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Gialamas I, Arvanitaki A, Rosenkranz S, Wort SJ, Rådegran G, Badagliacca R, Giannakoulas G. The impact of cardiovascular and lung comorbidities in patients with pulmonary arterial hypertension: A systematic review and meta-analysis. J Heart Lung Transplant 2024; 43:1383-1394. [PMID: 38744353 DOI: 10.1016/j.healun.2024.04.066] [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: 01/15/2024] [Revised: 04/14/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Contemporary patients with pulmonary arterial hypertension (PAH) are older and exhibit cardiovascular or/and lung comorbidities. Such patients have typically been excluded from major PAH drug trials. This systematic review compares baseline characteristics, hemodynamic parameters, and mortality rate between PAH patients with significant number of comorbidities compared to those with fewer or no comorbidities. ΜETHODS: A systematic literature search in PubMed, Web of Science, and Cochrane databases was conducted searching for studies comparing PAH patients with more than 2 cardiovascular comorbidities or/and at least a lung comorbidity against those with fewer comorbidities. RESULTS Seven observational studies were included. PAH patients with comorbidities were older, with an almost equal female-to-male ratio, shorter 6-minute walk distance, higher N-terminal pro-brain natriuretic peptide levels, and lower lung diffusion for carbon monoxide. In terms of hemodynamics, they had higher mean right atrial pressure and pulmonary artery wedge pressure, lower mean pulmonary arterial pressure, pulmonary vascular resistance and mixed venous oxygen saturation. Pooled analysis of 6 studies demonstrated a higher mortality risk for PAH patients with comorbidities compared to those without (HR 1.86, 95% CI 1.20 to 2.89, p < 0.001, I²=92%), with the subgroup of PAH patients with lung comorbidities having an even higher mortality risk (test for subgroup differences: p < 0.001). Combination drug therapy for PAH was less frequently used in patients with comorbidities. CONCLUSIONS Cardiovascular and lung comorbidities impact the clinical characteristics and outcomes of PAH patients, highlighting the need for optimal phenotyping and tailored management for this high-risk population.
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Affiliation(s)
- Ioannis Gialamas
- Third Department of Cardiology, National and Kapodistrian University of Athens, Sotiria Chest Disease Hospital, Athens, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; National Pulmonary Hypertension Service, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Department of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - S John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Göran Rådegran
- Department of Clinical Sciences Lund, The Section for Cardiology, Lund University, Lund, Sweden; The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Goncharova N, Lapshin K, Berezina A, Simakova M, Marichev A, Zlobina I, Marukyan N, Malikov K, Aseeva A, Zaitsev V, Moiseeva O. Elderly Patients with Idiopathic Pulmonary Hypertension: Clinical Characteristics, Survival, and Risk Stratification in a Single-Center Prospective Registry. Life (Basel) 2024; 14:259. [PMID: 38398770 PMCID: PMC10890450 DOI: 10.3390/life14020259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION The predictive value of the risk stratification scales in elderly patients with IPAH might differ from that in younger patients. It is unknown whether young and older IPAH patients have the same survival dependence on PAH-specific therapy numbers. The aim of this study was to evaluate the prognostic relevance of risk stratification scales and PAH medication numbers in elderly IPAH patients in comparison with young IPAH patients. MATERIALS AND METHODS A total of 119 patients from a prospective single-center PAH registry were divided into group I < 60 years old (n = 89) and group II ≥ 60 years old (n = 30). ESC/ERS, REVEAL, and REVEAL 2.0 risk stratification scores were assessed at baseline, as well as H2FpEF score and survival at follow-up. RESULTS During a mean follow-up period of 2.9 years (1.63; 6.0), 42 (35.3%) patients died; at 1, 2, 3, 5, 7, and 10 years, survival was 95%, 88.6%, 78.5%, 61.7%, 48.5%, and 33.7%, respectively. No survival differences were observed between the two groups, despite the use of monotherapy in the elderly patients. The best predictive REVEAL value in elderly patients (IPAH patients ≥ 60 years) was AUC 0.73 (0.56-0.91), p = 0.03; and in patients with LHD comorbidities in the entire cohort, it was AUC 0.73 (0.59-0.87), p < 0.009. Factors independently associated with death in the entire cohort were CKD (p = 0.01, HR 0.2), the right-to-left ventricle dimension ratio (p = 0.0047, HR 5.97), and NT-proBNP > 1400 pg/mL (p = 0.008, HR 3.18). CONCLUSION Risk stratification in the elderly IPAH patients requires a fundamentally different approach than that of younger patients, taking into account the initial limitations in physical performance and comorbidities that interfere with current assessment scores. The REVEAL score reliably stratifies patients at any age and LHD comorbidities. The initial monotherapy seems to be reasonable in patients over 60 years. Selection tools for initial combination PAH therapy in older IPAH patients with comorbidities need to be validated in prospective observational studies.
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Affiliation(s)
- Natalia Goncharova
- Almazov National Medical Research Centre, Ministry of Health of Russia, Saint Petersburg 197341, Russia (A.B.); (A.M.); (I.Z.); (N.M.); (K.M.); (A.A.); (V.Z.); (O.M.)
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension (PH) is a common complication of chronic obstructive lung disease (COPD), but clinical presentation is variable and not always 'proportional' to the severity of the obstructive disease. This review aims to analyze heterogeneity in clinical features of PH-COPD, providing a guide for diagnosis and management according to phenotypes. RECENT FINDINGS Recent works have focused on severe PH in COPD, providing insights into the characteristics of patients with predominantly vascular disease. The recently recognized 'pulmonary vascular phenotype', characterized by severe PH and mild airflow obstruction with severe hypoxemia, has markedly worse prognosis and may be a candidate for large trials with pulmonary vasodilators. In severe PH, which might be best described by a pulmonary vascular resistance threshold, there may also be a need to distinguish patients with mild COPD (pulmonary vascular phenotype) from those with severe COPD ('Severe COPD-Severe PH' phenotype). SUMMARY Correct phenotyping is key to appropriate management of PH associated with COPD. The lack of evidence regarding the use of pulmonary vasodilators in PH-COPD may be due to the existence of previously unrecognized phenotypes with different responses to therapy. This review offers the clinician caring for patients with COPD and PH a phenotype-focused approach to diagnosis and management, aimed at personalized care.
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Affiliation(s)
| | - Lucilla Piccari
- Department of Pulmonary Medicine, Hospital del Mar, Barcelona, Spain
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Stubbe B, Halank M, Seyfarth HJ, Obst A, Desole S, Opitz CF, Ewert R. [Risk Stratification in Patients with Pulmonary Arterial Hypertension under Treatment - Results of Four German Centers]. Pneumologie 2022; 76:330-339. [PMID: 35373311 DOI: 10.1055/a-1740-3377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). According to the current European guidelines the expected 1-year risk of mortality for PAH patients can be categorized as low, intermediate, or high, based on clinical, non-invasive and hemodynamic data.Data from 131 patients with incident PAH (age 64 ± 14) and frequent comorbidities (in 66.4 %) treated between 2016 and 2018 at 4 German PH centers were analyzed. At baseline, most patients were classified as intermediate risk (76 %), 13.8 % as high risk and only 9.9 % as low risk.During follow-up while on treatment after 12 ± 3 months (range 9-16 months) 64.9 % were still classified as intermediate risk (76 %), 14.4 % as high risk and 20.7 % as low risk.Survival at 12 and 24 months was 96 % and 82 % in the intermediate risk group, while only 89 % and 51 % of the high risk patients were alive at these time points. In contrast, all patients in the low risk category were alive at 24 months.Despite the availability of various treatment options for patients with PAH even in specialized centers only a minority of patients can be stabilized in the low risk group associated with a good outcome.
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Affiliation(s)
- Beate Stubbe
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | | | - Anne Obst
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | - Susanna Desole
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
| | | | - Ralf Ewert
- University Medicine Greifswald, Internal Medicine B, Pneumology, Greifswald
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Sun X, Chen R, Yao X, Zheng Z, Wang M, Wang C, Cheng J. Treatment of Pulmonary Hypertension: Is Triple Therapy Necessarily Better than Monotherapy? Am J Respir Crit Care Med 2021; 204:1492-1493. [PMID: 34672866 PMCID: PMC8865714 DOI: 10.1164/rccm.202108-1965le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Xishi Sun
- Affiliated Hospital of Guangdong Medical University Zhanjiang, China.,The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Riken Chen
- The First Affiliated Hospital of Guangzhou Medical University Guangzhou, China.,State Key Laboratory of Respiratory Disease Guangzhou, China.,Guangzhou Institute of Respiratory Disease Guangzhou, China
| | - Xiaoyun Yao
- Central Hospital of Guangdong Nongken Zhanjiang, China
| | - Zhenzhen Zheng
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Manxia Wang
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Chaoyu Wang
- Taishan Hospital of Traditional Chinese Medicine Jiangmen, China
| | - Junfen Cheng
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
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Boucly A, Weatherald J, Savale L, Jaïs X, Montani D, Humbert M, Sitbon O. Reply to Jin et al. and to Sun et al.. Am J Respir Crit Care Med 2021; 204:1494-1495. [PMID: 34672868 PMCID: PMC8865711 DOI: 10.1164/rccm.202107-1725le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | | | - Laurent Savale
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Xavier Jaïs
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Marc Humbert
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
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