
Schistosomiasis is a major cause of pulmonary arterial hypertension (PAH) worldwide, but the prevalence and risk factors for schistosomiasis-associated PAH (SchPAH) development are not well understood. Schistosomiasis-associated hepatosplenic disease (SchHSD) is thought to be a major risk factor for PAH development. Herein, we describe our plans for prospectively screening SchHSD subjects for clinical evidence of PAH at two major academic medical centers and national referral hospitals in Addis Ababa, Ethiopia and Lusaka, Zambia. The screening study will primarily be conducted by echocardiography, in addition to clinical assessments. Plasma samples will be drawn and banked for subsequent analysis based on preclinical animal model rationale. If successful, this study will demonstrate feasibility of conducting prospective cohort studies of SchPAH screening in schistosomiasis-endemic regions of Africa, and provide initial data on clinic-based disease prevalence and potential mechanistic biomarkers underlying disease pathogenesis.
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Affiliation(s)
- Edford Sinkala
- Hepatology Clinic, Department of MedicineUniversity of Zambia Teaching HospitalLusakaZambia
| | - Hanan Yusuf Ahmed
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Tikur Anbessa Specialized Hospital, College of Health SciencesUniversity of Addis AbabaAddis AbabaEthiopia
| | - Jean Pierre Sibomana
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Tikur Anbessa Specialized Hospital, College of Health SciencesUniversity of Addis AbabaAddis AbabaEthiopia
- Department of Medicine, Butare University Teaching HospitalUniversity of RwandaButareRwanda
| | - Michael H. Lee
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Biruk Kassa
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Rahul Kumar
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sula Mazimba
- Department of Medicine, Division of CardiologyUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Amsalu B. Binegdie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Tikur Anbessa Specialized Hospital, College of Health SciencesUniversity of Addis AbabaAddis AbabaEthiopia
| | - Sydney Mpisa
- Hepatology Clinic, Department of MedicineUniversity of Zambia Teaching HospitalLusakaZambia
| | - Kawana Wamundila
- Hepatology Clinic, Department of MedicineUniversity of Zambia Teaching HospitalLusakaZambia
| | - Brian B. Graham
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Joan F. Hilton
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
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29
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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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30
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Rahaghi FF, Balasubramanian VP, Bourge RC, Burger CD, Chakinala MM, Eggert MS, Elwing JM, Feldman J, King C, Klinger JR, Mathai SC, Wesley McConnell J, Palevsky HI, Restrepo‐Jaramillo R, Safdar Z, Sager JS, Sood N, Sulica R, James White R, Hill NS. Delphi Consensus Recommendation for Optimization of Pulmonary Hypertension Therapy Focusing On Switching from a Phosphodiesterase 5 Inhibitor to Riociguat. Pulm Circ 2022; 12:e12055. [PMID: 35514769 PMCID: PMC9063960 DOI: 10.1002/pul2.12055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/06/2022] Open
Abstract
Dual combination therapy with a phosphodiesterase‐5 inhibitor (PDE5i) and endothelin receptor antagonist is recommended for most patients with intermediate‐risk pulmonary arterial hypertension (PAH). The RESPITE and REPLACE studies suggest that switching from a PDE5i to a soluble guanylate cyclase (sGC) activator may provide clinical improvement in this situation. The optimal approach to escalation or transition of therapy in this or other scenarios is not well defined. We developed an expert consensus statement on the transition to sGC and other treatment escalations and transitions in PAH using a modified Delphi process. The Delphi process used a panel of 20 physicians with expertise in PAH. Panelists answered three questionnaires on the management of treatment escalations and transitions in PAH. The initial questionnaire included open‐ended questions. Later questionnaires consolidated the responses into statements that panelists rated on a Likert scale from −5 (strongly disagree) to +5 (strongly agree) to determine consensus. The Delphi process produced several consensus recommendations. Escalation should be considered for patients who are at high risk or not achieving treatment goals, by adding an agent from a new class, switching from oral to parenteral prostacyclins, or increasing the dose. Switching to a new class or within a class should be considered if tolerability or other considerations unrelated to efficacy are affecting adherence. Switching from a PDE5i to an SGC activator may benefit patients with intermediate risk who are not improving on their present therapy. These consensus‐based recommendations may be helpful to clinicians and beneficial for patients when evidence‐based guidance is unavailable.
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Affiliation(s)
- Franck F. Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida Weston FL USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Zeenat Safdar
- Center for Advanced Lung Diseases, Houston Methodist Hospital, Weill Cornell Medicine Houston TX USA
| | | | - Namita Sood
- University of California‐ Davis Sacramento CA
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31
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Benza RL, Farber HW, Frost AE, Ghofrani HA, Corris PA, Lambelet M, Nikkho S, Meier C, Hoeper MM. Application of the REVEAL risk score calculator 2.0 in the CHEST study. Respir Med 2022; 195:106783. [DOI: 10.1016/j.rmed.2022.106783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 10/19/2022]
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32
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Wu SH, Wu YJ. Regular Risk Assessment in Pulmonary Arterial Hypertension - A Whistleblower for Hidden Disease Progression. ACTA CARDIOLOGICA SINICA 2022; 38:113-123. [PMID: 35273432 PMCID: PMC8888324 DOI: 10.6515/acs.202203_38(2).20211005a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/05/2021] [Indexed: 01/24/2023]
Abstract
Despite developments in the treatment of pulmonary arterial hypertension, timely treatment is seldom achieved, and hidden progression is not uncommonly disguised as a seemingly "stable" condition. Appropriate risk assessment tools facilitate goal-oriented treatment strategies. This article aimed to review the development of these risk assessment tools including early assessment equations/scores, European guidelines-based risk assessment scores, and tools derived from the United States nationwide registry. A stepwise and regular approach with these assessment tools in clinical practice is highly recommended for timely treatment escalation to stop disease progression early. In this review, a practical and recommended algorithm of these assessment tools is also provided.
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Affiliation(s)
- Shu-Hao Wu
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital, Taipei;
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Department of Medicine, and Institute of Biomedical Sciences, MacKay Medical College, New Taipei City, Taiwan
| | - Yih-Jer Wu
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital, Taipei;
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Department of Medicine, and Institute of Biomedical Sciences, MacKay Medical College, New Taipei City, Taiwan
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33
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Hu S, Tan JS, Liu S, Guo TT, Song W, Peng FH, Wu Y, Gao X, Hua L. Development and Validation of a Nomogram for Predicting the Long-Term Survival in Patients With Chronic Thromboembolic Pulmonary Hypertension. Am J Cardiol 2022; 163:109-116. [PMID: 34774286 DOI: 10.1016/j.amjcard.2021.09.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 01/15/2023]
Abstract
There remains a lack of prognosis models for patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study aims to develop a nomogram predicting 3-, 5-, and 7-year survival in patients with CTEPH and verify the prognostic model. Patients with CTEPH diagnosed in Fuwai Hospital were enrolled consecutively between May 2013 and May 2019. Among them, 70% were randomly split into a training set and the other 30% as a validation set for external validation. Cox proportional hazards model was used to identify the potential survival-related factors which were candidate variables for the establishment of nomogram and the final model was internally validated by the bootstrap method. A total of 350 patients were included in the final analysis and the median follow-up period of the whole cohort was 51.2 months. Multivariate analysis of Cox proportional hazards regression showed body mass index, mean right atrial pressure, N-terminal pro-brain natriuretic peptide (per 500 ng/ml increase in concentration), presence of anemia, and main treatment choice were the independent risk factors of mortality. The nomogram demonstrated good discrimination with the corrected C-index of 0.82 in the training set, and the C-index of 0.80 (95% CI: 0.70 to 0.91) in the external validation set. The calibration plots also showed a good agreement between predicted and actual survival in both training and validation sets. In conclusion, we developed an easy-to-use nomogram with good apparent performance using 5 readily available variables, which may help physicians to identify CTEPH patients at high risk for poor prognosis and implement medical interventions.
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Affiliation(s)
- Song Hu
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang-Shan Tan
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiac Surgery, Adult Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ting-Ting Guo
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wu Song
- Department of Cardiac Surgery, Adult Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Hua Peng
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Wu
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Thrombosis Center, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Yang Y, Yang B, Li X, Xue L, Liu B, Liang Y, Zhao Z, Luo Q, Liu Z, Zeng Q, Xiong C. Higher circulating Trimethylamine N-oxide levels are associated with worse severity and prognosis in pulmonary hypertension: a cohort study. Respir Res 2022; 23:344. [PMID: 36517838 PMCID: PMC9749156 DOI: 10.1186/s12931-022-02282-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Trimethylamine N-oxide (TMAO), the gut microbiota-dependent metabolite, is a potential biomarker in several cardiovascular diseases. However, no study has investigated its value in pulmonary hypertension (PH). Therefore, this study aimed to explore the association between plasma TMAO levels and prognosis in patients with PH. METHODS Inpatients with idiopathic/heritable pulmonary arterial hypertension (IPAH/HPAH), PAH associated with congenital heart disease (CHD-PAH), and chronic thromboembolic pulmonary hypertension (CTEPH) at Fuwai Hospital were enrolled after excluding those with relative comorbidities. The endpoint was defined as a composite outcome including death, rehospitalisation due to heart failure, and at least 15% decreased 6-min walk distance from the baseline. Fasting blood samples were collected to measure plasma levels of TMAO and other clinical indicators. The associations between TMAO levels with disease severity and patients' prognosis were investigated. RESULTS In total, 163 patients with PH were included, with a mean follow-up duration of 1.3 years. After adjusting for confounding factors, elevated TMAO levels were still associated with severe disease conditions. TMAO levels dynamically decreased in stable and improved patients after treatment [ΔTMAO = - 0.2 (- 1.6, 0.7) μmol/L, P = 0.006]. Moreover, high plasma TMAO levels predicted a poor prognosis in the PH cohort (P < 0.001), and the association remained significant after adjusting the confounders, including treatment, risk stratification, and PH subtypes. CONCLUSION Elevated plasma TMAO levels were associated with severe disease conditions and poor prognosis in patients with PH, indicating its potential biomarker role in PH.
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Affiliation(s)
- Yicheng Yang
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Beilan Yang
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Xin Li
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Lin Xue
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Bingyang Liu
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Yanru Liang
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Zhihui Zhao
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Qin Luo
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Zhihong Liu
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Qixian Zeng
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
| | - Changming Xiong
- grid.506261.60000 0001 0706 7839Center of Respiratory and Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, 100037 China
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Diamanti E, Karava V, Yerly P, Aubert JD. Carbon Monoxide Diffusion Capacity as a Severity Marker in Pulmonary Hypertension. J Clin Med 2021; 11:jcm11010132. [PMID: 35011871 PMCID: PMC8745155 DOI: 10.3390/jcm11010132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 01/09/2023] Open
Abstract
Carbon monoxide diffusion capacity (DLCO) is negatively associated with patient survival in idiopathic pulmonary hypertension (PH), but is not included in the risk stratification score proposed by the 2015 European guidelines. Since 2015, several new stratification scores based on a 3- or 4-severity scale have been explored. This retrospective cohort single-center study sought to investigate the association between DLCO and PH severity and survival. We included 85 treatment-naive patients with precapillary PH and DLCO measurement at diagnosis. DLCO status, based on lower and upper quartiles ranges, was added to a 3- and a 4-strata modified-risk assessment. DLCO was strongly associated with transplant-free survival (HR 0.939, 95% CI: 0.908–0.971, p < 0.001). In the intermediate and high-risk categories, DLCO was associated with transplant-free survival, irrespective of the risk category (HR 0.934, 95% CI: 0.880–0.980, p = 0.005). The correlation between modified-risk category and transplant-free survival was significant (HR 4.60, 95% CI: 1.294–16.352, p = 0.018). Based on the Akaike information criterion (AIC) levels, the 3- and 4-strata modified-risk stratification fits our results better than the conventional stratification. Low DLCO is associated with patient transplant-free survival, independently of the risk category. Inclusion of DLCO into a PH risk stratification score seems promising and needs further investigation.
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Affiliation(s)
- Eleni Diamanti
- Division of Pulmonology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - Vasiliki Karava
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Patrick Yerly
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - John David Aubert
- Division of Pulmonology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
- Correspondence:
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Yogeswaran A, Tello K, Lund J, Klose H, Harbaum L, Sommer N, Oqueka T, Hennigs JK, Grimminger F, Seeger W, Ghofrani HA, Richter MJ, Gall H. Risk assessment in pulmonary hypertension based on routinely measured laboratory parameters. J Heart Lung Transplant 2021; 41:400-410. [PMID: 34857454 DOI: 10.1016/j.healun.2021.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 10/12/2021] [Accepted: 10/28/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND γ-glutamyl transferase (GGT), the aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, and the neutrophil-to-lymphocyte ratio (NLR) are prognostic biomarkers in several cardiovascular diseases, but their relevance in pulmonary hypertension (PH) is not fully understood. We aimed to assess their prognostic value in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). METHODS We retrospectively analyzed 731 incident patients with idiopathic PAH or CTEPH who entered the Giessen PH registry during 1993-2019. A risk stratification score based on GGT, AST/ALT ratio, and NLR tertiles was compared with a truncated version of the European Society of Cardiology/European Respiratory Society (ESC/ERS) risk stratification scheme. Associations with survival were evaluated using Kaplan-Meier and Cox regression analyses. External validation was performed in 311 patients with various types of PAH or CTEPH from a second German center. RESULTS GGT levels, AST/ALT, and NLR independently predicted mortality at baseline and during follow-up. The scoring system based on these biomarkers predicted mortality at baseline and during follow-up (both log-rank p < 0.001; hazard ratio [95% confidence interval], high vs low risk: baseline, 7.6 [3.9, 15.0]; follow-up, 13.3 [4.8, 37.1]). Five-year survival of low, intermediate, and high risk groups was 92%, 76%, and 51%, respectively, at baseline and 95%, 78%, and 50%, respectively, during follow-up. Our scoring system showed characteristics comparable to the ESC/ERS scheme, and predicted mortality in the validation cohort. CONCLUSION GGT, AST/ALT, and NLR were reliable prognostic biomarkers at baseline and during follow-up, with predictive power comparable to the gold standard for risk stratification.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Jonas Lund
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hans Klose
- Department of Respiratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Harbaum
- Department of Respiratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natascha Sommer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Tim Oqueka
- Department of Respiratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan K Hennigs
- Department of Respiratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.
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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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Benza RL, Boucly A, Farber HW, Frost AE, Ghofrani HA, Hoeper MM, Lambelet M, Rahner C, Bansilal S, Nikkho S, Meier C, Sitbon O. Change in REVEAL Lite 2 risk score predicts outcomes in patients with pulmonary arterial hypertension in the PATENT study. J Heart Lung Transplant 2021; 41:411-420. [PMID: 34848133 DOI: 10.1016/j.healun.2021.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 09/24/2021] [Accepted: 10/20/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Risk assessment is essential in pulmonary arterial hypertension (PAH) management. We investigated the effect of riociguat on REVEAL Lite 2 score, an abridged version of the REVEAL risk score, and its association with long-term outcomes in PATENT. METHODS PATENT-1 was a randomized, double-blind study of riociguat vs placebo in patients with PAH. In the PATENT-2 open-label extension, all patients received riociguat up to 2.5 mg three times daily (n = 396). REVEAL Lite 2 scores were calculated at baseline, PATENT-1 Week 12, and PATENT-2 Week 12, with patients stratified as low- (1-5), intermediate- (6-7), or high-risk (≥8). Kaplan-Meier and Cox proportional hazards analyses assessed association of riociguat with survival and clinical worsening-free survival (CWFS). RESULTS REVEAL Lite 2 score improved with riociguat 2.5 mg at PATENT-1 Week 12 (least-squares mean difference vs placebo: -0.8; p = 0.0004). More patients receiving riociguat 2.5 mg stabilized or improved risk stratum at PATENT-1 Week 12 vs placebo (p = 0.0005) and achieved low-risk status. REVEAL Lite 2 score at baseline and PATENT-1 Week 12 were associated with survival and CWFS (all p < 0.0001), as was change in score from baseline to Week 12 (p = 0.0002 and p < 0.0001, respectively). Survival and CWFS differed between risk strata at baseline (p < 0.0001) and PATENT-1 Week 12 (p < 0.0001). CONCLUSIONS This analysis confirms the risk-reduction benefits of riociguat in patients with PAH and further contributes to the validation of REVEAL Lite 2 in facilitating PAH risk assessment.
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Affiliation(s)
- Raymond L Benza
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Athénaïs Boucly
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Harrison W Farber
- Pulmonary Hypertension Center, Boston University/Boston Medical Center, Boston, Massachusetts
| | - Adaani E Frost
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Hossein-Ardeschir Ghofrani
- Department of Medicine, University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Imperial College London, London, UK; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and the German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | | | | | | | - Sylvia Nikkho
- Global Clinical Development, Bayer AG, Berlin, Germany
| | | | - Olivier Sitbon
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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39
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Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center. J Clin Med 2021; 10:jcm10184251. [PMID: 34575363 PMCID: PMC8466098 DOI: 10.3390/jcm10184251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Clinical presentation, disease distribution, or treatment received may provide insights into the reasons contributing to sex differences in chronic thromboembolic pulmonary hypertension (CTEPH). (2) Methods: We evaluated 453 patients (56% women) between 2007-2019. Data was collected from REHAP (Registro Español de Hipertensión Arterial Pulmonar) registry. Two time periods were selected to evaluate the influence of new treatments over time. (3) Results: Women were older. Baseline functional class was worse, and distance walked shorter in women compared with men. Women had higher pulmonary vascular resistances. Despite this, pulmonary endarterectomy (PEA) was carried out in more men, and women received more frequently pulmonary vasodilators exclusively. The 2014-2019 interval was associated with a better survival only among women. Interestingly, women had a more distal disease during this second period of time. (4) Conclusions: Even though women were older, and received invasive treatments less frequently, mortality was similar in both sexes. The introduction of balloon pulmonary angioplasty and the improvement of pulmonary endarterectomy, especially during the last years, could be associated with a survival benefit among women.
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40
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Benza RL, Ghofrani HA, Grünig E, Hoeper MM, Jansa P, Jing ZC, Kim NH, Langleben D, Simonneau G, Wang C, Busse D, Meier C, Ghio S. Effect of riociguat on right ventricular function in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2021; 40:1172-1180. [PMID: 34353714 DOI: 10.1016/j.healun.2021.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/11/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND In the Phase III PATENT-1 (NCT00810693) and CHEST-1 (NCT00855465) studies, riociguat demonstrated efficacy vs placebo in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Clinical effects were maintained at 2 years in the long-term extension studies PATENT-2 (NCT00863681) and CHEST-2 (NCT00910429). METHODS This post hoc analysis of hemodynamic data from PATENT-1 and CHEST-1 assessed whether riociguat improved right ventricular (RV) function parameters including stroke volume index (SVI), stroke volume, RV work index, and cardiac efficiency. REVEAL Risk Score (RRS) was calculated for patients stratified by SVI and right atrial pressure (RAP) at baseline and follow-up. The association between RV function parameters and SVI and RAP stratification with long-term outcomes was assessed. RESULTS In PATENT-1 (n = 341) and CHEST-1 (n = 238), riociguat improved RV function parameters vs placebo (p < 0.05). At follow-up, there were significant differences in RRS between patients with favorable and unfavorable SVI and RAP, irrespective of treatment arm (p < 0.0001). Multiple RV function parameters at baseline and follow-up were associated with survival and clinical worsening-free survival (CWFS) in PATENT-2 (n = 396; p < 0.05) and CHEST-2 (n = 237). In PATENT-2, favorable SVI and RAP at follow-up only was associated with survival and CWFS (p < 0.05), while in CHEST-2, favorable SVI and RAP at baseline and follow-up were associated with survival and CWFS (p < 0.05). CONCLUSION This post hoc analysis of PATENT and CHEST suggests that riociguat improves RV function in patients with PAH and CTEPH.
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Affiliation(s)
- Raymond L Benza
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Ohio, USA.
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, German Center of Lung Research (DZL), Heidelberg, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, German Center of Lung Research (DZL), Hannover, Germany
| | - Pavel Jansa
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zhi-Cheng Jing
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, California
| | - David Langleben
- Centre for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Gérald Simonneau
- Centre de Référence de l'Hypertension Pulmonaire Sévère, Service de Pneumologie et Réanimation, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S999, LabEx LERMIT, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Respiratory Diseases, Beijing, China; Chinese Academy of Medical Sciences, Peking Union Medica, Beijing, China; WHO Collaboration Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China
| | - Dennis Busse
- Employee of Chrestos Concept GmbH & Co. KG, Essen, Germany
| | | | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
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Hendriks PM, van Thor MCJ, Wapenaar M, Chandoesing P, van den Toorn LM, van den Bosch AE, Post MC, Boomars KA. The longitudinal use of EmPHasis-10 and CAMPHOR questionnaire health-related quality of life scores in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Respir Med 2021; 186:106525. [PMID: 34218166 DOI: 10.1016/j.rmed.2021.106525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/11/2021] [Accepted: 06/26/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is impaired in patients with pulmonary hypertension (PH). The EmPHasis-10 and CAMPHOR questionnaires are developed to evaluate HRQoL specifically in patients with PH. Data on the longitudinal use of both questionnaires are still limited. We evaluated the longitudinal value of both questionnaires and established minimal clinically important differences (MCID). METHODS Sixty-one treatment naïve pulmonary arterial hypertension or chronic thromboembolic patients were prospectively included. Patients were treated according to the current ESC/ERS guidelines. We compared EmPHasis-10 and CAMPHOR scores between baseline, 6 and 12 months of follow-up and evaluated the correlation between these scores and a 5-scale symptom severity score, 5-scale overall health score, NYHA-classification, 6 min walk test distance (6MWD), NT-proBNP and echocardiographic parameters. RESULTS After one year of treatment a significant reduction in EmPHasis-10 score and CAMPHOR QoL and symptoms domain score was observed. Moderate to good correlations were observed between the questionnaires and the overall-health and symptom severity score and 6MWD. No relevant correlations were seen between the questionnaires and NT-pro-BNP and echocardiographic parameters. EmPHasis-10 scores showed strong correlations with all CAMPHOR domains. The MCID for the EmPHasis-10 questionnaire was -8. The MCIDs for the CAMPHOR domains were: activity -3, symptoms -4, QoL -3. CONCLUSION The EmPHasis-10 and CAMPHOR questionnaires are valid tools for the longitudinal measurement of HRQoL in patients with PH. The much shorter EmPHasis-10 correlates well with the CAMPHOR domain scores and with the clinical endpoints and it may be easier to use in daily practice.
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Affiliation(s)
- Paul M Hendriks
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands; Department of Cardiology, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Mitch C J van Thor
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, the Netherlands
| | - Monique Wapenaar
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Prewesh Chandoesing
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Leon M van den Toorn
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Annemien E van den Bosch
- Department of Cardiology, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, the Netherlands; Department of Cardiology, Utrecht University Medical Center, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Karin A Boomars
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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Kylhammar D, Hjalmarsson C, Hesselstrand R, Jansson K, Kavianipour M, Kjellström B, Nisell M, Söderberg S, Rådegran G. Predicting mortality during long-term follow-up in pulmonary arterial hypertension. ERJ Open Res 2021; 7:00837-2020. [PMID: 34084789 PMCID: PMC8165378 DOI: 10.1183/23120541.00837-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022] Open
Abstract
The European Society of Cardiology (ESC) and European Respiratory Society (ERS) guideline recommendation of comprehensive risk assessments, which classify patients with pulmonary arterial hypertension (PAH) as having low, intermediate or high mortality risk, has not been evaluated during long-term follow-up in a “real-life” clinical setting. We therefore aimed to investigate the utility of risk assessment in a clinical setting for up to 5 years post diagnosis. 386 patients with PAH from the Swedish PAH Registry were included. Risk group (low/intermediate/high) and proportion of low-risk variables were investigated at 3-, 4- and 5-year follow-ups after time of diagnosis. In an exploratory analysis, survival rates of patients with low-intermediate or high-intermediate risk scores were compared. A low-risk profile was in multivariate Cox proportional hazards regressions found to be a strong, independent predictor of longer transplant-free survival (p<0.001) at the 3-, 4- and 5-year follow-ups. Also, for the 3-, 4- and 5-year follow-ups, survival rates significantly differed (p<0.001) between the three risk groups. Patients with a greater proportion of low-risk variables had better (p<0.001) survival rates. Patients with a high-intermediate risk score had worse survival rates (p<0.001) than those with a low-intermediate risk score. Results were similar when excluding patients with ≥3 risk factors for heart failure with preserved ejection fraction, atrial fibrillation and/or age >75 years at diagnosis. Our findings suggest that the ESC/ERS guideline strategy for comprehensive risk assessments in PAH is valid also during long-term follow-up in a “real-life” clinical setting. ESC/ERS guidelines' risk stratification table successfully predicts outcome during long-term follow-up in pulmonary arterial hypertensionhttps://bit.ly/3nXJbop
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Affiliation(s)
- David Kylhammar
- Division of Diagnostics and Specialist Medicine, Dept of Health, Medicine and Caring Sciences, and Dept of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Clara Hjalmarsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University, and Dept of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Hesselstrand
- Dept of Clinical Sciences Lund, Rheumatology, Lund University, and Skåne University Hospital, Lund, Sweden
| | - Kjell Jansson
- Division of Diagnostics and Specialist Medicine, Dept of Health, Medicine and Caring Sciences, and Dept of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Mohammad Kavianipour
- Dept of Public Health and Clinical Medicine, Sundsvall Research Unit, Umeå University, Umeå, Sweden
| | - Barbro Kjellström
- Dept of Clinical Sciences in Lund, Clinical Physiology, Faculty of Medicine, Lund University, and Skåne University Hospital, Lund, Sweden.,Cardiology Unit, Dept of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Magnus Nisell
- Lung Unit, Dept of Medicine, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Söderberg
- Dept of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Umeå, Sweden
| | - Göran Rådegran
- Dept of Clinical Sciences Lund, Cardiology, Lund University, and Skåne University Hospital, Lund, Sweden
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Factors contributing to exercise capacity in chronic thromboembolic pulmonary hypertension with near-normal hemodynamics. J Heart Lung Transplant 2021; 40:677-686. [PMID: 33879384 DOI: 10.1016/j.healun.2021.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite improved survival for patients with chronic thromboembolic pulmonary hypertension (CTEPH) due to progressive medical and interventional treatment, impaired exercise capacity remains common due to poorly understood mechanisms. We aimed to clarify the exercise capacity of CTEPH patients with near-normal pulmonary hemodynamics and evaluate its determinants among the hemodynamic, peripheral (e.g., oxygen use by the peripheral tissues), and muscular (e.g., skeletal muscle strength) factors. METHODS Three hundred and twenty-nine patients with CTEPH (mean age, 63 ± 12 years; men/women, 73/256) with a near-normal mean pulmonary artery pressure (≤30 mm Hg) at rest were enrolled. We assessed exercise capacity by peak oxygen consumption (peak VO2) using cardiopulmonary exercise testing with a right heart catheter. We also measured the 6-minute walk distance (6MWD) and quadriceps muscle strength. RESULTS The mean pulmonary artery pressure was 19 ± 4 mmHg and mean cardiac output was 4.8 ± 1.5 L/min at rest. The mean 6MWD was 444 ± 101 m, while the mean peak VO2 was 14.4 ± 3.9 mL/min/kg. A multivariate model that predicted 6MWD included quadriceps strength (β = 0.45, p < 0.001) and peak arterial venous oxygen difference (β = 0.29, p < 0.001). In contrast, the peak VO2 was best correlated with mPAP-CO slope (β = -0.30, p < 0.001), followed by quadriceps strength and peak arterial venous oxygen difference. CONCLUSIONS The 6MWD performance may be significantly influenced by peripheral oxygen use and muscular factors, while peak VO2 is influenced by hemodynamic and peripheral factors in CTEPH patients with near-normal hemodynamics.
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Quan R, Yang Y, Yang Z, Tian H, Li S, Shen J, Ji Y, Zhang G, Zhang C, Wang G, Liu Y, Cheng Z, Yu Z, Song Z, Zheng Z, Cui W, Chen Y, Liu S, Chen X, Qian Y, Xiong C, Shan G, He J. Risk prediction in medically treated chronic thromboembolic pulmonary hypertension. BMC Pulm Med 2021; 21:128. [PMID: 33879094 PMCID: PMC8056726 DOI: 10.1186/s12890-021-01495-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND At present, there is no generally accepted comprehensive prognostic risk prediction model for medically treated chronic thromboembolic pulmonary hypertension (CTEPH) patients. METHODS Consecutive medically treated CTEPH patients were enrolled in a national multicenter prospective registry study from August 2009 to July 2018. A multivariable Cox proportional hazards model was utilized to derive the prognostic model, and a simplified risk score was created thereafter. Model performance was evaluated in terms of discrimination and calibration, and compared to the Swedish/COMPERA risk stratification method. Internal and external validation were conducted to validate the model performance. RESULTS A total of 432 patients were enrolled. During a median follow-up time of 38.73 months (IQR: 20.79, 66.10), 94 patients (21.8%) died. The 1-, 3-, and 5-year survival estimates were 95.5%, 83.7%, and 70.9%, respectively. The final model included the following variables: the Swedish/COMPERA risk stratum (low-, intermediate- or high-risk stratum), pulmonary vascular resistance (PVR, ≤ or > 1600 dyn·s/cm5), total bilirubin (TBIL, ≤ or > 38 µmol/L) and chronic kidney disease (CKD, no or yes). Compared with the Swedish/COMPERA risk stratification method alone, both the derived model [C-index: 0.715; net reclassification improvement (NRI): 0.300; integrated discriminatory index (IDI): 0.095] and the risk score (C-index: 0.713; NRI: 0.300; IDI: 0.093) showed improved discriminatory power. The performance was validated in a validation cohort of 84 patients (C-index = 0.707 for the model and 0.721 for the risk score). CONCLUSIONS A novel risk stratification strategy can serve as a useful tool for determining prognosis and guide management for medically treated CTEPH patients. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT01417338).
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Affiliation(s)
- Ruilin Quan
- Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yuanhua Yang
- Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Zhenwen Yang
- Cardiovascular, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Hongyan Tian
- Peripheral Vascular Department of First Affiliated Hospital, Medical College of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Shengqing Li
- Department of Respiratory Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jieyan Shen
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200240, China
| | - Yingqun Ji
- Department of Respiratory, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
| | - Gangcheng Zhang
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, 430022, China
| | - Caojin Zhang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Guangyi Wang
- Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, 100039, China
| | - Yuhao Liu
- Heart Center of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 450003, China
| | - Zhaozhong Cheng
- Respiratory Department, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zhiyuan Song
- Department of Cardiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Zeqi Zheng
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Wei Cui
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Shuang Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Xiaoxi Chen
- Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yuling Qian
- Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Changming Xiong
- Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Guangliang Shan
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Jianguo He
- Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China.
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Ghio S, Klersy C, Corsico A, Gamba SL, Monterosso C, Masiglat J, Borrelli E, Scelsi L, Greco A, Piloni D, Visconti LO, D'Armini AM. Risk stratification in patients with residual pulmonary hypertension after pulmonary endarterectomy. Int J Cardiol 2021; 334:116-122. [PMID: 33823214 DOI: 10.1016/j.ijcard.2021.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/06/2021] [Accepted: 04/02/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Few studies addressed the issue of risk stratification in patients with residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). This study tested the potential added value of parameters that have not been included in existing risk models. METHODS We evaluated 546 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent PEA and were followed-up for a median period of 58 months. RESULTS Among the 242 with residual PH, 27 died and had 127 a clinical worsening event. At univariable analysis, the parameters associated with poor survival were pulmonary vascular resistance (PVR) ≥425 dyn·s·cm-5 (p ≤ 0.001), mean pulmonary artery pressure (mPAP) ≥38 mmHg (p = 0.003) and pulmonary artery compliance (CPA) ≤1.8 ml/mmHg (p = 0.014). In the bivariable models including either PVR or mPAP as first parameter, the addition of CPA was not statistically significant. The parameters associated with poor clinical worsening were CPA ≤1.8 ml/mmHg (p < 0.001), PVR ≥425 dyn·s·cm-5 (p = 0.002), arterial oxygen tension (PaO2) ≤ 75 mmHg (p = 0.003), mPAP ≥38 mmHg (p = 0.008). In a multivariable analysis which included PVR ≥425 as the first parameter, the addition of both CPA ≤1.8 ml/mmHg and of PaO2 ≤ 75 mmHg significantly improved prognostic stratification (Harrel's C of the model = 0.64, p < 0.001). Noticeably, the lower tertile of the model's predictor index identified a subgroup of 91 patients who had an event rate numerically similar to that of patients without residual PH. CONCLUSIONS Risk stratification in residual PH can be refined if CPA and PaO2 are considered in association with standard hemodynamic parameters.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy.
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Sofia Lucia Gamba
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Cristian Monterosso
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Joice Masiglat
- Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
| | - Ermelinda Borrelli
- Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | | | - Andrea Maria D'Armini
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy; Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
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Abstract
Pulmonary hypertension is the term used to describe a group of disorders characterized by abnormally high pressures in the pulmonary arteries. Initial evaluation is focused on identifying the cause, which helps guide appropriate treatment. Pulmonary hypertension is often a feature of advanced common diseases, such as chronic obstructive pulmonary disease and left heart disease, and treatment is focused primarily on the underlying disease. More rarely, pulmonary hypertension results from chronic organized thromboemboli or a primary vasculopathy. The former requires evaluation for surgical intervention, and the latter is treated with advanced medical therapies.
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Affiliation(s)
- David Poch
- From the University of California San Diego School of Medicine, La Jolla, California
| | - Jess Mandel
- From the University of California San Diego School of Medicine, La Jolla, California
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47
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Taran IN, Valieva ZS, Belevskaya AA, Saidova MA, Martynyuk TV, Chazova IE. Influence of demographic characteristics on the clinical course and results of therapy in patients with precapillary pulmonary hypertension. TERAPEVT ARKH 2021; 93:283-289. [DOI: 10.26442/00403660.2021.03.200655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022]
Abstract
Aim. To assess the clinical course of the disease and the features of the treatment goals achievement in patients with IPAH and inoperable CTEPH depending on gender and age at the time of diagnosis verification.
Materials and methods. The study included 88 patients with IPAH and 38 patients with inoperable CTEPH with a PAWP 12 mm Hg and the duration of PAH-specific therapy treatment more than 12 months. IPAH/CTEPH patients were divided into groups depending on age at the time of diagnosis verification: age 50 years (n=69)/ 50 years (n=57), and gender: 106 women/20 men.
Results. Patients with age 50 years at the time of diagnosis verification have significantly more severe functional class (WHO). In IPAH/CTEPH male patients a significant hemodynamic disorder also as significantly higher level of NT-proBNP at the time of diagnosis verification were observed. In men with IPAH/CTEPH and patients aged 50 years more pronounced deterioration of right ventricular systolic function was observed (ECHO). Patients with IPAH younger than 50 years were significantly more likely to achieve the treatment goals by the median 26.5 months of treatment compared to the patients aged 50 years (21% vs 6.45%). Men with IPAH/CTEPH were significantly more likely to have a high risk of death (90%) at baseline compared to the women (61%).
Conclusion. IPAH/inoperable CTEPH patients with male sex, as well as the age 50 years and older at the time of diagnosis verification, compared with younger ones, are associated with a less favorable course of the disease.
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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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Tonelli AR, Sahay S, Gordon KW, Edwards LD, Allmon AG, Broderick M, Nelsen AC. Impact of inhaled treprostinil on risk stratification with noninvasive parameters: a post hoc analysis of the TRIUMPH and BEAT studies. Pulm Circ 2020; 10:2045894020977025. [PMID: 33403101 PMCID: PMC7739096 DOI: 10.1177/2045894020977025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
The 2015 European Society of Cardiology/European Respiratory Society treatment guidelines recommend frequent risk assessment in pulmonary arterial hypertension utilizing risk variables. Our objectives were: (1) to investigate the impact of inhaled treprostinil on risk stratification using the French noninvasive approach and REVEAL 2.0, and (2) to analyze the prognostic utility of both risk stratification methods in the predominantly New York Heart Association/World Health Organization functional class III/IV cohorts of TRIUMPH and BEAT. A post hoc analysis was performed to assess risk at baseline and follow-up at Week 12 in the TRIUMPH cohort (n = 148) and at Week 16, 21, and 30 in the inhaled treprostinil naïve placebo BEAT cohort (n = 73). Overall survival, clinical worsening-free survival, and pulmonary arterial hypertension-related hospitalization-free survival were all assessed in the pooled TRIUMPH and inhaled treprostinil naïve placebo BEAT cohorts based on risk group/strata at Week 12/16 follow-up. Inhaled treprostinil improved REVEAL 2.0 risk stratum (OR: 2.38, 95% CI: 1.09–5.19, p = 0.0298) and REVEAL 2.0 score (p = 0.0008) compared to placebo in the TRIUMPH cohort at Week 12. REVEAL 2.0 risk stratum and the number of low-risk criteria by the French approach improved at Weeks 16, 21, and 30 in the inhaled treprostinil naïve placebo BEAT cohort. Combining cohorts, REVEAL 2.0 risk stratification at follow-up was prognostic for clinical worsening-free, pulmonary arterial hypertension hospitalization-free, and overall survival, whereas the number of low-risk criteria was not. These post-hoc pooled analyses suggest inhaled treprostinil improves risk status and indicates that the REVEAL 2.0 calculator may be more suitable than the French noninvasive method for evaluating short-term clinical change in the New York Heart Association/World Health Organization functional class III/IV population.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH, USA
| | - Sandeep Sahay
- Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Lung Center, Houston Methodist Hospital, Houston, TX, USA
| | - Kathryn W Gordon
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Lisa D Edwards
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Andrew G Allmon
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Andrew C Nelsen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
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Sitbon O, Nikkho S, Benza R, Cq Deng C, W Farber H, Gomberg-Maitland M, Hassoun P, Meier C, Pepke-Zaba J, Prasad K, Seeger W, Corris PA. Novel composite clinical endpoints and risk scores used in clinical trials in pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020962960. [PMID: 33282190 PMCID: PMC7682238 DOI: 10.1177/2045894020962960] [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: 06/11/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022] Open
Abstract
This manuscript on endpoints incorporates the broad experience of members of Pulmonary Vascular Research Institute’s Innovative Drug Development Initiative as an open debate platform for academia, the pharmaceutical industry and regulatory experts surrounding the future design of clinical trials in pulmonary hypertension. It reviews our current understanding of endpoints used in phase 2 and 3 trials for pulmonary hypertension and discusses in detail the value of newer approaches. These include the roles of composite endpoints and how these can be developed and validated. The newer concept of risk analysis is also discussed, including how such risk scores might be utilised as endpoints in clinical trials.
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Affiliation(s)
- Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | - Paul Hassoun
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Paul A Corris
- Clinical and Translational Research Institute Newcastle University, Newcastle upon Tyne, UK
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