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Marongiu F, Ruberto MF, Barcellona D. Is anticoagulative therapy in systemic sclerosis to be reconsidered? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:81-85. [PMID: 38910594 PMCID: PMC11188846 DOI: 10.1177/23971983241256250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 06/25/2024]
Abstract
Systemic sclerosis is a rare disease with a high mortality rate. It is a multisystem connective tissue disease due to endothelial autoimmune activation along with tissue and vascular fibrosis, inducing vasculopathy, with an angiogenesis wasting. The endothelial damage provokes platelet activation and immune cell adhesion. The detachment of endothelial cells leads to the interaction of platelets and collagen present in the exposed subendothelial layer. This provokes the activation of several coagulative factors, inducing a pro-thrombotic condition by thrombin generation, which converts fibrinogen into fibrin. Moreover, thrombin has other functions, such as the induction of hyperplasia in smooth muscle cells and fibroblasts, thereby favouring fibrosis. An increased risk of venous thromboembolism has been found in systemic sclerosis, whereas pulmonary hypertension may be due to the obstruction of small pulmonary arteries. Pulmonary veno-occlusive disease may also occur. Warfarin showed inconsistent results, while the outcomes of a randomised, placebo-controlled clinical trial on apixaban versus placebo are still awaited. A new anticoagulation strategy based on anti-factor XI drugs is being developed, with the aim of achieving optimal anticoagulation along with a low risk of bleeding. The molecule types under investigation in this category include monoclonal antibodies, small molecules, natural inhibitors, antisense oligonucleotides, and aptamers. Patients with systemic sclerosis may be ideal candidates for clinical trials planned to analyse the efficacy and safety of these molecules.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
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2
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Thoreau B, Mouthon L. Pulmonary arterial hypertension associated with connective tissue diseases (CTD-PAH): Recent and advanced data. Autoimmun Rev 2024; 23:103506. [PMID: 38135175 DOI: 10.1016/j.autrev.2023.103506] [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: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 12/24/2023]
Abstract
Pulmonary arterial hypertension (PAH), corresponding to group 1 of pulmonary hypertension classification, is a rare disease with a major prognostic impact on morbidity and mortality. PAH can be either primary in idiopathic and heritable forms or secondary to other conditions including connective tissue diseases (CTD-PAH). Within CTD-PAH, the leading cause of PAH is systemic sclerosis (SSc) in Western countries, whereas systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD) are predominantly associated with PAH in Asia. Although many advances have been made during the last two decades regarding classification, definition early screening and risk stratification and therapeutic aspects with initial combination treatment, the specificities of CTD-PAH are not yet clear. In this manuscript, we review recent literature data regarding the updated definition and classification of PAH, pathogenesis, epidemiology, detection, prognosis and treatment of CTD-PAH.
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Affiliation(s)
- Benjamin Thoreau
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, AP-HP.Centre, Université Paris Cité, Hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Cedex 14 Paris, France; Université Paris Cité, F-75006 Paris, France; INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France.
| | - Luc Mouthon
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, AP-HP.Centre, Université Paris Cité, Hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Cedex 14 Paris, France; Université Paris Cité, F-75006 Paris, France; INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France
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3
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Marongiu F, Ruberto MF, Marongiu S, Matucci Cerinic M, Barcellona D. A journey to vasculopathy in systemic sclerosis: focus on haemostasis and thrombosis. Clin Exp Med 2023; 23:4057-4064. [PMID: 37914967 DOI: 10.1007/s10238-023-01222-x] [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: 07/16/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023]
Abstract
Systemic sclerosis is a multisystem connective tissue disease, characterized by endothelial autoimmune activation, along with tissue and vascular fibrosis leading to vasculopathy and to a progressive loss of angiogenesis. This condition further deranges the endothelial barrier favouring the opening of the endothelial junctions allowing the vascular leak in the surrounding tissues: this process may induce cell detachment which allows the contact between platelets and collagen present in the exposed subendothelial layer. Platelets first adhere to collagen via glycoprotein VI and then, immediately aggregate because of the release of von Willebrand factor which is a strong activator of platelet aggregation. Activated platelets exert their procoagulant activity, exposing on their membrane phospholipids and phosphatidylserine, enabling the adsorption of clotting factors ready to form thrombin which in turn drives the amplification of the coagulative cascade. An essential role in the activation of blood coagulation is the tissue factor (TF), which triggers blood coagulation. The TF is found abundantly in the subendothelial collagen and is also expressed by fibroblasts providing a haemostatic covering layer ready to activate coagulation when the endothelial injury occurs. The aim of this review is to focus the attention on the underlying mechanisms related to haemostasis and thrombosis pathophysiology which may have a relevant role in SSc as well as on a possible role of anticoagulation in this disease.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Thrombosis and Haemostasis Unit, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvia Marongiu
- Internal Medicine Unit, SS Trinità Hospital of Cagliari, Cagliari, Italy
| | - Marco Matucci Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
- Thrombosis and Haemostasis Unit, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
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Chen X, Quan R, Qian Y, Yang Z, Yu Z, Zhang C, Yang Y, Zhang G, Shen J, Wang Q, Gu Q, Xiong C, Jing X, Han H, He J. 10-year survival of pulmonary arterial hypertension associated with connective tissue disease: insights from a multicentre PAH registry. Rheumatology (Oxford) 2023; 62:3555-3564. [PMID: 36912696 PMCID: PMC10629783 DOI: 10.1093/rheumatology/kead103] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES To report the 10-year survival rate and prognostic factors of pulmonary arterial hypertension associated with CTD (CTD-PAH) patients, to compare treatment and survival between patients enrolled before and after 2015, and to validate the discrimination of the recommended four-strata model in predicting 10-year survival at follow-up in Chinese CTD-PAH patients. METHODS This study was derived from a Chinese national multicentre prospective registry study from 2009 to 2019. Medical records were collected at baseline and follow-up, including PAH-targeted therapy and binary therapy (both CTD and PAH-targeted therapy). RESULTS A total of 266 CTD-PAH patients were enrolled and the 10-year survival rate was 59.9% (median follow-up time: 4.85 years). Underlying CTD (SSc), baseline 6-min walking distance and SaO2 were independent risk factors for 10-year survival. The proportion of patients receiving PAH-targeted combination therapy increased from 10.1% (2009-2014) to 26.5% (2015-2019) and that of binary therapy increased from 14.8% to 35%. The 1-year survival rate increased from 89.8% (2009-2014) to 93.9%, and the 3-year survival rate increased from 80.1% (2009-2014) to 86.5% (both P > 0.05). The four-strata strategy performed well in predicting 10-year survival at follow-up (C-index = 0.742). CONCLUSION The 10-year survival rate of CTD-PAH patients was reported for the first time. The 10-year prognosis was poor, but there was a tendency for more standardized treatment and better survival in patients enrolled after 2015. The recommended four-strata model at follow-up can effectively predict 10-year survival in CTD-PAH patients.
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Affiliation(s)
- Xiaoxi Chen
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Ruilin Quan
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Yuling Qian
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China
| | - Caojin Zhang
- Department of Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhua Yang
- Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Gangcheng Zhang
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, China
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Gu
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Changming Xiong
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Xiaoli Jing
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Huijun Han
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo He
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
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Mihailovic J, Ribi C, Chizzolini C, Trendelenburg M, Von Kempis J, Dahdal S, Huynh-Do U. Worse cardiovascular and renal outcome in male SLE patients. Sci Rep 2023; 13:18628. [PMID: 37903784 PMCID: PMC10616173 DOI: 10.1038/s41598-023-45171-7] [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: 11/22/2021] [Accepted: 10/17/2023] [Indexed: 11/01/2023] Open
Abstract
Systemic lupus erythematosus (SLE) in males is rare and poorly understood. Thus, still little is known about sex differences in SLE. We set out to identify sex differences regarding clinical manifestations as well as renal and cardiovascular outcomes of SLE. We analyzed patient data from the Swiss SLE Cohort Study. Cumulative clinical manifestations according to the updated American College of Rheumatology criteria were recorded at inclusion. Cardiovascular events were recorded within Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-SDI). Renal failure was defined as eGFR < 15 ml/min/1.73 m2, initiation of renal replacement therapy or doubling of serum creatinine which were all assessed yearly or documented as end stage renal disease in SLICC-SDI. Risk differences were calculated using logistic regression and cox regression models. We analyzed 93 men and 529 women with a median follow up time of 2 years. Males were significantly older at diagnosis (44.4 versus 33.1 years, p < 0.001) and had less often arthritis (57% versus 74%, p = 0.001) and dermatological disorders (61% versus 76%, p < 0.01). In multivariate analysis female sex remained a significantly associated with arthritis and dermatological disorders. In multivariate analysis men had a significantly higher hazard ratio of 2.3 for renal failure (95% confidence interval (95%-CI) 1.1-5.2, p < 0.04). Total SLICC-SDI Score was comparable. Men had significantly more coronary artery disease (CAD) (17% versus 4%, p < 0.001) and myocardial infarction (10% versus 2%, p < 0.01). In multivariate analysis, male sex remained a significant risk factor for CAD (odds ratio (OR) 5.6, 95%-CI 2.3-13.7, p < 0.001) and myocardial infarction (OR 8.3, 95%-CI 2.1-32.6, p = 0.002). This first sex study in a western European population demonstrates significant sex differences in SLE. Male sex is a risk factor for cardiovascular events and renal failure in SLE. Potential etiological pathomechanisms such as hormonal or X-chromosomal factors remain to be further investigated.
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Affiliation(s)
- Jelena Mihailovic
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Camillo Ribi
- Division of Clinical Immunology and Allergy, University Hospital Lausanne, Lausanne, Switzerland
| | - Carlo Chizzolini
- Pathology and Immunology, School of Medicine, Geneva University, Geneva, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine and Clinical Immunology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Johannes Von Kempis
- Division of Rheumatology and Immunology, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Suzan Dahdal
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
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Lai J, Feng S, Xu S, Liu X. Effects of oral anticoagulant therapy in patients with pulmonary diseases. Front Cardiovasc Med 2022; 9:987652. [PMID: 36035947 PMCID: PMC9399807 DOI: 10.3389/fcvm.2022.987652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTo evaluate the effect of oral anticoagulants (OACs) therapy, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC) in patients with pulmonary diseases.MethodsLiterature from PubMed, MEDLINE, and Cochrane Library were screened until June 2022. Studies assessing OACs for pulmonary hypertension (PH), pulmonary embolism (PE), pulmonary fibrosis (PF), or chronic obstructive pulmonary disease (COPD) were evaluated for inclusion.ResultsOur study indicated that in patients with PH, PE, and COPD, OACs could significantly reduce the mortality risk, and the effects of VKA and DOACs without statistical difference in reducing the risk of recurrent embolism events. In patients with sclerosis-associated pulmonary arterial hypertension (SSc-PAH) or idiopathic pulmonary fibrosis (IPF), vitamin K antagonist (warfarin) significantly increased the mortality risk, while DOACs were not. As for the safety outcome of OACs, existing studies indicate that compared with patients treated with warfarin, the users of DOAC have a lower risk of major bleeding, while there is no statistical significance between them in non-major bleeding events. In current guidelines, the anticoagulation regimen for patients with pulmonary disease has not been defined. The results of our study confirm that DOACs (apixaban, rivaroxaban, dabigatran, and edoxaban) are superior to VKAs in the efficacy and safety outcomes of patients with pulmonary disease.ConclusionsOral anticoagulant therapy brings benefits to patients with PH, PE, or COPD, while the anticoagulation regimen for patients with SSc-PAH or IPF requires serious consideration. Compared with VKA, DOAC is a non-inferior option for anticoagulation in pulmonary disease treatment. Further studies are still needed to provide more reliable evidence about the safety outcome of pulmonary disease anticoagulation.
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Affiliation(s)
- Jiying Lai
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Shenghui Feng
- Queen Mary School, Medical Department, Nanchang University, Nanchang, China
| | - Shuo Xu
- Department of Respiratory and Critical Care Medicine, The Ganzhou People's Hospital, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- Shuo Xu
| | - Xin Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- *Correspondence: Xin Liu
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Prognostic Significance of Small Pulmonary Vessel Alteration Measured by Chest Computed Tomography in Connective Tissue Diseases With Pulmonary Arterial Hypertension. J Thorac Imaging 2022; 37:336-343. [DOI: 10.1097/rti.0000000000000643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Hughes M, Zanatta E, Sandler RD, Avouac J, Allanore Y. Improvement with time of vascular outcomes in systemic sclerosis: a systematic review and meta-analysis study. Rheumatology (Oxford) 2021; 61:2755-2769. [PMID: 34791057 DOI: 10.1093/rheumatology/keab850] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/15/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Vascular disease in systemic sclerosis (SSc) is associated with significant morbidity and mortality. Preliminary data may lead to the suggestion of a modifiable unified-vascular endophenotype. Our aim was to determine whether the prevalence, mortality, and severity of SSc-vascular disease have changed over time. METHODS We performed a systematic review and meta-analysis of the literature in PubMed 1950-2019 related to SSc-digital ulcers (DUs), pulmonary artery hypertension (PAH) and scleroderma renal crisis (SRC). We included full-text articles and extracted study characteristics and assessed risk of bias/quality. We examined the prevalence, mortality, and surrogate measures of SSc-associated vascular disease severity. RESULTS We included 55 studies in our meta-analysis. The pooled prevalence of DUs (41.0%), PAH (9.5%) and SRC (4.9%) remained largely stable over time. There was significant improvement in PAH 1-year (p= 0.001) and SRC mortality (P = <0.001), but not PAH 3-year (p= 0.312) or 5-year (p= 0.686) mortality. The prevalence of DU healing did not significantly change (p= 0.265). There was a trend (all P=∼0.1) towards improvement in PAH surrogates: mean pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure. For SRC, there was evidence that the overall frequency of dialysis (66.7%, p= 0.297) and permanent dialysis (34.5%, p= 0.036) increased over time. CONCLUSION Despite the heterogeneity and scarcity of the disease, there have been major improvements obtained in the various vascular complications in SSc leading to benefit in survival. This is supported by a trend towards improvement in several surrogate markers and demonstrates that progresses in vascular management translate into major patient benefit.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Robert D Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Jérôme Avouac
- Rhumatologie, Hôpital Cochin, APHP, Université de Paris, Paris, France
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, AP-HP, Paris Descartes University, Paris, France
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Guo X, Lai J, Wang H, Tian Z, Wang Q, Zhao J, Li M, Fang Q, Fang L, Liu Y, Zeng X. Predictive value of non-invasive right ventricle to pulmonary circulation coupling in systemic lupus erythematosus patients with pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging 2021; 22:111-118. [PMID: 31872222 DOI: 10.1093/ehjci/jez311] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS Pulmonary arterial hypertension (PAH) is a serious and devastating complication of systemic lupus erythematosus (SLE), especially when the right ventricle (RV) fails. Whether the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) measured by echocardiography as a simple surrogate of RV to pulmonary circulation (PC) coupling predicts the outcome of SLE-associated PAH has not been investigated. METHODS AND RESULTS Between February 2010 and August 2015, 112 consecutive patients with a diagnosis of SLE-associated PAH confirmed by right heart catheterization were enrolled prospectively. The endpoint was a composite of all-cause mortality and clinical worsening. Baseline clinical characteristics and echocardiographic assessment were analysed. Among all the patients, 47 (42%) patients experienced the endpoint (mean follow-up period 18.1 ± 12.0 months), including 20 patients who died during a median follow-up period of 48.5 months. Multivariable Cox regression analysis showed that TAPSE/PASP ratio [hazard ratio (HR) 0.004, P = 0.017] and 6-min walk distance (6MWD) (HR 0.997, P = 0.036) were the independent predictors for the endpoint. A three-group prediction risk was created based on combined assessment of the TAPSE/PASP ratio and 6MWD relative to their cut-off values. The patients with the worse RV-PC coupling (TAPSE/PASP <0.184 mm/mmHg) and the lower 6MWD (<395 m) had the highest risk (HR 4.62, confidence interval 2.27-9.41, P < 0.001) of experiencing the endpoint. CONCLUSION The TAPSE/PASP ratio, combined with 6MWD, provides clinical and prognostic insights into patients with SLE-associated PAH. A low TAPSE/PASP and low 6MWD identifies the subgroup of patients with high risk of poor prognosis.
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Affiliation(s)
- Xiaoxiao Guo
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Jinzhi Lai
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Hui Wang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - MengTao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Ligang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1. Shuaifuyuan, Dongcheng District, Beijing 100730, China
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Zhao J, Wang Q, Wang Q, Zhang Y, Zhang N, Zhang R, Hao Y, Jia J, Li M, Zeng X. 2020 Chinese Expert-based Consensus on the Diagnosis and Treatment of Connective Tissue Disease Associated Pulmonary Arterial Hypertension. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2021; 2:63-78. [PMID: 36465975 PMCID: PMC9524783 DOI: 10.2478/rir-2021-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/12/2021] [Indexed: 06/17/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication of connective tissue disease (CTD) and is one of the leading causes of morbidity and mortality among patients with this condition. To establish an expert-based consensus on the diagnosis and treatment of CTD-associated PAH, a multidisciplinary consensus development panel was established. The consensus panel is composed of 45 experts in rheumatology, cardiology, pulmonology, and radiology, most of whom are members of the Group of Pulmonary Vascular and Interstitial Lung Diseases (ILD) Associated with Rheumatic Diseases. The consensus development panel compiled 9 recommendations for the diagnosis and treatment of CTD-associated PAH. It covers screening, diagnosis, disease evaluation, risk assessment, the use of immunosuppressive agents, and PAH-specific therapy with a treat-to-target approach. The consensus is intended to facilitate decision-making and standardize the care of CTD-associated PAH in China.
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Affiliation(s)
- Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Qiang Wang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yongfeng Zhang
- Department of Rheumatology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Na Zhang
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Zhang
- Department of Rheumatology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Junfeng Jia
- Department of Clinical Immunology, PLA Specialised Research Institute of Rheumatology and Immunology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
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Khanna D, Zhao C, Saggar R, Mathai SC, Chung L, Coghlan JG, Shah M, Hartney J, McLaughlin V. Long-Term Outcomes in Patients With Connective Tissue Disease-Associated Pulmonary Arterial Hypertension in the Modern Treatment Era: Meta-Analyses of Randomized, Controlled Trials and Observational Registries. Arthritis Rheumatol 2021; 73:837-847. [PMID: 33538058 PMCID: PMC8251834 DOI: 10.1002/art.41669] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
Objective Data on the magnitude of benefit of modern therapies for pulmonary arterial hypertension (PAH) in connective tissue disease (CTD)–associated PAH are limited. In this study, we performed meta‐analyses of randomized, controlled trials (RCTs) and registries to quantify the benefit of these modern therapies in patients with CTD‐PAH. Methods The PubMed and Embase databases were searched for articles reporting data from RCTs or registries published between January 1, 2000 and November 25, 2019. Eligibility criteria included multicenter studies with ≥30 CTD‐PAH patients. For an RCT to be included, the trial had to evaluate an approved PAH therapy, and long‐term risks of clinical morbidity and mortality or 6‐minute walk distance had to be reported. For a registry to be included, survival rates had to be reported. Random‐effects models were used to pool the data. Results Eleven RCTs (total of 4,329 patients; 1,267 with CTD‐PAH) and 19 registries (total of 9,739 patients; 4,008 with CTD‐PAH) were included. Investigational therapy resulted in a 36% reduction in the risk of clinical morbidity/mortality events both in the overall PAH population (hazard ratio [HR] 0.64, 95% confidence interval [95% CI] 0.54, 0.75; P < 0.001) and in CTD‐PAH patients (HR 0.64, 95% CI 0.51, 0.81; P < 0.001) as compared to control subjects. The survival rate was lower in CTD‐PAH patients compared to all PAH patients (survival rate 62%, 95% CI 57, 67% versus 72%, 95% CI 69, 75% at 3 years). The survival rate in CTD‐PAH patients treated primarily after 2010 was higher than that in CTD‐PAH patients treated before 2010 (survival rate 73%, 95% CI 62, 81% versus 65%, 95% CI 59, 71% at 3 years). Conclusion Modern therapy provides a similar reduction in morbidity/mortality risk in patients with CTD‐PAH when compared to the PAH population overall. Risk of death is higher in CTD‐PAH patients than in those with PAH overall, but survival has improved in the last 10 years, which may be related to increased screening and/or new treatment approaches. Early detection of PAH in patients with CTD and up‐front intensive treatment are warranted.
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Affiliation(s)
| | - Carol Zhao
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | | | - Stephen C Mathai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Mehul Shah
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | - John Hartney
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
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12
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Tran-Duy A, Morrisroe K, Clarke P, Stevens W, Proudman S, Sahhar J, Nikpour M. Cost-Effectiveness of Combination Therapy for Patients With Systemic Sclerosis-Related Pulmonary Arterial Hypertension. J Am Heart Assoc 2021; 10:e015816. [PMID: 33759539 PMCID: PMC8174376 DOI: 10.1161/jaha.119.015816] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background To evaluate the cost‐effectiveness of combination pulmonary arterial hypertension specific therapy in systemic sclerosis–related PAH. Methods and Results Health outcomes and costs were captured through data linkage. Health utility was derived from Medical Outcomes Study Short Form‐36 scores. A probabilistic discrete‐time model was developed to simulate lifetime changes in costs and health utility. Mortality was predicted using a Gompertz parametric survival model. For both treatment arms, the simulations were started using the same cohort of 10 000 patients. Probabilistic sensitivity analysis was performed using the Monte Carlo simulation with 1000 sets of sampled parameter values. Of 143 patients with systemic sclerosis–related pulmonary arterial hypertension, 89 were on monotherapy and 54 on combination therapy. Mean simulated costs per patient per year in monotherapy and combination therapy groups were AU$23 411 (US$16 080) and AU$29 129 (US$19 982), respectively. Mean life years and quality‐adjusted life years from pulmonary arterial hypertension diagnosis to death of patients receiving monotherapy were 7.1 and 3.0, respectively, and of those receiving combination therapy were 9.2 and 3.9, respectively. Incremental costs per life year and quality‐adjusted life year gained of combination therapy compared with monotherapy were AU$47 989 (US$32 920) and AU$113 823 (US$78 082), respectively. At a willingness‐to‐pay threshold of AU$102 000 (US$69 972) per life year gained, and of AU$177 222 (US$121 574) per quality‐adjusted life year gained, the probability of combination therapy being cost‐effective was 0.95. Conclusions The incremental cost per quality‐adjusted life year gained of combination therapy compared with monotherapy was substantial in the base case analysis. Given the fatal prognosis of systemic sclerosis–related pulmonary arterial hypertension and the incremental cost per life year of AU$47 989 (US$32 920), combination therapy could be considered cost‐effective in systemic sclerosis–related pulmonary arterial hypertension.
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Affiliation(s)
- An Tran-Duy
- Centre for Health PolicyMelbourne School of Population and Global HealthThe University of Melbourne Parkville VIC Australia
| | - Kathleen Morrisroe
- Department of Medicine The University of Melbourne at St Vincent's Hospital (Melbourne) Fitzroy VIC Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne) Fitzroy VIC Australia
| | - Philip Clarke
- Centre for Health PolicyMelbourne School of Population and Global HealthThe University of Melbourne Parkville VIC Australia.,Health Economics Research Centre Nuffield Department of Population Health University of Oxford Headington United Kingdom
| | - Wendy Stevens
- Department of Medicine The University of Melbourne at St Vincent's Hospital (Melbourne) Fitzroy VIC Australia
| | - Susanna Proudman
- Rheumatology Unit Royal Adelaide Hospital North Terrace SA Australia.,Discipline of Medicine University of Adelaide SA Australia
| | - Joanne Sahhar
- Department of Medicine Monash University Clayton VIC Australia
| | - Mandana Nikpour
- Department of Medicine The University of Melbourne at St Vincent's Hospital (Melbourne) Fitzroy VIC Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne) Fitzroy VIC Australia
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13
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Li X, Zhang C, Sun X, Yang X, Zhang M, Wang Q, Zhu Y. Prognostic factors of pulmonary hypertension associated with connective tissue disease: pulmonary artery size measured by chest CT. Rheumatology (Oxford) 2021; 59:3221-3228. [PMID: 32221604 DOI: 10.1093/rheumatology/keaa100] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Pulmonary artery enlargement is a common manifestation of chest CT in patients with pulmonary arterial hypertension (PAH). The exact clinical significance of this phenomenon has not been clarified in connective tissue disease (CTD)-associated PAH (CTD-PAH). We aimed to explore the association between the dilatation of pulmonary artery and prognosis of CTD-PAH patients. METHODS We retrospectively investigated 140 CTD-PAH patients diagnosed by echocardiography from 2009 to 2018. A chest multi-slice CT was performed on all the patients. Main pulmonary artery (MPA), right pulmonary artery (RPA), left pulmonary artery (LPA), ascending aorta (AAo) and descending aorta (DAo) diameters were measured. The ratios MPA/AAo and MPA/DAo were also calculated. The primary end point was all-cause mortality. RESULTS During the observational period of 3.44 (0.23) years, 36 patients were followed to death. Cox univariate proportional hazard analysis showed that age, gender, MPA diameter, LPA diameter and RPA diameter were related to the risk of 5-year all-cause mortality in patients with CTD-PAH. In Cox multivariate proportional hazard analysis, MPA diameter and gender were predictors of all-cause mortality in CTD-PAH patients. An all-cause mortality risk prediction model revealed that baseline MPA diameter has the ability to predict 5-year all-cause mortality in CTD-PAH patients. Kaplan-Meier analysis showed that the 5-year survival rate was significantly lower in patients with MPA ≥37.70 mm (P ≤ 0.00012) compared with MPA ≤ 37.70 mm. CONCLUSION MPA diameter ≥37.70 mm measured by chest multi-slice CT was a potential independent risk factor of the poor long-term prognosis in Chinese CTD-PAH patients.
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Affiliation(s)
- Xiaodi Li
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing.,Department of Rheumatology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi
| | - Chunfang Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Xiaoxuan Sun
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Xiaoman Yang
- Department of Cardiology, Jiangsu Province Official Hospital, Nanjing, Jiangsu, China
| | - Miaojia Zhang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Qiang Wang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Yinsu Zhu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
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14
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Rawal H, Suman A, Bhoite RR, Kanwal A, Young RK, Aronow WS, Lavie C, Ghosh RK. Anticoagulation in Pulmonary Arterial Hypertension: Do We Know the Answer? Curr Probl Cardiol 2020; 46:100738. [PMID: 33250263 DOI: 10.1016/j.cpcardiol.2020.100738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 01/11/2023]
Abstract
The shear stress and hypoxia in the pulmonary artery in patients with pulmonary arterial hypertension(PAH) causes endothelial dysfunction, smooth muscle proliferation and activation of thrombotic pathways leading to in situ thrombosis. Targeting the thrombotic pathways is a proposed mechanism to slow disease progression and improve survival. Over the years, the survival in patients with PAH has improved due to multiple factors with the increased use of anticoagulation as one of them. Both European Respiratory Society/European Society of Cardiology and American College of Cardiology/American Heart Association guidelines make grade II recommendations for using anticoagulation in PAH. The guidelines are based on weak observational studies with high risk of bias which have only studied warfarin as the choice of anticoagulation. In this article, we review the pathophysiology, rationale and the current literature investigating the role of anticoagulation in PAH.
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Affiliation(s)
- Himanshu Rawal
- Department of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest Baptist Health, Winston-Salem, NC
| | - Annya Suman
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Rahul R Bhoite
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Arjun Kanwal
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Raymond K Young
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Carl Lavie
- John Ochsner Heart and Vascular Institute, New Orleans, LA
| | - Raktim K Ghosh
- MedStar Heart and Vascular Institute, Union Memorial Hospital, Baltimore, MD.
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15
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Kato M, Sugimoto A, Atsumi T. Diagnostic and prognostic markers and treatment of connective tissue disease-associated pulmonary arterial hypertension: current recommendations and recent advances. Expert Rev Clin Immunol 2020; 16:993-1004. [PMID: 32975145 DOI: 10.1080/1744666x.2021.1825940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH), also referred to as group 1 pulmonary hypertension, occurs either primarily or in association with other diseases such as connective tissue diseases (CTD). Of CTD, systemic sclerosis (SSc), systemic lupus erythematosus and mixed connective tissue disease are commonly accompanied with PAH. It is of note that SSc-PAH is associated with distinctive histopathology, an unfavorable outcome, and a blunted responsiveness to modern PAH therapies. AREAS COVERED The data in articles published until May 2020 in peer-reviewed journals, covered by PubMed databank, are discussed. The current review introduces recent advances over the past years which have moved our understanding of CTD-PAH forward and discusses what we are currently able to do and what will be necessary in the future to overcome the yet unsatisfactory situation in the management of CTD-PAH, particularly in that of SSc-PAH. EXPERT OPINION A multifaceted and integrated approach would be crucial to improve the outcome of patients with SSc-PAH. The authors also propose a possible algorithm to classify and treat SSc patients with suspicion of pulmonary vascular disease.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University , Sapporo, Japan
| | - Ayako Sugimoto
- First Department of Medicine, Hokkaido University Hospital , Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University , Sapporo, Japan
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16
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Guo X, Lai J, Wang H, Tian Z, Zhao J, Li M, Fang Q, Fang L, Liu Y, Zeng X. Predictive Value of Pulmonary Arterial Compliance in Systemic Lupus Erythematosus Patients With Pulmonary Arterial Hypertension. Hypertension 2020; 76:1161-1168. [PMID: 32772648 DOI: 10.1161/hypertensionaha.120.15682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Pulmonary arterial hypertension is a serious complication of systemic lupus erythematosus. It is characterized by increased right ventricular afterload which mainly comprises pulmonary arterial compliance (PAC) and pulmonary vascular resistance. The role of PAC in predicting the outcome of systemic lupus erythematosus-associated pulmonary arterial hypertension has not been investigated yet. Between February 2012 to December 2016, 120 consecutive patients diagnosed with systemic lupus erythematosus-associated pulmonary arterial hypertension based on right heart catheterization were enrolled, prospectively. Baseline clinical characteristics and hemodynamic assessment were analyzed. Baseline right ventricular afterload was stratified according to the PAC and pulmonary vascular resistance. The end point was a composite of all-cause mortality and clinical worsening. Among them, end points occurred in 49 (41%) patients after 15 months (interquartile range, 8.5-24.0). Patients with a PAC <1.39 mL/mm Hg had a 3.09-fold higher risk (95% CI, 1.54-6.20, P=0.001) of the end point events than the patients with a PAC ≥1.39 mL/mm Hg. Multivariable Cox regression analysis showed that stratified right ventricular afterload was the only independent predictor for the end point (hazard ratio, 2.009 [95% CI, 1.390-2.904], P<0.001). A 3-group prediction risk was created. The patients with the highest right ventricular afterload (PAC <1.39 mL/mm Hg and pulmonary vascular resistance ≥10.3Wood Unit) had the highest risk (χ2, 6.10; P<0.014) of experiencing the end point. Our results suggest that PAC is a good predictor of mortality and clinical worsening in systemic lupus erythematosus-associated pulmonary arterial hypertension. PAC, in addition to pulmonary vascular resistance, may be an attractive tool for screening high-risk populations in these patients.
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Affiliation(s)
- Xiaoxiao Guo
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jinzhi Lai
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Wang
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhuang Tian
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology (J.Z., M.L., X.Z.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mengtao Li
- Department of Rheumatology (J.Z., M.L., X.Z.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Quan Fang
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ligang Fang
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yongtai Liu
- From the Department of Cardiology (X.G., J.L., H.W., Z.T., Q.F., L.F., Y.L.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology (J.Z., M.L., X.Z.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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17
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Kelly C. Lung Disease in Rheumatic Disorders. Mediterr J Rheumatol 2020; 30:147-154. [PMID: 32185357 PMCID: PMC7045857 DOI: 10.31138/mjr.30.3.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/19/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Clive Kelly
- University of Newcastle upon Tyne, Newcastle, United Kingdom
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18
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Dubroff J, Melendres L, Lin Y, Beene DR, Ketai L. High geographic prevalence of pulmonary artery hypertension: associations with ethnicity, drug use, and altitude. Pulm Circ 2020; 10:2045894019894534. [PMID: 32110384 PMCID: PMC7000864 DOI: 10.1177/2045894019894534] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022] Open
Abstract
While estimates of pulmonary arterial hypertension incidence and prevalence commonly range from 1-3/million and 15-25/million, respectively, clinical experience at our institution suggested much higher rates. We sought to describe the disease burden of pulmonary arterial hypertension in the geographic area served by our Pulmonary Hypertension Clinic and compare it to the REVEAL registry. Our secondary objectives were to document pulmonary arterial hypertension prevalence in minorities underrepresented in REVEAL (Hispanics and Native Americans) and to address the association of pulmonary arterial hypertension with exposure to drugs and moderately increased residential altitude in this population. Retrospective review of pulmonary arterial hypertension clinic patients alive during 2016 identified 154 patients. Hispanic patients made up 35.7% of the cohort, a much greater percentage than REVEAL, p < .001 but smaller than the percentage of Hispanic patients (48.4%) in geographic area served by the clinic. Pulmonary arterial hypertension due to drug exposure was more common and idiopathic pulmonary arterial hypertension was less common than in REVEAL (p < .001). Overall, pulmonary arterial hypertension incidence was 14 cases per million, greater than the REVEAL registry, odds ratio 6.3 (95% CI: 4.2-9.5), (p < .001). Annual period prevalence of pulmonary arterial hypertension was 93 cases per million, also greater than the REVEAL, odds ratio = 7.5 (95% CI: 6.4-8.8) and remained greater when the clinic cohort was constrained to patients with hemodynamic severity comparable to REVEAL, odds ratio = 3.8 (95% CI: 3.0-4.6), (p < .001). There was a strong association between pulmonary arterial hypertension prevalence and residence at altitude > 4000 ft, odds ratio = 26.6 (95% CI: 8.5-83.5), p < .001; however, this was potentially confounded by pulmonary arterial hypertension treatment referral patterns. These findings document a much higher local pulmonary arterial hypertension incidence and prevalence than previously reported in REVEAL. While population ethnicity differed markedly from REVEAL, the disease burden was not driven by these differences. The possible association of moderately increased residential altitude with pulmonary arterial hypertension warrants further evaluation.
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Affiliation(s)
- Jason Dubroff
- Department of Internal Medicine,
University of Utah, Salt Lake City, UT, USA
| | - Lana Melendres
- Department of Internal Medicine,
University of New Mexico, Albuquerque, NM, USA
| | - Yan Lin
- Department of Geography and
Environmental Studies, University of New Mexico, Albuquerque, NM, USA
| | - Daniel Raley Beene
- Department of Geography and
Environmental Studies, University of New Mexico, Albuquerque, NM, USA
| | - Loren Ketai
- Department of Radiology, University of
New Mexico, Albuquerque, NM, USA
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19
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Khan MS, Usman MS, Siddiqi TJ, Khan SU, Murad MH, Mookadam F, Figueredo VM, Krasuski RA, Benza RL, Rich JD. Is Anticoagulation Beneficial in Pulmonary Arterial Hypertension? Circ Cardiovasc Qual Outcomes 2019; 11:e004757. [PMID: 30354550 DOI: 10.1161/circoutcomes.118.004757] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Data about anticoagulation in pulmonary arterial hypertension (PAH) patients are inconsistent. The objective of this study was to examine the impact of adjunctive oral anticoagulants in patients with PAH through meta-analysis, and to further assess whether response differs by PAH subtype. Methods and Results Cochrane CENTRAL, Medline, and Scopus databases were searched for randomized or nonrandomized studies that assessed the association between anticoagulation and outcomes in patients with PAH. Hazard ratios (HRs) for mortality were pooled using the random effects model. Subgroup analyses were performed for type of PAH and study design. Twelve nonrandomized studies, at moderate risk of bias, were included. These consisted of 2512 patients (1342 receiving anticoagulation and 1170 controls). Anticoagulation significantly reduced mortality in the overall PAH cohort (HR, 0.73 [0.57, 0.93]; P=0.001; I2=64%). On subgroup analysis, a significant mortality reduction was seen in idiopathic PAH patients (HR, 0.73 [0.56, 0.95]; P=0.02; I2=46%), whereas no significant difference was observed in connective tissue disease-related PAH (HR, 1.16 [0.58, 2.32]; P=0.67; I2=71%). Sensitivity analysis specific to scleroderma-associated PAH demonstrated a significant increase in mortality with anticoagulant use (HR, 1.58 [1.08, 2.31]; P=0.02; I2=9%). Conclusions This meta-analysis shows that use of anticoagulation may improve survival in idiopathic PAH patients, while increasing mortality when used in scleroderma-associated-PAH patients. Currently, no randomized clinical trials have been published, and until randomized data are available, anticoagulant use in PAH should be tailored to PAH subtype.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL (M.S.K.)
| | - Muhammad Shariq Usman
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan (M.S.U., T.J.S.)
| | - Tariq Jamal Siddiqi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan (M.S.U., T.J.S.)
| | - Safi U Khan
- Department of Internal Medicine, Robert Packer Hospital, Sayre, PA (S.U.K.)
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN (M.H.M.)
| | - Farouk Mookadam
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ (F.M.)
| | - Vincent M Figueredo
- Department of Cardiovascular Medicine, Institute for Heart and Vascular Health, Einstein Medical Center Philadelphia, PA (V.M.F.)
| | - Richard A Krasuski
- Department of Cardiovascular Medicine, Duke University Health System, Durham, NC (R.A.K.)
| | - Raymond L Benza
- Department of Cardiovascular Medicine, Allegheny Health Network, Pittsburgh, PA (R.L.B.)
| | - Jonathan D Rich
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.R.)
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20
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Clinical Value of Asymmetrical Dimethylarginine Detection in Patients with Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Cardiol Res Pract 2019; 2019:3741909. [PMID: 31485349 PMCID: PMC6710784 DOI: 10.1155/2019/3741909] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/29/2019] [Accepted: 07/27/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the clinical value of serum asymmetrical dimethylarginine (ADMA) in patients with connective tissue disease- (CTD-) associated pulmonary arterial hypertension (PAH). Methods 88 patients with CTD were recruited between December 2017 and August 2018 in Jiangxi Provincial People's Hospital. Patients were further divided into two groups: CTD-without PAH (n = 45 cases) and CTD-with PAH (n = 43 cases), according to the pulmonary systolic blood pressure measured by echocardiography. 40 healthy controls were also included (n = 40 cases). The clinical data, including laboratory examinations, echocardiographic measurements, pulmonary function, and serum ADMA levels determined by enzyme-linked immunosorbent assay, (ELISA) were collected. The correlation between ADMA levels and the occurrence of PAH, pulmonary function, and other laboratory indexes in CTD patients were analyzed. Statistical analyses were performed by SPSS (version 23); P < 0.05 was considered statistically significant. Results The serum levels of ADMA in the CTD-PAH group were significantly higher than those of the CTD-without PAH group and healthy control group (P < 0.05); the serum ADMA levels were (0.706 ± 0.153 μmol/L), (1.015 ± 0.122 μmol/L), and (0.661 ± 0.113 μmol/L), respectively. There was no significant difference between the CTD-without PAH group and healthy control group (P < 0.05). Correlation analysis showed that serum ADMA levels were positively correlated with sPAP and NT-proBNP and negatively correlated with DLCO% (r = 0.802, 0.475, −0.585, P < 0.001). Multivariate analysis indicated that elevated serum ADMA levels increased the risk for the appearance of PAH in CTD patients (OR = 57.460, P < 0.001). Using the receiver operating characteristic (ROC) curve analysis, at the cutoff level of 0.810 μmol/L, ADMA showed good diagnostic efficacy as follows: sensitivity was 97.7%, specificity was 75.6%, and the area under the curve (AUC) was 0.947 (P < 0.001). Conclusion Increased ADMA levels are independently associated with the presence and severity of PAH in CTD patients. The levels of ADMA in the serum may contribute to be a noninvasive indicator for early diagnosis of CTD-with PAH patients.
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21
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Nagel C, Marra AM, Benjamin N, Blank N, Cittadini A, Coghlan G, Distler O, Denton CP, Egenlauf B, Fiehn C, Fischer C, Harutyunova S, Hoeper MM, Lorenz HM, Xanthouli P, Bossone E, Grünig E. Reduced Right Ventricular Output Reserve in Patients With Systemic Sclerosis and Mildly Elevated Pulmonary Artery Pressure. Arthritis Rheumatol 2019; 71:805-816. [PMID: 30615302 DOI: 10.1002/art.40814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This prospective study was undertaken to evaluate right ventricular function and pulmonary arterial compliance (PAC; ratio of stroke volume to pulse pressure) at rest and during exercise in patients with systemic sclerosis (SSc) with normal mean pulmonary artery pressure (PAP), patients with SSc with mildly elevated mean PAP, and patients with SSc with manifest pulmonary hypertension (PH). METHODS Patients with SSc (n = 112) underwent clinical assessment and right-sided heart catheterization at rest and during exercise and were divided into 3 groups according to their resting mean PAP values: normal mean PAP (≤20 mm Hg), mildly elevated mean PAP (21-24 mm Hg), and PH (mean PAP ≥25 mm Hg). Results were compared between groups by analysis of variance followed by post hoc Student's t-test. RESULTS Compared to patients with normal mean PAP, patients with mildly elevated mean PAP had a lower 6-minute walking distance (P = 0.008), lower cardiac index (P = 0.027) and higher pulmonary vascular resistance (P = 0.0002) during exercise, and lower PAC at rest (P = 0.016) and different stages of exercise (P = 0.033 for 25W and P = 0.024 for 75W). CONCLUSION The results of this study suggest that impaired 6-minute walking distance in SSc patients with mildly elevated mean PAP might be caused by reduced PAC during exercise and reduced right ventricular output reserve, presumably due to impaired coupling between the right ventricle and the pulmonary vasculature. These findings provide further evidence of the clinical relevance of mildly elevated mean PAP in patients with SSc.
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Affiliation(s)
- Christian Nagel
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany, and Klinikum Mittelbaden Baden-Baden Balg, Baden-Baden, Germany
| | - Alberto M Marra
- SDN Scientific Institute for Research and Healthcare, Naples, Italy
| | - Nicola Benjamin
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | | | | | | | - Benjamin Egenlauf
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Satenik Harutyunova
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Panagiota Xanthouli
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | - Ekkehard Grünig
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
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22
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Zhang N, Li M, Qian J, Wang Q, Zhao J, Yang Z, Tian Z, Zhang X, Zuo X, Zhang M, Zhu P, Ye S, Zhang W, Zheng Y, Qi W, Li Y, Zhang Z, Ding F, Gu J, Liu Y, Wei W, Zeng X. Pulmonary arterial hypertension in systemic lupus erythematosus based on a CSTAR-PAH study: Baseline characteristics and risk factors. Int J Rheum Dis 2019; 22:921-928. [PMID: 30746850 DOI: 10.1111/1756-185x.13478] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/09/2018] [Accepted: 12/17/2018] [Indexed: 02/05/2023]
Abstract
AIM Pulmonary arterial hypertension (PAH) is a complex and devastating complication of systemic lupus erythematosus (SLE). We sought to describe the baseline characteristics of right heart catheterization (RHC)-confirmed SLE-associated PAH and identify risk factors for PAH in SLE patients. METHODS A multicenter, cross-sectional study was conducted using the Chinese SLE Treatment and Research group (CSTAR) registry. Baseline data for patients with SLE-associated PAH and SLE patients without PAH were collected and compared. Risk factors for PAH among patients with SLE were identified. RESULTS A total of 292 patients with SLE-associated PAH were enrolled. RHC was used to reveal hemodynamic features, including mean pulmonary arterial pressure (46.2 ± 12.0 mm Hg), pulmonary arterial wedge pressure (7.84 ± 3.92 mm Hg), pulmonary vascular resistance (10.86 ± 5.57 Wood units), and cardiac index (2.77 ± 0.91 L/min × m2 ). A multivariate logistic regression analysis showed that serositis (odds ratio [OR] = 5.524, 95% CI 3.605-8.465, P < 0.001), anti-ribonucleoprotein (RNP) antibody positivity (OR = 13.332, 95% CI 9.500-18.710, P < 0.001), and diffusion capacity of carbon monoxide in the lung (DLCO)/%Pred <70% (OR = 10.018, 95% CI 6.619-15.162, P < 0.001) were independent predictors of PAH. We recommend using transthoracic echocardiography (TTE) to perform early screening of SLE patients who have serositis, anti-RNP antibody positivity, or DLCO/%Pred <70%. RHC is suggested for patients suspected of having PAH. Once a diagnosis of SLE-PAH is confirmed, evaluation and treatment should immediately begin. CONCLUSION Overall, we recommend performing early screening using TTE in SLE patients with serositis, anti-RNP antibodies, or a DLCO/%Pred <70%, even for patients in a relatively stable condition according to SLE disease activity index.
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Affiliation(s)
- Na Zhang
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Junyan Qian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Zhang
- Department of Rheumatology, Guangdong General Hospital, Guangzhou, China
| | - Xiaoxia Zuo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Miaojia Zhang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ping Zhu
- Department of Clinical Immunology, PLA Specialized Research Institute of Rheumatology & Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital South Campus, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Rheumatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Zheng
- Department of Rheumatology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wufang Qi
- Department of Rheumatology, The First Central Hospital, Tianjin, China
| | - Yang Li
- Department of Rheumatology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Feng Ding
- Department of Rheumatology, Qilu Hospital of Shandong University, Jinan, China
| | - Jieruo Gu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Wei
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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23
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De Filippo O, Gatti P, Rettegno S, Iannaccone M, D’Ascenzo F, Lazaros G, Brucato A, Tousoulis D, Adler Y, Imazio M. Is pericardial effusion a negative prognostic marker? Meta-analysis of outcomes of pericardial effusion. J Cardiovasc Med (Hagerstown) 2019; 20:39-45. [DOI: 10.2459/jcm.0000000000000720] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Liu Z, Wang J, Lai J, Wang Q, Zhao J, Huang C, Yang X, Qian J, Wang H, Guo X, Liu Y, Tian Z, Li M, Zhao Y, Zeng X. Is it possible to apply the treat-to-target strategy in primary Sjögren’s syndrome-associated pulmonary arterial hypertension? Clin Rheumatol 2018; 37:2989-2998. [DOI: 10.1007/s10067-018-4184-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 05/12/2018] [Accepted: 06/19/2018] [Indexed: 02/07/2023]
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25
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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26
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Abstract
Scleroderma is an uncommon autoimmune disease of unknown cause that may affect any organ system in the body. Patients with scleroderma are prone to developing pulmonary complications, including pulmonary arterial hypertension (PAH), that are the leading cause of death in this population. This article describes scleroderma-related PAH and its diagnosis and management.
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27
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Karampitsakos T, Tzouvelekis A, Chrysikos S, Bouros D, Tsangaris I, Fares WH. Pulmonary hypertension in patients with interstitial lung disease. Pulm Pharmacol Ther 2018; 50:38-46. [PMID: 29605286 DOI: 10.1016/j.pupt.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/12/2018] [Accepted: 03/28/2018] [Indexed: 01/20/2023]
Abstract
Interstitial lung diseases (ILDs) comprise a broad and heterogeneous group of more than two hundred diseases with common functional characteristics. Their diagnosis and management require a multidisciplinary approach. This multidisciplinary approach involves the assessment of comorbid conditions including pulmonary hypertension (PH) that exerts a dramatic impact on survival. The current World Health Organization (WHO) classification of PH encompasses many of the interstitial lung diseases into WHO Group 3, while sarcoidosis, Pulmonary Langerhans Cell Histiocytosis and lymphangioleiomyomatosis are placed into WHO Group 5 as diseases with unclear or multifactorial mechanisms. Connective tissue diseases could span any of the 5 WHO groups based on the primary phenotype into which they manifest. Interestingly, several challenging phenotypes present with features that overlap between two or more WHO PH groups. Currently, PH-specific treatment is recommended only for patients classified into WHO Group 1 PH. The lack of specific treatment for other groups, including PH in the setting of ILD, reflects the poor outcomes of these patients. Thus, identification of the optimal strategy for ILD patients with PH remains an amenable need. This review article provides a brief overview of biomarkers indicative of vascular remodeling in interstitial lung disease, summarizes the current state of knowledge regarding patients with PH and ILD and highlights future perspectives that remain to be addressed.
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Affiliation(s)
| | - Argyrios Tzouvelekis
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece; Division of Immunology, Biomedical Sciences Research Center "Alexander Fleming", Athens, Greece
| | - Serafeim Chrysikos
- 5(th) Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Iraklis Tsangaris
- Second Critical Care Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Wassim H Fares
- Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
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28
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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29
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Sinha A, Patti R, Ambesh P, Obiagwu C, Malhan N, Chawla K. Severe Pulmonary Hypertension Due to Adult-Onset Still's Disease. J Investig Med High Impact Case Rep 2018; 6:2324709618757260. [PMID: 29468168 PMCID: PMC5815417 DOI: 10.1177/2324709618757260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/07/2018] [Indexed: 01/01/2023] Open
Abstract
A 29-year-old female with adult-onset Still’s disease (AOSD) presented with progressive shortness of breath both on rest and on exertion, increased abdominal girth, and swelling in both legs. She was on oral prednisone and was recently started on canakinumab (interleukin-1 antagonist) for joint pain and rash of AOSD. Echocardiogram showed severely dilated right ventricle, dilated pulmonary artery, moderately reduced right ventricular systolic function, but with normal left ventricular systolic function. Computed tomography with contrast ruled out pulmonary embolism. Blood tests ruled out other rheumatologic diseases. The patient was diagnosed with right-sided heart failure likely secondary to AOSD. Right heart catheterization was needed but could not be performed because of severely dilated pulmonary artery. The patient was transferred to a higher center for further management and possible cardiopulmonary transplant.
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Affiliation(s)
- Ankur Sinha
- Maimonides Medical Center, Brooklyn, NY, USA
| | | | | | | | - Namrita Malhan
- Sri Aurobindo Institute of Medical Sciences, Indore, India
| | - Kabu Chawla
- Maimonides Medical Center, Brooklyn, NY, USA
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30
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Liu Z, Yang X, Tian Z, Qian J, Wang Q, Zhao J, Huang C, Liu Y, Guo X, Wang H, Lai J, Li M, Zhao Y, Zeng X. The prognosis of pulmonary arterial hypertension associated with primary Sjögren's syndrome: a cohort study. Lupus 2018; 27:1072-1080. [PMID: 29419347 DOI: 10.1177/0961203318756287] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare and severe complication of primary Sjögren's syndrome (pSS). Cohort studies indicate that the underlying diseases of PAH associated with connective tissue disease (CTD-PAH) in Asian countries are different from that in the United States and in Europe. This study investigated the clinical characteristics, survival, and prognostic factors of pSS-PAH in Chinese patients. We enrolled 29 patients with pSS-PAH who visited our referral center during August 2007 and May 2015. PAH was confirmed by right heart catheterization (RHC). Baseline demographic data, clinical manifestations, laboratory tests, autoantibody results, hemodynamics data, and treatment regimens were analyzed. All patients were followed up at the Department of Rheumatology, Peking Union Medical College Hospital (PUMCH) every three to six months. All patients were female. Mean age of pSS onset was 34.4 ± 11.1 years. Mean age of PAH diagnosed by RHC was 40.6 ± 9.0 years. There was no significant difference in age, disease duration, and hemodynamic findings between the survivors and the non-survivors in this cohort. The overall one-, three-, and five-year survival rates were 80.2%, 74.8%, and 67.4%, respectively. Prognostic factors of mortality were time between pSS onset and PAH onset (HR 1.102, 95% CI 1.017-1.185, p = 0.018) and cardiac index < 2 l/min/m2 (HR 5.497, 95% CI 1.063-28.434, p = 0.042). In contrast, the use of immunosuppressants (HR 0.110, 95% CI 0.024-0.495, p = 0.004) was related to better survival. This study demonstrates that the predictors of mortality in patients with pSS-PAH include delayed onset of PAH in pSS and worse cardiac function. Immunosuppressants can improve the prognosis of pSS-PAH.
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Affiliation(s)
- Z Liu
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - X Yang
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Z Tian
- 2 Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - J Qian
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Q Wang
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - J Zhao
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - C Huang
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Y Liu
- 2 Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - X Guo
- 2 Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - H Wang
- 2 Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - J Lai
- 2 Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - M Li
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Y Zhao
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - X Zeng
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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31
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Kato M, Atsumi T. Pulmonary arterial hypertension associated with connective tissue diseases: A review focusing on distinctive clinical aspects. Eur J Clin Invest 2018; 48. [PMID: 29285766 DOI: 10.1111/eci.12876] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
Recent studies have clarified that pulmonary arterial hypertension associated with connective tissue diseases (CTD-PAH) has some distinctive clinical aspects from other PAH, such as high prevalence, venous and cardiac involvement, less favourable outcome, helpfulness of detection algorithm, response to immunosuppression, pre-PAH conditions in borderline pulmonary arterial pressure and coexistence of interstitial lung disease. In this review, by focusing on these distinctive aspects, we discuss how to provide an efficacious and safe management of CTD-PAH and garner attention to areas where further evidence is desired.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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32
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Morrisroe K, Stevens W, Proudman S, Nikpour M. A systematic review of the epidemiology, disease characteristics and management of systemic sclerosis in Australian adults. Int J Rheum Dis 2017; 20:1728-1750. [PMID: 29076640 DOI: 10.1111/1756-185x.13203] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Australia has one of the highest prevalence rates of systemic sclerosis (SSc) worldwide. In order to highlight management deficiencies and key areas for further research, it is essential to understand its local epidemiological patterns, natural history, prognosis and mortality trends over time. METHODS To identify Australian SSc-specific information through a systematic review focusing on areas of epidemiology, disease characteristics, treatment, functional ability, disease burden and health-related quality of life (HRQoL). RESULTS MEDLINE, EMBASE and the Cochrane Library were searched on 14 September, 2016. All original full text articles on SSc in Australia were included. Of the 54 articles included in this review, the majority of studies recruited from South Australia, Victoria and New South Wales. The prevalence of SSc in Australia is increasing and is similar among the general population and the Aboriginal population. Despite improvements in care over the last three decades, morbidity and mortality remain high, with an overall standardized mortality ratio of 3.4 and a 10-year survival of 84% in a newly diagnosed patient. Cardiorespiratory manifestations are the leading cause of SSc-related death. Malignancy is the leading cause of non-SSc-related death. The role of autoantibodies in predicting disease subtype, visceral involvement and their use as a prognostic marker is becoming increasingly recognized. CONCLUSION Information on SSc in Australia, particularly unmet healthcare needs, HRQoL and economic burden, is limited. As a heterogenous condition, SSc requires a multi-disciplinary approach to care. Research aimed at quantifying HRQoL and burden of disease in Australia is essential for advocacy and resource allocation.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Melbourne, Vic., Australia.,Department of Rheumatology, St Vincent's Hospital, Melbourne, Vic., Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Vic., Australia
| | - Susanna Proudman
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Melbourne, Vic., Australia.,Department of Rheumatology, St Vincent's Hospital, Melbourne, Vic., Australia
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33
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Nakamura H, Kato M, Nakaya T, Kono M, Tanimura S, Sato T, Fujieda Y, Oku K, Ohira H, Bohgaki T, Yasuda S, Tsujino I, Nishimura M, Atsumi T. Decreased haptoglobin levels inversely correlated with pulmonary artery pressure in patients with pulmonary arterial hypertension: A cross-sectional study. Medicine (Baltimore) 2017; 96:e8349. [PMID: 29069014 PMCID: PMC5671847 DOI: 10.1097/md.0000000000008349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We investigated the serum haptoglobin levels in patients with pulmonary arterial hypertension (PAH) based on the hypothesis that haptoglobin levels would reflect subclinical hemolysis due to microangiopathy in pulmonary arterioles.This cross-sectional study included 3 groups of patients attending Hokkaido University Hospital: PAH, chronic thromboembolic pulmonary hypertension (CTEPH), and connective tissue diseases (CTD) without PAH (CTD-non-PAH) group. Serum haptoglobin levels were measured by standardized turbidimetric immunoassay in all patients. Demographic data, laboratory results, right heart catheter, and echocardiographic findings were extracted from the medical records. Decreased haptoglobin levels were defined as below 19 mg/dL based on the 95th percentile of healthy controls.Thirty-five patients in PAH group including 11 with idiopathic PAH (IPAH) and 24 with CTD-associated PAH (CTD-PAH), 27 in CTEPH group, and 32 in CTD-non-PAH group were analyzed. Serum haptoglobin levels in PAH group (median 66 mg/dL) were significantly lower than those in CTEPH group (median 94 mg/dL, P = .03) and CTD-non-PAH group (median 79 mg/dL, P = .03). The prevalence of decreased haptoglobin levels was 26% in PAH group, 15% in CTEPH group, and 6% in CTD-non-PAH group. Serum haptoglobin levels had a significant negative correlation (r = -0.66, P < .001) with mean pulmonary artery pressure in PAH group, particularly in CTD-PAH subgroup (r = -0.74, P < .001), but no correlation in IPAH subgroup (r = -0.52, P = .13) and in CTEPH group (r = -0.17, P = .41). Follow-up cases of CTD-PAH showed lowering pulmonary artery pressure led to normalizing serum haptoglobin levels.Serum haptoglobin levels decreased in PAH patients and inversely correlated with pulmonary artery pressure in CTD-PAH patients, suggesting their potential as a surrogate marker for CTD-PAH.
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Affiliation(s)
- Hiroyuki Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Toshitaka Nakaya
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Michihiro Kono
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Shun Tanimura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Takahiro Sato
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Hiroshi Ohira
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Toshiyuki Bohgaki
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Shinsuke Yasuda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Ichizo Tsujino
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Masaharu Nishimura
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
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Austin C, Burger C, Kane G, Safford R, Blackshear J, Ung R, Ray J, Alsaad A, Alassas K, Shapiro B. High-risk echocardiographic features predict mortality in pulmonary arterial hypertension. Am Heart J 2017. [PMID: 28625373 DOI: 10.1016/j.ahj.2017.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Echocardiography is the most common imaging modality for assessment of the right ventricle in patients with pulmonary arterial hypertension (PAH). Echocardiographic parameters were identified as independent risk factors for mortality in the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) and other PAH cohorts. We sought to identify readily obtained echocardiographic features associated with PAH survival. METHODS AND RESULTS Retrospective analysis of 175 patients with Group 1 was performed. Baseline clinical and laboratory assessment including REVEAL risk criteria were obtained and standard 2-Dimensional and Doppler echocardiography performed at baseline was reviewed. Univariate and multivariate analyses of echocardiographic parameters were performed. Estimated right atrial pressure> 15 mmHg (HR 2.39, P = .02), tricuspid regurgitation ≥ moderate (HR 2.16, P = .04), and presence of pericardial effusion (HR 1.8, P = .05) were identified as independent, high-risk echocardiographic features in PAH. A validation cohort of 677 patients was identified and Kaplan-Meier survival analysis was performed in both cohorts. High-risk echocardiographic features stratified survival curves of both cohorts (P < .01 for all). The presence of 3 high-risk echocardiographic features greatly increased risk of 1-year (RR 4.86) and 3-year (RR 3.35) mortality (P < .05 for both). CONCLUSION Estimated right atrial pressure> 15, tricuspid regurgitation ≥ moderate, and presence of pericardial effusion are high-risk echocardiographic features in PAH. When seen in combination, these features greatly increase risk of mortality in PAH and may lead to more timely enhanced therapy for patients identified as having an increased risk for death.
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Abstract
Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are
leading causes of morbidity and mortality in systemic sclerosis (SSc). As
symptoms are often under-reported in SSc, early screening of ILD and PAH is of
paramount importance, and early treatment may be associated with better clinical
outcomes. Serologies are particularly helpful in identifying patients at risk
for pulmonary involvement. Pulmonary function testing, high-resolution computed
tomography of the chest and echocardiography are important tools in the initial
screening of these patients. Extensive research has also led to an improved
understanding of the mediators involved in the pathogenesis of ILD and PAH. As a
result, there have been significant advances in the development of novel
targeted therapeutics and an increase in the number of early-phase clinical
trials in SSc.
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Affiliation(s)
- Sara R Schoenfeld
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 2C-2100, Boston, MA 02114, USA
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36
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Morrisroe K, Stevens W, Huq M, Prior D, Sahhar J, Ngian GS, Celermajer D, Zochling J, Proudman S, Nikpour M. Survival and quality of life in incident systemic sclerosis-related pulmonary arterial hypertension. Arthritis Res Ther 2017; 19:122. [PMID: 28576149 PMCID: PMC5457656 DOI: 10.1186/s13075-017-1341-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/18/2017] [Indexed: 12/23/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a leading cause of mortality in systemic sclerosis (SSc). We sought to determine survival, predictors of mortality, and health-related quality of life (HRQoL) related to PAH in a large SSc cohort with PAH. Methods We studied consecutive SSc patients with newly diagnosed (incident) World Health Organization (WHO) Group 1 PAH enrolled in a prospective cohort between 2009 and 2015. Survival methods were used to determine age and sex-adjusted standardised mortality ratio (SMR) and years of life lost (YLL), and to identify predictors of mortality. HRQoL was measured using the Short form 36 (SF-36) instrument. Results Among 132 SSc-PAH patients (112 female (85%); mean age 62 ± 11 years), 60 (45.5%) died, with a median (±IQR) survival time from PAH diagnosis of 4.0 (2.2–6.2) years. Median (±IQR) follow up from study enrolment was 3.8 (1.6–5.8) years. The SMR for patients with SSc-PAH was 5.8 (95% CI 4.3–7.8), with YLL of 15.2 years (95% CI 12.3–18.1). Combination PAH therapy had a survival advantage (p < 0.001) compared with monotherapy, as did anticoagulation compared with no anticoagulation (p < 0.003). Furthermore, combination PAH therapy together with anticoagulation had a survival benefit compared with monotherapy with or without anticoagulation and combination therapy without anticoagulation (hazard ratio 0.28, 95% CI 0.1–0.7). Older age at PAH diagnosis (p = 0.03), mild co-existent interstitial lung disease (ILD) (p = 0.01), worse WHO functional class (p = 0.03) and higher mean pulmonary arterial pressure at PAH diagnosis (p = 0.001), and digital ulcers (p = 0.01) were independent predictors of mortality. Conclusions Despite the significant benefits conferred by advanced PAH therapies suggested in this study, the median survival in SSc PAH remains short at only 4 years. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1341-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia.,Department of Rheumatology St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia
| | - Molla Huq
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia.,Department of Rheumatology St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia
| | - David Prior
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia
| | - Jo Sahhar
- Monash University and Monash Health, 246 Clayton Road, Clayton, 3168, Victoria, Australia
| | - Gene-Siew Ngian
- Monash University and Monash Health, 246 Clayton Road, Clayton, 3168, Victoria, Australia
| | - David Celermajer
- The University of Sydney at Royal Prince Alfred Hospital, Missenden Road, Camperdown, 2050, NSW, Australia
| | - Jane Zochling
- Department of Rheumatology, Menzies Institute for Medical Research, Hobart, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia. .,Department of Rheumatology St Vincent's Hospital, 41 Victoria Parade, Fitzroy, 3065, Melbourne, Victoria, Australia.
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37
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Zhao J, Wang Q, Liu Y, Tian Z, Guo X, Wang H, Lai J, Huang C, Yang X, Li M, Zeng X. Clinical characteristics and survival of pulmonary arterial hypertension associated with three major connective tissue diseases: A cohort study in China. Int J Cardiol 2017; 236:432-437. [DOI: 10.1016/j.ijcard.2017.01.097] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
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Abstract
Pulmonary arterial hypertension (PAH) is characterized by molecular and pathologic alteration to the pulmonary circulation, resulting in increased pulmonary vascular resistance, right ventricular failure, and eventual death. Pharmacologic treatment of PAH consists of use of a multitude of pulmonary vasodilators, sometimes in combination. PAH has been associated with increased thrombosis and disrupted coagulation and fibrinolysis, making anticoagulation an attractive and frequently employed therapeutic modality. Observational studies have provided some insight into the therapeutic potential of anticoagulation in idiopathic PAH, but there is a distinct lack of well-controlled prospective trials. Due to the conflicting evidence, there is a large amount of heterogeneity in the application of therapeutic anticoagulation in PAH and further well-controlled prospective trials are needed to clarify its role in treating PAH.
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39
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Aithala R, Alex AG, Danda D. Pulmonary hypertension in connective tissue diseases: an update. Int J Rheum Dis 2017; 20:5-24. [PMID: 28205373 DOI: 10.1111/1756-185x.13001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary hypertension (PH) is a relatively commoner complication of systemic sclerosis (SSc) with estimated prevalence ranging between 8% and 12% as compared to much lower figures in other connective tissue diseases (CTD). It is a major cause of morbidity and mortality in CTDs. PH is classified into five major groups. CTD-associated PH belongs to group 1 PH, also known as pulmonary arterial hypertension (PAH). Around 30% of scleroderma-related deaths are due to PAH. Underlying pathogenesis is related to pulmonary vasculopathy involving small vessels. The Evidence-based Detection of Pulmonary Arterial Hypertension in Systemic sclerosis (DETECT) algorithm outperforms the current European Society of Cardiology/European Respiratory Society guidelines as a screening tool in SSc-PAH; it can, therefore, suggest when to refer a patient for right heart catheterization. CTD-PAH patients constitute at least 20% of patients included in all major trials of PH-specific therapy and the results are comparable to those of idiopathic PAH. The role of anticoagulation in CTD-PAH is associated with a high risk-benefit ratio with the caveat of its potential role in those with severe disease. There appears to be no role of immunosuppression in scleroderma-PAH; however, immunosuppressive agents, namely the combination of glucocorticoids and pulse cyclophosphamide / possibly mycophenolate, may result in clinical improvement in a subset of patients with systemic lupus erythematosus and mixed connective tissue disease-related PAH.
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Affiliation(s)
- Ramya Aithala
- Department ofClinical Immunology & Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anoop G Alex
- Department ofCardiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Debashish Danda
- Department ofClinical Immunology & Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India
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40
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Calderone A, Stevens W, Prior D, Nandurkar H, Gabbay E, Proudman SM, Williams T, Celermajer D, Sahhar J, Wong PKK, Thakkar V, Dwyer N, Wrobel J, Chin W, Liew D, Staples M, Buchbinder R, Nikpour M. Multicentre randomised placebo-controlled trial of oral anticoagulation with apixaban in systemic sclerosis-related pulmonary arterial hypertension: the SPHInX study protocol. BMJ Open 2016; 6:e011028. [PMID: 27932335 PMCID: PMC5168661 DOI: 10.1136/bmjopen-2016-011028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a severe and costly multiorgan autoimmune connective tissue disease characterised by vasculopathy and fibrosis. One of the major causes of SSc-related death is pulmonary arterial hypertension (PAH), which develops in 12-15% of patients with SSc and accounts for 30-40% of deaths. In situ thrombosis in the small calibre peripheral pulmonary vessels resulting from endothelial dysfunction and an imbalance of anticoagulant and prothrombotic mediators has been implicated in the complex pathophysiology of SSc-related PAH (SSc-PAH), with international clinical guidelines recommending the use of anticoagulants for some types of PAH, such as idiopathic PAH. However, anticoagulation has not become part of standard clinical care for patients with SSc-PAH as only observational evidence exists to support its use. Therefore, we present the rationale and methodology of a phase III randomised controlled trial (RCT) to evaluate the efficacy, safety and cost-effectiveness of anticoagulation in SSc-PAH. METHODS AND ANALYSIS This Australian multicentre RCT will compare 2.5 mg apixaban with placebo, in parallel treatment groups randomised in a 1:1 ratio, both administered twice daily for 3 years as adjunct therapy to stable oral PAH therapy. The composite primary outcome measure will be the time to death or clinical worsening of PAH. Secondary outcomes will include functional capacity, health-related quality of life measures and adverse events. A cost-effectiveness analysis of anticoagulation versus placebo will also be undertaken. ETHICS AND DISSEMINATION Ethical approval for this RCT has been granted by the Human Research Ethics Committees of all participating centres. An independent data safety monitoring board will review safety and tolerability data for the duration of the trial. The findings of this RCT are to be published in open access journals. TRIAL REGISTRATION NUMBER ACTRN12614000418673, Pre-results.
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Affiliation(s)
- Alicia Calderone
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Harshal Nandurkar
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eli Gabbay
- The University of Notre Dame, Fremantle, Western Australia, Australia
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
- University of Adelaide Discipline of Medicine at Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
| | - Trevor Williams
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Monash University, Prahran, Victoria, Australia
| | - David Celermajer
- Department of Cardiology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health and Monash University, Clayton, Victoria, Australia
| | - Peter K K Wong
- Mid-North Coast Arthritis Clinic, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, Rural Clinical School, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Nathan Dwyer
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Weng Chin
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Margaret Staples
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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41
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Preston IR, Roberts KE, Miller DP, Sen GP, Selej M, Benton WW, Hill NS, Farber HW. Response to Letter Regarding Article, "Effect of Warfarin Treatment on Survival of Patients With Pulmonary Arterial Hypertension (PAH) in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL)". Circulation 2016; 133:e662. [PMID: 27185031 DOI: 10.1161/circulationaha.116.022321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Mona Selej
- Actelion Pharmaceuticals US Inc South San Francisco, CA
| | - Wade W Benton
- Actelion Pharmaceuticals US Inc South San Francisco, CA
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42
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Current Approaches to the Treatment of Systemic-Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH). Curr Rheumatol Rep 2016; 18:10. [PMID: 26841964 DOI: 10.1007/s11926-015-0560-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe condition causing significant morbidity and mortality in patients with systemic sclerosis (SSc). Despite the use of specific treatments, SSc-PAH survival remains poorer than in idiopathic PAH (IPAH). Recent therapeutic advances in PAH show a lower magnitude of response in SSc-PAH and a higher risk of adverse events, as compared to IPAH. The multifaceted underlying mechanisms and the multisystem nature of SSc probably explain part of the worse outcomes in SSc-PAH compared to IPAH. This review describes the current management of SSc-PAH with an emphasis on the impact of the different organ involvements in the prognosis and treatment response. An earlier detection of PAH and a better characterization of the clinical phenotypes of SSc-PAH are warranted in clinical practice and future trials. Determinants of prognosis, surrogate markers of clinical improvement or worsening, and relevance of the common endpoints used in clinical trials should be evaluated in this specific population. A multidisciplinary approach in expert referral centers is mandatory for SSc-PAH management.
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43
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Thakkar V, Lau EMT. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol 2016; 30:22-38. [PMID: 27421214 DOI: 10.1016/j.berh.2016.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/12/2016] [Accepted: 03/29/2016] [Indexed: 01/05/2023]
Abstract
Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH.
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Affiliation(s)
- Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Ingham Institute, Liverpool, Australia.
| | - Edmund M T Lau
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Camperdown, Australia.
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44
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Cirulis MM, Ryan JJ. Where do we go from here? Reappraising the data on anticoagulation in pulmonary arterial hypertension. J Thorac Dis 2016; 8:E298-304. [PMID: 27162687 PMCID: PMC4842822 DOI: 10.21037/jtd.2016.03.67] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 03/02/2016] [Indexed: 01/24/2023]
Abstract
The use of anticoagulation as part of the treatment regimen in pulmonary arterial hypertension (PAH) remains a topic of debate. A recently published analysis of anticoagulation use in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) study offers conflicting conclusions regarding the benefit of this therapeutic strategy. There remains no robust randomized trial in PAH weighing the risks versus benefits of including anticoagulation in treatment regimens, leaving clinicians to surmise value in individual patients. Reexamination of available data may help to provide guidance on this controversial topic in the absence of future dedicated investigations.
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Affiliation(s)
- Meghan M Cirulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
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45
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Monfredi O, Heward E, Griffiths L, Condliffe R, Mahadevan VS. Effect of dual pulmonary vasodilator therapy in pulmonary arterial hypertension associated with congenital heart disease: a retrospective analysis. Open Heart 2016; 3:e000399. [PMID: 27099763 PMCID: PMC4836289 DOI: 10.1136/openhrt-2016-000399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/24/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients with pulmonary arterial hypertension (PAH) are managed according to evidence-based treatment guidelines. METHODS AND RESULTS In this single-centre retrospective analysis, we examined outcomes of patients with PAH caused by congenital heart disease (PAH-CHD) with respect to exercise capacity and survival of adults treated with either bosentan or sildenafil monotherapy or bosentan-sildenafil dual therapy between January 2007 and January 2014. Of the 82 patients analysed, 29 had Down syndrome; 54 (65.8%) received bosentan monotherapy, 16 (19.5%) sildenafil monotherapy and 12 (14.6%) dual therapy. Mean treatment duration was 2.5 years for all patients and 4.1 years for 38 patients treated for ≥2 years. Pooled patient and treatment data showed initial improvement followed by stabilisation in mean 6 min walk distance (6MWD). For Down and non-Down patients, mean 6MWD increased and then stabilised on bosentan monotherapy. Mean 6MWD of patients on dual therapy at the time of analysis was 246.3 m before PAH-specific therapy initiation, 211.9 m immediately prior to addition of a second therapy and 214.4 m at last visit while on dual therapy. 1, 2 and 3-year survival rates for all patients from time of treatment initiation were 96%, 87% and 80%, respectively. CONCLUSIONS For the majority of patients, monotherapy with a PAH-specific medication provided improved and sustained exercise benefits. For the small percentage of patients who required it, add-on therapy appeared to prevent further deterioration in exercise capacity but did not improve 6MWD.
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Affiliation(s)
- Oliver Monfredi
- University of Manchester, Institute of Cardiovascular Sciences, Manchester, UK; Manchester Heart Centre, Manchester Royal Infirmary, UK; Laboratory of Cardiovascular Science, National Institute on Aging-Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
| | - Elliot Heward
- University of Manchester, Institute of Cardiovascular Sciences , Manchester , UK
| | | | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit , Royal Hallamshire Hospital , Sheffield , UK
| | - Vaikom S Mahadevan
- University of Manchester, Institute of Cardiovascular Sciences, Manchester, UK; Manchester Heart Centre, Manchester Royal Infirmary, UK; Heart and Vascular Center, University of California, San Francisco, California, USA
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Sitbon O, Sattler C, Bertoletti L, Savale L, Cottin V, Jaïs X, De Groote P, Chaouat A, Chabannes C, Bergot E, Bouvaist H, Dauphin C, Bourdin A, Bauer F, Montani D, Humbert M, Simonneau G. Initial dual oral combination therapy in pulmonary arterial hypertension. Eur Respir J 2016; 47:1727-36. [DOI: 10.1183/13993003.02043-2015] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/22/2016] [Indexed: 11/05/2022]
Abstract
Treatment for pulmonary arterial hypertension (PAH) has been underpinned by single-agent therapy to which concomitant drugs are added sequentially when pre-defined treatment goals are not met.This retrospective analysis of real-world clinical data in 97 patients with newly diagnosed PAH (86% in New York Heart Association functional class III−IV) explored initial dual oral combination treatment with bosentan plus sildenafil (n=61), bosentan plus tadalafil (n=17), ambrisentan plus tadalafil (n=11) or ambrisentan plus sildenafil (n=8).All regimens were associated with significant improvements in functional class, exercise capacity, dyspnoea and haemodynamic indices after 4 months of therapy. Over a median follow-up period of 30 months, 75 (82%) patients were still alive, 53 (71%) of whom received only dual oral combination therapy. Overall survival rates were 97%, 94% and 83% at 1, 2 and 3 years, respectively, and 96%, 94% and 84%, respectively, for the patients with idiopathic PAH, heritable PAH and anorexigen-induced PAH. Expected survival rates calculated from the French equation for the latter were 86%, 75% and 66% at 1, 2 and 3 years, respectively.Initial combination of oral PAH-targeted medications may offer clinical benefits, especially in PAH patients with severe haemodynamic impairment.
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Qian J, Wang Y, Huang C, Yang X, Zhao J, Wang Q, Tian Z, Li M, Zeng X. Survival and prognostic factors of systemic lupus erythematosus-associated pulmonary arterial hypertension: A PRISMA-compliant systematic review and meta-analysis. Autoimmun Rev 2016; 15:250-7. [DOI: 10.1016/j.autrev.2015.11.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/24/2015] [Indexed: 12/21/2022]
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Sobanski V, Giovannelli J, Lynch BM, Schreiber BE, Nihtyanova SI, Harvey J, Handler CE, Denton CP, Coghlan JG. Characteristics and Survival of Anti-U1 RNP Antibody-Positive Patients With Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Arthritis Rheumatol 2016; 68:484-93. [DOI: 10.1002/art.39432] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 09/08/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Vincent Sobanski
- Royal Free Hospital and University College London, London, UK, and Université de Lille, Centre National de Référence de la Sclérodermie Systémique, Hôpital Claude Huriez, EA2686, INSERM U995, Lille Inflammation Research International Centre, and Fédération Hospitalo-Universitaire Immune-Mediated Inflammatory Diseases and Targeted Therapies (IMMINeNT); Lille France
| | - Jonathan Giovannelli
- Université de Lille, Fédération Hospitalo-Universitaire IMMINeNT, and Centre Hospitalier Régional Universitaire de Lille; Lille France
| | | | | | | | - Jennifer Harvey
- Royal Free Hospital and University College London; London UK
| | | | | | - John G. Coghlan
- Royal Free Hospital and University College London; London UK
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Anticoagulation in patients with pulmonary arterial hypertension: An update on current knowledge. J Heart Lung Transplant 2015; 35:151-64. [PMID: 26527532 DOI: 10.1016/j.healun.2015.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/05/2015] [Accepted: 10/01/2015] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is a severe clinical condition characterized by molecular and anatomic changes in pulmonary circulation. It is associated with increased pulmonary vascular resistance, which leads to right-sided heart failure if left untreated and, ultimately, death. Treatment of patients with pulmonary arterial hypertension (PAH) involves a complex strategy that takes into consideration disease severity, general and supportive measures, and combination drug regimens. Abnormalities of blood coagulation factors, anti-thrombotic factors, and the fibrinolytic system may contribute to a prothrombotic state in patients with idiopathic PAH. These physiologic changes, in concert with the presence of non-specific risk factors for venous thromboembolism such as heart failure and immobility, are thought to be the basis for oral anticoagulation in PAH. Several observational studies provide helpful information in favor of anticoagulation use in idiopathic PAH but not in other pulmonary hypertension etiologies. Guideline recommendations are based on the lack of prospective comparative trials in this regard. For that reason, large differences exist in the use of anticoagulants in different countries and centers. More studies should be carried out to clarify the risks and the potential benefits of anticoagulant use in a heterogeneous population of patients who are already at considerable life risk.
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Kang KY, Jeon CH, Choi SJ, Yoon BY, Choi CB, Lee CH, Suh CH, Lee CW, Cho CS, Nam EJ, Koh EM, Kim HY, Choi HJ, Kim HA, Jun JB, Lee J, Kim J, Ji JD, Min JK, Kim KJ, Shin K, So MW, Kwon SR, Kim SK, Nah SS, Kwok SK, Lee SK, Lee SW, Park SH, Park W, Park YB, Lee YH, Lee SS, Yoo DH. Survival and prognostic factors in patients with connective tissue disease-associated pulmonary hypertension diagnosed by echocardiography: results from a Korean nationwide registry. Int J Rheum Dis 2015. [PMID: 26214170 DOI: 10.1111/1756-185x.12645] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). The survival rates and mortality-predictive factors of a nationwide registry of Korean patients with CTD-PH measured by echocardiography were determined. METHODS Patients with CTD-PH were enrolled between April 2008 and December 2012. Hemodynamic parameters and clinical data (WHO-functional class [FC], organ involvement, laboratory tests and treatment agents) were recorded. Survival rates were calculated by using the Kaplan-Meier method. Mortality-associated factors were examined by Cox proportional hazards regression analysis. RESULTS In total, 174 incident PH cases (61 with systemic lupus erythematosus, 50 with systemic sclerosis, 10 with mixed CTD, 22 with rheumatoid arthritis (RA) and 31 with other CTDs) were diagnosed by Doppler echocardiography. Of these, 25 (14%) died during the 3.8 ± 2.7 year follow-up period after PH diagnosis. The 1- and 3-year survival rates were 90.7% and 87.3%, respectively. Compared to the other CTD-PHs, RA-PH had the lowest survival rates (56% 3 year survival; P = 0.022). Multiple regression analysis revealed that low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were poor prognostic factors (P = 0.008, 0.04 and 0.009, respectively). Anti-UI-RNP (ribonucleoprotein) antibody positivity was protective (P = 0.022). In patients with WHO-FC III/IV, patients who received vasodilators had lower mortality than those who did not (P = 0.038). CONCLUSIONS In Korean patients with CTD-PH, the 3-year survival rate was 87%. Low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were independent poor prognostic factors. Anti-UI-RNP antibody was protective. Prompt PAH-specific vasodilator therapy may improve the survival of patients with severe CTD-PH.
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Affiliation(s)
- Kwi Young Kang
- Department of Internal Medicine, Incheon Saint Mary's Hospital, Catholic University of Korea, Incheon, Korea
| | - Chan Hong Jeon
- Department of Internal Medicine, Hospital Bucheon, Soonchunhyang University, Bucheon, Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Bo Young Yoon
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chan-Bum Choi
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Chang Hoon Lee
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Choong Won Lee
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Chul Soo Cho
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eon Jeong Nam
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eun-Mi Koh
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Ho-Youn Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Bum Jun
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jaejoon Lee
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jinseok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Dae Ji
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Jun Ki Min
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Jo Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kichul Shin
- Department of Internal Medicine, Borame Hospital, Seoul National University, Seoul, Korea
| | - Min Wook So
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Ryul Kwon
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Seong-Kyu Kim
- Department of Internal Medicine, Catholic University of Daegu, Daegu, Korea
| | - Seong-Su Nah
- Department of Internal Medicine, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Kon Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, Dong-A University, Pusan, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Park
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Yong-Beom Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School, Kwangju, Korea
| | - Dae Hyun Yoo
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
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