Guidelines for the Treatment of Pulmonary Hypertension (JCS 2017/JPCPHS 2017)

Insights into balloon pulmonary angioplasty and the WHO functional class of chronic thromboembolic pulmonary hypertension patients: findings from the CTEPH AC registry

Advances in chronic thromboembolic pulmonary hypertension (CTEPH) treatment have improved prognosis, shifting focus towards symptom management. This study aimed to identify factors influencing the World Health Organization functional class (WHO-FC) in CTEPH patients. The CTEPH AC registry is a prospective, multicenter database from 35 Japanese institutions, analyzing data from August 2018 to July 2023. We examined factors associated with achieving WHO-FC I and WHO-FC changes over time in 1,270 patients. Significant factors for WHO-FC I achievement included male sex (odds ratio: 1.86, p = 0.019), age (0.98, p = 0.007), pulmonary vasodilator use (0.51, p = 0.001), post-balloon pulmonary angioplasty (BPA) (1.93, p = 0.010), lower mean pulmonary arterial pressure (0.94, p = 0.004), and lower pulmonary vascular resistance (PVR) (0.78, p = 0.006). Multivariate analysis showed that WHO-FC improvement correlated with male sex, baseline PVR, and BPA during follow-up. WHO-FC deterioration was associated with cancer, history of pulmonary endarterectomy and/or BPA at registration, bleeding risks, and thyroid disease or hormone therapy. BPA implementation is closely linked to symptomatic improvement and achieving WHO-FC I, while symptom worsening is often associated with patient-specific, difficult-to-control conditions.

Utility of liver stiffness for the classification of portopulmonary hypertension in precapillary pulmonary hypertension

BACKGROUND

Invasive right heart catheterization plays a central role in identifying pulmonary hypertension (PH) disorders. However, non-invasive biomarkers of portopulmonary hypertension (PoPH) are required. Liver stiffness evaluated by FibroScan® is useful for the assessment of liver fibrosis in patients with chronic liver diseases. This study sought to investigate the utility of liver stiffness for the classification of PoPH among precapillary PH patients.

METHODS

A total of 46 patients [38 females, median (interquartile range) age 63.0 (50.8-72.0) years old] with precapillary PH were divided into a PoPH group (N = 6) and a non-PoPH group (N = 40) based on the presence of portosystemic shunts and/or portal hypertension with hepatic venous pressure gradient >5 mmHg.

RESULTS

The PoPH group showed higher cardiac index and lower pulmonary vascular resistance than the non-PoPH group. Other hemodynamic variables and liver fibrosis biomarkers such as fibrosis-4 index and albumin-bilirubin score were comparable between the 2 groups. Liver stiffness measurements in the PoPH group were significantly higher than those in the non-PoPH group [12.8 kPa (9.4-17.3 kPa) vs 4.15 kPa (3.30-5.50 kPa), p < 0.001]. The cut-off value for the classification of PoPH was 8.50 kPa from the receiver operating characteristic curve (area under curve 0.979, 95 % Confidence interval 8.50 kPa - 11.00 kPa).

CONCLUSIONS

Liver stiffness evaluated by transient elastography may be a non-invasive biomarker to detect the liver status that caused PoPH among precapillary PH patients.

Diagnostic Delays and Quality of Life in Japanese Patients with Pulmonary Hypertension: A Nationwide Survey

INTRODUCTION

Pulmonary hypertension (PH) is a rare and severe disorder that significantly affects patients' lives. However, a comprehensive picture of the diagnosis and treatment of this condition in Japan remains unclear. This study aimed to elucidate these aspects by conducting a nationwide survey targeting patients with PH and treating physicians.

METHODS

A cross-sectional survey was conducted among 160 patients with PH (119 with pulmonary arterial hypertension [PAH] and 41 with chronic thromboembolic pulmonary hypertension [CTEPH]), of whom 121 were female (75.6%), and 211 physicians across Japan. The questionnaires assessed patients' diagnostic journey, employment status, communication with physicians regarding treatment goals, health-related quality of life (HRQoL), and medication adherence.

RESULTS

Patients visited a mean of 2.3 medical facilities before receiving a PH diagnosis (PAH patients: 2.2 visits; CTEPH patients: 2.3 visits), with a mean time from symptom onset to diagnosis of 18.0 months (PAH: 20.2 months; CTEPH: 12.2 months). Employment and school attendance rates declined from 68.8% before diagnosis to 44.4% immediately after diagnosis, and further to 36.9% at the time of the survey. Discrepancies in communication about treatment goals were observed between patients and physicians, particularly in patients with CTEPH (82.9% of patients reported such discussions vs. 41.2% of treating physicians). Median HRQoL scores, as assessed by the emPHasis-10 questionnaire, indicated impairment (PAH: 21.5; CTEPH: 18.0), which worsened with increasing disease severity.

CONCLUSION

This nationwide study provides a comprehensive overview of the challenges faced by patients with PH in Japan. The findings suggest the essential need for earlier diagnosis, support for employment and education among patients, and improved patient-physician communication to reduce the burden of PH and enhance patient outcomes. Graphical abstract avaliable for this article.

Reduced hemoglobin-corrected diffusing capacity in pulmonary arterial hypertension with preserved pulmonary function and morphology

BACKGROUND

The diffusing capacity and the transfer coefficient of the lung for carbon monoxide (DLCO and KCO, respectively) are reduced in pulmonary arterial hypertension; however, the effect of pulmonary arterial hypertension alone on these parameters and their clinical impact remain unclear. We aimed to elucidate the exclusive impact of pulmonary arterial hypertension on these two parameters and examine their association with other parameters.

METHODS

We retrospectively selected patients with pulmonary arterial hypertension with normal pulmonary function upon pulmonary function testing and with normal lung parenchyma upon chest computed tomography. We calculated the hemoglobin-corrected DLCO (DLCO-Hbc) and KCO (KCO-Hbc) and examined their association with established pulmonary hypertension-related parameters. An exploratory analysis of pulmonary vasculopathy was performed in an autopsy case.

RESULTS

We included 50 patients with pulmonary arterial hypertension for analysis. Their median %DLCO-Hbc and %KCO-Hbc were 62 % and 70 %, respectively. The DLCO-Hbc was associated with functional class, 6-min walk distance, alveolar-arterial oxygen tension difference, cardiac output, and pulmonary arterial hypertension-related death. The DLCO-Hbc and KCO-Hbc were also correlated with the lowest minute ventilation/carbon dioxide production ratio (ρ = -0.84 and -0.49, respectively), an index that represents ventilation-perfusion mismatch. The autopsy revealed pulmonary arterial hypertension-specific arteriopathy that was heterogeneously distributed in the lungs.

CONCLUSIONS

The DLCO-Hbc and KCO-Hbc were reduced to 60 %-70 % in patients with pulmonary arterial hypertension even when their pulmonary function and morphology were preserved. The decreases were associated with pulmonary hypertension-related clinical parameters and survival and may be caused by heterogeneous vasculopathy and subsequent ventilation-perfusion mismatch.

An overview of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe and progressive condition caused by unresolved pulmonary arterial obstructions, leading to secondary microvasculopathy and poor hemodynamics. Pulmonary endarterectomy (PEA) is the first-line treatment for operable patients. Balloon pulmonary angioplasty (BPA) has emerged as a promising treatment option for patients considered inoperable due to distal lesions, comorbidities, or residual pulmonary hypertension (PH) after PEA. Following the development of the BPA in safety and efficacy, it has been widely adopted and utilized across the globe.

AREAS COVERED

This review covers the historical development of BPA, its clinical role, and technical methodologies. Medical therapies as an adjunctive role in CTEPH management are also discussed. Finally, we present recent BPA experiences from our institution, highlighting hemodynamic outcomes and survival rates.

EXPERT OPINION

BPA is a transformative treatment for patients with CTEPH, particularly those ineligible for PEA. Procedural refinements have significantly improved safety and efficacy. However, challenges remain, including the standardization of decision-making processes for management and the establishment of optimal treatment goals. Ongoing research continues to refine the role of BPA to improve outcomes and enhance the quality of life for patients with CTEPH. [Figure: see text].

Preference for advance care planning in patients with pulmonary hypertension

Implementing advance care planning (ACP) is recommended in clinical guidelines. However, in pulmonary hypertension, patients' preference toward ACP remains unclear. We aimed to elucidate the preference of patients with pulmonary hypertension for ACP conversations and the association of ACP with important patient factors underlying treatment decision-making. We conducted a cross-sectional questionnaire-based study, assessing patients' preferred and actual participation in ACP conversations, as well as important patient factors underlying their treatment decision-making (including prognosis; patient values; physician recommendation; and symptom, financial, family, and social burdens). Univariate logistic regression analysis was conducted to identify patients with positive attitudes toward ACP conversations. Of 133 patients with pulmonary hypertension (median age, 60 years; mean pulmonary arterial pressure, 23 mmHg; female, 71.4%), 78.2% recognized the importance of ACP conversations. Regarding the patients' perception of appropriate ACP timing, 37.8% chose after repeated hospitalizations for worsening pulmonary hypertension and 22.4% chose during readmission for worsening pulmonary hypertension. Among these, 40.8% engaged in ACP conversations. A positive attitude toward ACP conversations was associated with marital status (married), having children, better oxygenation, and patients' preference toward physician recommendations in pulmonary hypertension treatment decision-making, but not with age, pulmonary hypertension etiology, or other patient preferences in treatment decision-making. Most patients with pulmonary hypertension preferred ACP conversations. A positive attitude toward ACP was associated with patients' preference toward physicians' recommendations in pulmonary hypertension treatment decision-making. Further research is required to establish an appropriate ACP approach that aligns with patient preference and physician recommendations for this patient population.

Assessment of Riociguat-related adverse events: a disproportionality analysis utilizing the FDA adverse event reporting system database

BACKGROUND

Riociguat is a novel soluble guanylate cyclase stimulator approved for the treatment of pulmonary arterial hypertension (PAH). Despite its widespread use, there has been a lack of large-scale studies assessing the adverse events (AEs) associated with this medication.

RESEARCH DESIGN AND METHODS

This study aimed to evaluate the AEs related to Riociguat by analyzing data from the FDA Adverse Event Reporting System (FAERS) from Q4 2013 to Q1 2024. A total of 12,149 AE reports were analyzed using four different disproportionality signal detection methodologies to identify significant AEs associated with Riociguat.

RESULTS

The analysis revealed 117 preferred terms (PTs) with significant disproportionality signals across all four methods. Among these, common AEs included 'headache,' 'dizziness,' 'hypotension,' 'nausea,' 'fall,' and 'loss of consciousness.' Notably, several unexpected AEs, such as 'fatigue,' 'malaise,' 'asthenia,' 'feeling abnormal,' and 'pain in extremity,' were identified, which were not highlighted in the product's package insert. Additionally, gender-specific differences were observed in certain adverse events.

CONCLUSIONS

This study offers insights into Riociguat's side effects. Clinicians should monitor patients closely for unexpected symptoms like limb pain and fatigue, paying particular attention to male patients, as some AEs occur more frequently in this group.

Safety and Efficacy of Selexipag for Pediatric Pulmonary Arterial Hypertension in Japanese Patients - An Open-Label Phase 2 Study

BACKGROUND

Selexipag, an oral prostacyclin (PGI2) receptor agonist, is approved for adult patients with pulmonary arterial hypertension (PAH). This study evaluated the efficacy and safety of selexipag for Japanese pediatric patients with PAH.

METHODS AND RESULTS

The study enrolled 6 patients who received selexipag twice daily at an individualized dose based on body weight; maintenance doses were determined for each patient by 12 weeks after starting administration. Efficacy, including pulmonary hemodynamics, was evaluated after 16 weeks, and efficacy and safety were further evaluated 52 weeks after treatment was initiated in the last enrolled patient. The mean (±SD) change in the pulmonary vascular resistance index from baseline to Week 16 (the primary endpoint of the study) was -5.55±6.88 Wood units·m2; improvements were also seen in other pulmonary hemodynamic parameters. The 6-min walk distance increased and N-terminal pro-B-type natriuretic peptide decreased up to Week 64, but the between-subject variability was large. The World Health Organization functional class was improved in 1 of 6 patients at Week 16 and in 2 of 4 patients at Week 64. No patient worsened. The major side effects of selexipag were those characteristic of PGI2, and the safety profile of selexipag was similar to that in adult patients.

CONCLUSIONS

The efficacy and safety of selexipag in Japanese pediatric patients with PAH were demonstrated.

Sotatercept: A New Era in Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a progressive disease characterized by proliferative remodeling and obliterative narrowing of the pulmonary vasculature. While outcomes have improved with existing treatments targeting 3 main pathways, there remains a critical need for novel therapies that address different and novel mechanisms of PAH. Sotatercept, recently Food and Drug Administration (FDA) approved, is a groundbreaking fusion protein that binds to activin and growth differentiation factors, rebalancing antiproliferative and pro-proliferative signals to reverse remodeling in both the pulmonary vasculature and the right ventricle. This review highlights current evidence exploring the safety and efficacy of sotatercept in the 2 landmark trials, phase 2 Pulmonary Arterial Hypertension and Sotatercept Trial and Research and phase 3 Sotatercept Treatment in Expansion of Long-term Learning and Assessment in PAH trial, which were instrumental in securing FDA approval for adult PAH patients with WHO functional class II or III symptoms already receiving background pulmonary hypertension therapy. Overall, sotatercept represents a landmark advancement in PAH treatment, offering hope for patients and the potential to delay or avoid lung transplantation. Importantly, this marks the beginning of an era of targeted therapies aimed at reverse remodeling in PAH while improving outcomes.

Clinical Characteristics and Treatment of Patients Diagnosed with Pulmonary Arterial Hypertension: A Real-World Study in the USA, Europe and Japan

INTRODUCTION

This study aimed to describe the clinical characteristics of patients with pulmonary arterial hypertension, treatment received, and factors predicting initial or earlier combination therapy.

METHODS

The Adelphi Real World Pulmonary Arterial Hypertension (PAH) Disease Specific Programme™ is a cross-sectional survey with retrospective data collection conducted in the USA, Europe (France, Germany, Italy, Spain, and the UK), and Japan from March to August 2022. Physicians reported patient characteristics, treatment history, and reasons for treatment selection. Descriptive statistics were grouped by country and World Health Organization functional classification. A multivariable Cox regression analysis investigated factors predicting initial or earlier combination therapy use.

RESULTS

Data for 1173 patients was provided by 293 physicians. Patients' mean (standard deviation) age was 58.7 (13.8) years and 54.6% were female. Overall, 91.2% of patients were receiving, or had previously received, PAH-specific treatment. About three-quarters of the cohort were still taking the initial treatment strategy: for this group, 54% were prescribed monotherapy and 32% combination therapy; 15% of patients received supportive therapy alone. The proportion of patients receiving PAH-specific treatment was lowest in the USA (82.0%) and highest in France (94.6%). The proportion of patients receiving PAH on combination therapy was lowest in the USA (23.8%) and highest in Germany (36.5%). Treatment was prescribed for PAH in 87.6%, 89.8%, 89.3%, and 75.0% of patients who were functional class I, II, III, and IV, respectively, and combination therapy usage was more likely for those with more advanced functional class. Higher risk status, care by a pulmonologist, Japanese residence, more complete assessments, and hospitalization in the past 12 months were statistically associated with decreased time to combination therapy for PAH. Older age was statistically associated with increased time to combination therapy.

CONCLUSION

In this real-world, geographically diverse sample, monotherapy treatment was common, even among patients with advanced disease.

Clonal Hematopoiesis in Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND

The cause of chronic thromboembolic pulmonary hypertension (CTEPH) remains largely unknown. Recently, clonal hematopoiesis (CH) has been reported to be associated with cardiovascular and thromboembolic diseases. Here, we investigated the prevalence and clinical impact of CH in patients with CTEPH.

METHODS AND RESULTS

Whole-exome sequencing and deep-panel sequencing were performed in 214 patients with CTEPH. Clinical data before and after treatment were compared between patients with and without CH. RNA sequencing and serum analysis were performed to explore the pathogenesis that CH contributes to CTEPH. Among the enrolled patients, 20.1%, notably 44.4% who were 80 to 89 years old, had variants in CH-associated genes. In regard to clinical impact, B-type natriuretic peptide levels and home oxygen therapy rate were significantly higher, and 6-minute walk distance was significantly shorter after treatment in patients with CH than in those without CH. Moreover, novel clot reformation in the pulmonary artery despite the use of anticoagulants and additional angioplasty events after treatment completion were more frequent in patients with CH. RNA sequencing analysis revealed that blood coagulation and neutrophil extracellular trap formation pathways were enriched in patients with CH. Additionally, serum citrullinated histone H3 levels were higher in patients with CH than those without CH. These results were consistent in the subgroup of patients who did not have the history of hematological disorders.

CONCLUSIONS

The findings in this study raise the possibility that CH will induce a more prothrombotic state through neutrophil activation and neutrophil extracellular trap formation, contributing to pathogenesis and poor treatment response in patients with CTEPH.

Incidence of Chronic Thromboembolic Pulmonary Hypertension After Pulmonary Embolism in the Era of Direct Oral Anticoagulants: From the COMMAND VTE Registry-2

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication post-acute pulmonary embolism (PE). The assessment of CTEPH incidence and risk factors post-acute PE in the era of direct oral anticoagulants remains insufficient.

METHODS AND RESULTS

The COMMAND VTE Registry-2 (contemporary management and outcomes in patients with venous thromboembolism registry-2) is a multicenter registry that recruited consecutive patients with acute symptomatic venous thromboembolism from 31 centers across Japan. The primary outcome was to demonstrate the detection rate of CTEPH after acute PE in routine clinical practice. Out of the 5197 patients with venous thromboembolism included in the COMMAND VTE Registry-2, 2787 were diagnosed with acute PE. Following a median follow-up duration of 747 days, 48 cases of CTEPH were detected, and the cumulative diagnosis of CTEPH in routine clinical practice was 2.3% at 3 years. Independent risk factors for the detection of CTEPH by multivariable Cox regression analysis included women (hazard ratio [HR] 2.09 [95% CI, 1.05-4.14]), longer interval from symptom onset to diagnosis of PE (each 1 day, HR 1.04 [95% CI, 1.01-1.07]), hypoxemia at diagnosis (HR 2.52 [95% CI, 1.26-5.04]), right heart load (HR 9.28 [95% CI, 3.19-27.00]), lower D-dimer value (each 1 μg/mL, HR 0.96 [95% CI, 0.92-0.99]), and unprovoked PE (HR 2.77 [95% CI, 1.22-6.30]).

CONCLUSIONS

In the direct oral anticoagulant era, the cumulative diagnosis of CTEPH after acute PE was 2.3% at 3 years, and several independent risk factors for CTEPH were identified, which could be useful for screening a high-risk population after acute PE.

Carfilzomib-induced pulmonary hypertension in a patient with multiple myeloma

A 59-year-old female being treated for multiple myeloma (MM) was referred to the Division of Cardiology due to edema and dyspnea. She developed dyspnea on exertion 2 months previously when carfilzomib, a second-generation selective proteasome inhibitor which was approved for treatment of relapsed and refractory MM, was introduced, and facial edema appeared thereafter. The electrocardiogram showed sinus rhythm with T-wave inversion on extensive leads and the chest X-ray showed cardiomegaly. Although cancer therapeutics-related cardiac dysfunction was assumed to be the complication, echocardiogram revealed no evidence of elevated left ventricular filling pressure whereas elevated tricuspid regurgitation velocity (3.2 m/s) with right ventricular systolic dysfunction suggested pre-capillary pulmonary hypertension (PH). Right heart catheterization demonstrated elevated mean pulmonary artery pressure (33 mmHg) along with high pulmonary vascular resistance (11.54 Wood Units) and normal pulmonary capillary wedge pressure (9 mmHg), confirming the echocardiographic findings. After ruling out other causes, PH associated with carfilzomib was diagnosed. Cessation of carfilzomib along with pulmonary vasodilator therapy led to improvement of symptoms and reduction of right heart size along with reduced estimated pulmonary systolic pressure 2 months later. Although carfilzomib-induced PH is rare, we need to consider its possibility when we find PH in patients receiving carfilzomib.

Learning objective

While adverse cardiovascular events are often found in patients with multiple myeloma (MM) after use of carfilzomib, the occurrence of pulmonary hypertension (PH) is reported to be rare. Because temporal association of echocardiographic findings to carfilzomib therapy plays a key role for the diagnosis of drug-associated PH, serial echocardiographic examinations should be performed when we start carfilzomib therapy in refractory MM patients.

Tailoring oral anticoagulant treatment in the era of multi-drug therapies for PAH and CTEPH

The use of oral anticoagulants in the management of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) presents distinct therapeutic challenges and benefits. In PAH, the benefits of oral anticoagulation are uncertain, with studies yielding mixed results on their efficacy and safety. Conversely, oral anticoagulants are a cornerstone in the treatment of CTEPH, where their use is consistently recommended to prevent recurrent thromboembolic events. The choice between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) remains a significant clinical question, as each type presents advantages and potential drawbacks. Furthermore, drug-drug interactions (DDIs) with concomitant PAH and CTEPH treatments complicate anticoagulant management, necessitating careful consideration of individual patient regimens. This review examines the current evidence on oral anticoagulant use in PAH and CTEPH and discusses the implications of DDIs within a context of multi-drug treatments, including targeted drugs in PAH.

An autopsy case of constrictive pericarditis following open chest surgery with severe pulmonary hypertension treated as HFpEF

A 73-year-old man with a history of aortic arch replacement for chronic type B aortic dissective aneurysm was admitted for heart failure. He had normal left ventricular systolic function and had pulmonary hypertension with a pulmonary artery pressure of approximately 90 mmHg. He had been diagnosed with pneumoconiosis from his occupation and pulmonary hypertension due to heart failure with preserved ejection fraction (HFpEF) and respiratory disease. The patient continued to be treated for heart failure but died from pneumonia. An autopsy revealed a finding of full circumferential adhesions of the pericardium and myocardium. The lung had severe pleural adhesions and pulmonary interstitium showed peri bronchial interstitial changes and stasis of blood flow. Mild intimal thickening of the pulmonary vessels was noted. The patient was diagnosed with constrictive pericarditis mimicking HFpEF due to pericardial adhesion after open chest surgery. Significant pulmonary hypertension was thought to have been brought about by respiratory disease involving pleural adhesions due to surgery, in addition to being due to left heart disease due to constrictive pericarditis.

Learning objectives

1.When we see unexplained heart failure with preserved ejection fraction, we need to search for extra-cardiac causes as well.2.In cases of pulmonary hypertension that cannot be explained by an isolated condition, other complicating conditions must be pursued.

Catheter-based examination for pulmonary microcirculatory function in patients with pulmonary hypertension

A device that can evaluate human pulmonary microcirculation is currently unavailable. This study aimed to establish a novel approach for assessing pulmonary microcirculation in patients with pulmonary hypertension (PH). We used a guidewire embedded with temperature and pressure sensors to measure the following pulmonary microcirculatory function indicators: pulmonary flow reserve, pulmonary index of microcirculatory resistance (PIMR), and pulmonary resistive reserve ratio. Adenosine was administered to patients to induce hyperemia in the pulmonary artery for assessment. The correlation between these indicators and various parameters, including serum biomarkers, hemodynamic and respiratory functions, and exercise capacity, were examined. The procedure was performed in 19 patients with moderate PH, without major complications. The minimum effective adenosine dosage for maximal hyperemia, without severe side effects, was 150 μg∙kg-1∙min-1. Multivariate stepwise analysis revealed a positive correlation between the hyperemic PIMR and serum uric acid (p < 0.001) and N-terminal probrain natriuretic peptide levels (p = 0.014). Therefore, this catheter-based method offers an effective means to assess pulmonary microcirculatory function in patients with PH, and the optimal dose of adenosine for this evaluation was 150 μg∙kg-1∙min-1.

Patient characteristics, diagnostic testing, and initial treatment profiles of patients with connective tissue disease-associated pulmonary arterial hypertension using a Japanese claims database

OBJECTIVES

To investigate the diagnostic and therapeutic landscape for patients with connective tissue disease (CTD) and CTD-associated pulmonary arterial hypertension (CTD-PAH) in acute-care general hospitals in Japan.

METHODS

We conducted a retrospective cohort study by analysing the Medical Data Vision (MDV) database from April 2008 to September 2020. CTD patients who prescribed immunosuppressants were included in cohort 1, and CTD-PAH patients extracted from cohort 1 were included in cohort 2. Patient characteristics, diagnostic screening frequencies for PAH, and initial PAH-specific treatment patterns were assessed.

RESULTS

Overall, 16,648 patients with CTD and 81 patients with CTD-PAH were included in cohorts 1 and 2, respectively. The frequencies of screening tests for PAH, including brain natriuretic peptide (BNP), transthoracic echocardiogram (TTE), and 'diffusing capacity' of the 'lungs for carbon monoxide' (DLCO), among CTD patients were 0.7, 0.3, and 0.1 tests/person-year, respectively. The most common initial PAH-specific treatment therapy was monotherapy (87.7%), followed by dual therapy (7.4%) and triple therapy (2.5%).

CONCLUSION

This is the first study to describe the patient flow from PAH diagnosis to initial PAH-specific treatment for real-world patients who were followed regularly due to CTD in Japanese clinical practice.

Comprehensive Risk Assessment in Patients With Pulmonary Arterial Hypertension Referred for Lung Transplantation

BACKGROUND

Whether comprehensive risk assessment predicts post-referral outcome in patients with pulmonary arterial hypertension (PAH) referred for lung transplantation (LT) in Japan is unknown.

METHODS AND RESULTS

We retrospectively analyzed 52 PAH patients referred for LT. Risk status at referral was assessed using 3- and 4-strata models from the 2022 European Society of Cardiology and European Respiratory Society guidelines. The 3-strata model intermediate-risk group was further divided into 2 groups based on the median proportion of low-risk variables (modified risk assessment [MRA]). The primary outcome was post-referral mortality. During follow-up, 9 patients died and 13 patients underwent LT. There was no survival difference among 3-strata model groups. The 4-strata model classified 33, 16, and 3 patients as low intermediate, high intermediate, and high risk, respectively. The 4-strata model identified high-risk patients with a 1-year survival rate of 33%, but did not discriminate survival between the intermediate-risk groups. The MRA classified 15, 28, 8, and 1 patients as low, low intermediate, high intermediate, and high risk, respectively. High intermediate- or high-risk patients had worse survival (P<0.001), with 1- and 3-year survival rates of 64% and 34%, respectively. MRA high intermediate- or high-risk classification was associated with mortality (hazard ratio 12.780; 95% confidence interval 2.583-63.221; P=0.002).

CONCLUSIONS

Patients classified as high intermediate or high risk by the MRA after treatment should be referred for LT.

Prevalence, patient characteristics and treatment patterns among systemic lupus erythematosus-pulmonary arterial hypertension patients in real-world clinical practice: A retrospective analysis of Medical Data Vision Database in Japan

OBJECTIVES

Real-world evidence regarding prevalence, patient characteristics, and treatment patterns for pulmonary arterial hypertension (PAH) related to systemic lupus erythematosus (SLE) in Japan is limited.

METHODS

We conducted a retrospective study analysing Japan's Medical Data Vision database from April 2008 to September 2020. Prevalence, incidence, patient characteristics, treatment patterns, and use of vasodilators by treatment line were evaluated.

RESULTS

The prevalence of PAH was 0.392% in SLE patients (n = 114/29,077). Cumulative incidence was 0.53% (3 years) and 0.77% (5 years). Of 114 SLE-PAH patients, 49% developed PAH <1 year from SLE diagnosis. SLE-PAH patients were predominantly females (88% vs. 72%), had a lower mean age at SLE diagnosis (53 vs. 56 years), and had more severe SLE (61% vs. 25%) than non-PAH-SLE patients. Glucocorticoids (58%) and vasodilators (27%) were preferred first-line monotherapy for SLE-PAH. A combination of glucocorticoids and immunosuppressants (19%) was the predominant first-line combination therapy. Endothelin receptor antagonists (40% and 44%) and nitric oxide analogues (31% and 40%) were dominant first- and second-line vasodilators.

CONCLUSIONS

SLE-PAH patients were predominantly females, were younger at diagnosis, and had more severe SLE than non-PAH-SLE patients. Most were diagnosed <1 year of SLE diagnosis. In Japan's real-world practice, the initial treatment goal is SLE management, while vasodilators are preferred in advanced diseases, as per the Medical Data Vision database.

Pulmonary thrombotic pulmonary hypertension managed using antithrombotic and pulmonary vasodilator treatment

An 8-year-old Leonberger receiving immunosuppressive treatment with clinical signs of acute dyspnea, cyanosis, and difficulty standing was referred to our institution (Day 1). Treatment including oxygen, clopidogrel, and low-molecular-weight heparin was initiated for suspected pulmonary thrombosis. However, exertional dyspnea persisted until Day 10, and increased tricuspid regurgitation velocity, pulmonary vascular resistance, and McConnell's signs also were observed. Thus, beraprost sodium was administered PO on Day 11 to treat suspected pulmonary hypertension. On Day 13, contrast-enhanced computed tomography identified extensive contrast defects in the pulmonary arteries, and IV monteplase was administered on Days 14 and 18, with marked improvement in respiratory status and exertional dyspnea on Day 20. Right ventricular function and McConnell signs also improved, and tricuspid regurgitation velocity and pulmonary vascular resistance decreased. On Day 250, echocardiography indicated further improvement in pulmonary hypertension pathophysiology. The patient was still progressing well with antithrombotic and pulmonary vasodilator treatment 400 days later.

Laterality of CT-measured hepatic extracellular volume fraction in patients with chronic thromboembolic pulmonary hypertension

PURPOSE

This study examines the hepatic extracellular volume fraction (ECV) disparity between the left and right lobes (ECV_left and ECV_right) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), its association with right heart catheterization (RHC) metrics, and with intolerance to increased pulmonary hypertension (PH)-targeted medication dosages.

METHODS

We retrospectively analyzed 72 CTEPH-diagnosed patients who underwent equilibrium-phase abdominal dual-energy CT (DECT) and RHC. Hepatic ECVs, derived from DECT's iodine maps using circular regions of interest in the liver and aorta, were correlated with RHC parameters via Spearman's rank correlation and lobe differences through the Wilcoxon signed-rank test. Logistic regression assessed cases with ECV_left exceeding ECV_right by > 0.05, while receiver operating characteristic curve analysis gauged ECVs' predictive power for medication intolerance.

RESULTS

Of the 72 patients (57 females; median age 69), ECV_total (0.24, IQR 0.20-0.27) moderately correlated with RHC parameters (rs = 0.28, -0.24, 0.3 for mean pulmonary arterial pressure, cardiac index [CI], and pulmonary vascular resistance index, respectively). ECV_left significantly surpassed ECV_right (0.25 vs. 0.22, p < 0.001), with a greater ECV_left by > 0.05 indicating notably lower CI (p < 0.001). In 27 patients on PH medication, ECV_left effectively predicted medication intolerance (AUC = 0.84).

CONCLUSION

In CTEPH patients, hepatic ECV correlated with RHC metrics, where elevated left lobe ECV suggested reduced CI and potential medication intolerance.

Association of delayed diagnosis of pulmonary arterial hypertension with its prognosis

BACKGROUND

Currently, pulmonary hypertension-targeted therapy has been shown to improve the survival of patients with pulmonary artery hypertension (PAH). However, the importance of early diagnosis has not been investigated. Therefore, this study aimed to investigate whether a delayed diagnosis of PAH is associated with its prognosis.

METHODS AND RESULTS

A total of 66 consecutive untreated patients were diagnosed with PAH from January 2008 to December 2021 at the Kagoshima University Hospital. The time from symptom onset to diagnosis correlated with brain natriuretic peptide levels (p < 0.001), right ventricle (RV) Tei index (p < 0.001), and the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio (p = 0.003). These findings suggest that in patients with PAH, RV function declines with increasing time from symptom onset to diagnosis. Furthermore, older patients with PAH appeared to have a longer time from symptom onset to diagnosis. Next, patients were divided into delayed diagnosis (>3 months) and early diagnosis (≤3 months) groups based on the time from symptom onset to diagnosis. Patients were categorized into three groups according to the European Society of Cardiology (or the European Respiratory Society) risk stratification guidelines. Patients diagnosed with PAH within 3 months of symptom onset were significantly in the low- or intermediate-risk groups (p < 0.001). A Kaplan-Meier analysis revealed that the cumulative event-free rate was significantly lower (p < 0.01) in the delayed diagnosis group than in the early diagnosis group. A delayed diagnosis was significantly associated with a worse outcome than an early diagnosis, after adjusting for different sets of confounding factors.

CONCLUSIONS

A delayed PAH diagnosis is associated with a poor prognosis. Early diagnosis of PAH may lead to a low-risk treatment. Furthermore, older patients need more careful screening for PAH.

Recurrent pulmonary hypertension after balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

BACKGROUND

Balloon pulmonary angioplasty improves the hemodynamics of patients with inoperable chronic thromboembolic pulmonary hypertension; however, the clinical impact of recurrent pulmonary hypertension after balloon pulmonary angioplasty remains unclear.

METHODS

We retrospectively reviewed 262 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent balloon pulmonary angioplasty between July 2009 and December 2020; 158 (65 ± 12 years; males, 20%; median follow-up period, 45 [26, 66] months) with follow-up right heart catheterization and no residual pulmonary hypertension were included. Recurrent pulmonary hypertension was defined as mean pulmonary arterial pressure <25 mm Hg at the first evaluation after balloon pulmonary angioplasty and ≥25 mm Hg at follow-up evaluation requiring additional treatment with balloon pulmonary angioplasty or pulmonary vasodilators.

RESULTS

Recurrent pulmonary hypertension was observed in 11 patients; the state occupation probability of recurrence at 5 years was 9.0% (95% confidence interval: 5.0%-18.9%). Only 1 case (0.6%) of recurrent pulmonary hypertension showed vascular restenosis and reocclusion of previously treated lesions, with more significant hemodynamic and exercise capacity deterioration than the other cases. Additional treatments for recurrent pulmonary hypertension (balloon pulmonary angioplasty in 9 patients, pulmonary vasodilators in 4 patients) improved the mean pulmonary arterial pressure from 27 [26, 29] to 22 [19, 23] mm Hg (p < 0.01). Recurrence had a low probability of transitioning to death in an illness-death model. No specific risk factors for recurrent pulmonary hypertension were identified.

CONCLUSIONS

Symptomatic recurrent pulmonary hypertension due to vascular restenosis or reocclusion after balloon pulmonary angioplasty was extremely rare. Most cases of recurrent pulmonary hypertension were mild, did not worsen clinically, and had favorable prognoses.

Exploratory analysis of the accuracy of echocardiographic parameters for the assessment of right ventricular function and right ventricular-pulmonary artery coupling

Echocardiography is a widely used modality for the assessment of right ventricular (RV) function; however, few studies have comprehensively compared the accuracy of echocardiographic parameters using invasively obtained reference values. Therefore, this exploratory study aimed to compare the accuracy of echocardiographic parameters of RV function and RV-pulmonary artery (PA) coupling. We calculated four indices of RV function (end-systolic elastance [Ees] for systolic function [contractility], τ for relaxation, and β and end-diastolic elastance [Eed] for stiffness), and an index of RV-PA coupling (Ees/arterial elastance [Ea]), using pressure catheterization, cardiac magnetic resonance imaging, and a single-beat method. We then compared the correlations of RV indices with echocardiographic parameters. In 63 participants (54 with pulmonary hypertension (PH) and nine without PH), Ees and τ correlated with several echocardiographic parameters, such as RV diameter and area, but the correlations were moderate (|correlation coefficients (ρ)| < 0.5 for all parameters). The correlations of β and Eed with echocardiographic parameters were weak, with |ρ| < 0.4. In contrast, Ees/Ea closely correlated with RV free wall longitudinal strain (RVFW-LS)/estimated systolic PA pressure (eSPAP) (ρ = -0.72). Ees/Ea also correlated with tricuspid annular plane systolic excursion/eSPAP, RV diameter, and RV end-systolic area, with |ρ | >0.65. In addition, RVFW-LS/eSPAP yielded high sensitivity (0.84) and specificity (0.75) for detecting reduced Ees/Ea. The present study indicated a limited accuracy of echocardiographic parameters in assessing RV systolic and diastolic function. In contrast to RV function, they showed high accuracy for assessing RV-PA coupling, with RVFW-LS/eSPAP exhibiting the highest accuracy.

Severe pulmonary hypertension associated with hypothyroidism and mixed aortic valve disease: A case report

Pulmonary hypertension is a condition characterised by elevated pulmonary arterial pressures secondary to various aetiologies; the most common ones are left heart diseases. Similarly, an association between thyroid diseases and pulmonary hypertension has been reported in some cases, but the pathophysiological relationship has not been fully elucidated. Etiological investigation is an important step in the management of pulmonary hypertension and determines the appropriate treatment. In this report, we present a case of severe pulmonary hypertension in a 57-year-old woman, in which mixed aortic valve disease and hypothyroidism were involved.

Detrimental Impact of Comorbid Mental Disorders in Chronic Thromboembolic Pulmonary Hypertension - A Retrospective Observational Study

Background: The relationship between the prognosis of patients with both chronic thromboembolic pulmonary hypertension (CTEPH) and a mental disorder (MD) remains unclear. Methods and Results: The study group comprised 157 patients with CTEPH who underwent right heart catheterization and were subdivided into 2 groups according to the presence of MDs: MD and non-MD. The patients with MDs were defined as those who had visited a psychiatrist and were under psychotropic drug treatment. The primary outcome was a composite of all-cause death and worsening of PH. The median follow-up period was 1,164 days. The incidence of the primary composite outcome was higher in the MD group than in the non-MD group (24.0% vs. 6.8%), whereas the all-cause mortality rate was comparable between groups (12.0% vs. 6.1%). The mean pulmonary arterial pressure, cardiac index, and pulmonary vascular resistance at baseline were all similar between groups. The Cox proportional hazards model indicated that MD was an independent risk factor for the primary composite outcome (hazard ratio, 2.990; 95% confidence interval, 1.034-8.642). Conclusions: In the present study, concomitant CTEPH and MD was significantly associated with a poor prognosis and such patients should be carefully followed.

Patient and Therapeutic Profiles of Pulmonary Hypertension in Chronic Lung Diseases in Japan: A Cohort Study Using a Claims Database

INTRODUCTION

Pulmonary hypertension (PH) is often complicated by chronic lung diseases (CLDs) such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Differentiating between PH associated with CLD (group 3 PH) and pulmonary arterial hypertension (PAH) in CLD is often difficult and reporting on the efficacy of PAH-specific therapies is inconsistent as a result of the lack of understanding of the heterogeneity of patients with PH.

METHODS

A retrospective observational cohort study was conducted to understand the baseline characteristics, comorbidities, and treatment profiles of patients with PH in CLD in a real-world setting using a large-scale claims database (Medical Data Vision). Administrative and clinical data for patients admitted to acute-care hospitals in Japan between April 2008 and January 2021 were analyzed.

RESULTS

A total of 115,921 patients with CLD (109,578 with COPD and 6343 with ILD, of whom 569 and 176 had PH, respectively) were analyzed. This study found lower PH diagnosis rates among patients with COPD and patients with ILD than in previous studies. The majority of PH with CLD patients were elderly (mean age 75.7 years) and male (80.81%). Among patients with CLD prescribed PAH-specific therapies (105 patients with COPD; 64 patients with ILD), most received these as monotherapy (COPD, 84.76%; ILD, 75.56%); the most common were phosphodiesterase 5 inhibitors (COPD, 42.70%; ILD, 18.37%), prostacyclins (oral; COPD, 48.31%; ILD, 24.49%), and endothelin receptor antagonists (ERA) (COPD, 8.99%; ILD, 18.37%). Comorbidities (e.g., pulmonary, cardiac, kidney), home oxygen therapy (HOT), and echocardiography (ECHO) were factors associated with the diagnosis of PH.

CONCLUSION

This is the first study using an administrative database that provides real-world data on patients with PH in CLD in Japan. Our results indicate that PH may be misdiagnosed or underdiagnosed in Japan which may lead to suboptimal treatment for patients, and supports the need for further evidence to guide appropriate treatment.

Understanding Patient Perspectives Toward Shared Decision-Making in Patients With Pulmonary Hypertension

Clinical guidelines for pulmonary hypertension (PH) recommend shared decision-making and individualized treatment. However, patient perspectives on PH treatment goals, preference toward a decision-making style of treatment, and adoption of shared decision-making remain unclear. This cross-sectional questionnaire-based study assessed the patients' preferred and actual participation role in treatment decision-making, rated on 5 scales (ranging from passive [patients leave all decisions to physicians] to active [patients make the decision after physicians show patients several options]) and evaluated the concordance between preferred and actual participation roles. The important factors underlying patients' perspectives in treatment decision-making (i.e., prognosis; symptom, financial, family, and social burdens; patient values; and physician recommendation) were evaluated. Univariate logistic regression analysis was performed to determine the patients with a positive preference toward "physician recommendation" in treatment decision-making. Among 130 patients with PH (median age: 58 years; mean pulmonary arterial pressure: 23 mm Hg; 27.7% were males), 59.2% preferred that "physicians make the decision regarding treatment after showing patients therapeutic options (i.e., intermediate between passive and active roles)." The patient-preferred and actual participation roles in decision-making had moderate agreement (Cohen's kappa = 0.46). The most important factor in treatment decisions was "symptom burden reduction" (93.8%). Although 85.0% of patients chose "physician recommendation" as an important factor, 49.6% chose "alignment with my values." The determinants of patients who chose "physician recommendation" were less severe hemodynamics and better functional capacity. In conclusion, patients with PH preferred that the "physicians make the decision after showing patients therapeutic options" and prioritized physician recommendation over their values.

Pathophysiology and Treatment of Pulmonary Arterial Hypertension

Pulmonary hypertension (PH) is recognized as a pathophysiological disorder encompassing a wide spectrum of clinical conditions related to various cardiovascular and respiratory diseases [...].

Treating Pulmonary Arterial Hypertension With Sotatercept: A Meta-Analysis

Pulmonary arterial hypertension (PAH) results from proliferative remodeling and narrowing of the pulmonary vasculature. Sotatercept is a first-in-class fusion protein that has recently garnered attention for showing improvements in patients with PAH. This meta-analysis of randomized controlled trials (RCTs) assesses the overall efficacy of Sotatercept in treating PAH. PubMed, Google Scholar, and Clinicaltrials.gov were searched using relevant keywords and MeSH terms. Studies were included if RCTs compared Sotatercept with placebo in patients with PAH. Our comprehensive literature search yielded 3,127 results, of which two RCTs with 429 patients were included in this meta-analysis. The patients were on background therapy for PAH. Results of the meta-analysis show that when compared with placebo, Sotatercept improved the six-minute walk distance (mean difference [MD] 34.99; 95% confidence interval [CI] 19.02-50.95; P < 0.0001), the World Health Organization (WHO) functional class (odds ratio [OR] 2.50; 95% CI 1.50-4.15; P = 0.0004), and pulmonary vascular resistance (PVR, MD -253.90; 95% CI -356.05 to -151.75; P < 0.00001). However, reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP, MD -1563.14; 95% CI -3271.93 to 145.65; P = 0.07) was not statistically significant in the Sotatercept group versus placebo. In conclusion, Sotatercept improves the six-minute walk distance, WHO functional class, and PVR in patients with PAH receiving background therapy. However, the effect on NT-proBNP levels was not statistically significant. More research is needed to assess the clinical relevance of these findings.

Diagnostic Value of Serum Galectin-3 Binding Protein Level in Patients with Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) still lacks effective biomarkers to assist in its diagnosis and prognosis. Galectin-3 binding protein (Gal-3BP) plays a role in immune and inflammatory diseases.

OBJECTIVE

This study aimed to evaluate Gal-3BP as a prognostic and predictive factor in patients with PAH.

METHODS

From January 2017 to December 2019, we enrolled 167 consecutive PAH patients and 58 healthy controls. Right heart catheterization (RHC) was used to diagnose PAH. Serum Gal-3BP levels were measured by high-sensitivity human enzyme-linked immunosorbent assay (ELISA).

RESULTS

Serum Gal-3BP levels in the PAH group were significantly higher compared with the control group (4.87±2.09 vs 2.22±0.86 μg/mL, p<0.001). Gal-3BP level was correlated with several hemodynamic parameters obtained from RHC (p<0.001). Multivariate linear regression analysis showed that Gal-3BP was a risk factor for PAH (odds ratio (OR)=2.947, 95% CI: 1.821-4.767, p<0.001). The optimal cut-off value of serum Gal-3BP level for predicting PAH was 2.89 μg/mL (area under the curve (AUC)=0.860, 95 % CI: 0.811-0.910, p<0.001). Kaplan-Meier analysis showed that Gal-3BP levels above the median (4.87 μg/mL) were associated with an increased risk of death in patients with PAH (hazard ratio (HR)=8.868, 95 % CI: 3.631-21.65, p<0.0001). Cox multivariate risk regression analysis showed that Gal-3BP was a risk factor for death in PAH patients (HR=2.779, 95 % CI: 1.823-4.237, p<0.001).

CONCLUSION

Serum Gal-3BP levels were increased in patients with PAH, and levels of Gal-3BP were associated with the severity of PAH. Gal-3BP might have predictive value for the diagnosis and prognosis of PAH.

The diagnostic journey of pulmonary arterial hypertension patients: results from a multinational real-world survey

BACKGROUND

Pulmonary arterial hypertension (PAH) is a life-threatening, progressive disease often diagnosed late in its course.

OBJECTIVES

To present patient-reported data that were captured within a large, multinational, point-in-time survey of PAH-treating physicians and their patients to better understand the diagnostic journey.

DESIGN

Cross-sectional survey conducted in five European countries (EU5), Japan and the USA.

METHODS

PAH-treating pulmonologists, cardiologists, rheumatologists or internists (USA only) completed a patient record form (PRF) for the next four consecutive adult PAH patients they saw; these patients filled in a patient self-completion (PSC) form on an anonymous, voluntary basis. Our report focuses on patient data; data are from PSC forms unless stated otherwise.

RESULTS

Physician-reported PRFs and self-completed PSC forms were obtained for 1152 and 572 patients, respectively. Patients' mean (SD) age was 59.1 (14.0) years, 55.6% were female, and 57.3% had idiopathic PAH. Patient-reported data showed an average delay of 17.0 months between symptom onset and PAH diagnosis. This is longer than physicians estimated (13.8 months): this disparity may be partly due to the time taken by patients to consult a physician about their symptoms [9.6 months overall, longest in the USA (15.3 months)]. Most patients (71.6%) initially consulted primary care physicians about their symptoms and 76.4% of patients were referred to a specialist. Misdiagnoses occurred in 40.9% of patients [most frequent in the USA (51.3%), least common in Japan (27.6%)] and they saw an average of 2.9 physicians overall (3.5 in EU5 versus 2.0 in Japan/USA) before being diagnosed. Diagnosis was most often made by cardiologists (50.4%) or pulmonologists (49.3%).

CONCLUSION

Our data suggest that diagnostic delay in PAH results from patient- and physician-related factors, which differ across regions and include lack of awareness of PAH on both sides. Development of better screening strategies may help address this barrier to timely PAH diagnosis.

The role and mechanism of AMPK in pulmonary hypertension

Pulmonary hypertension (PH) is a chronic progressive disease with high mortality. There has been more and more research focusing on the role of AMPK in PH. AMPK consists of three subunits-α, β, and γ. The crosstalk among these subunits ultimately leads to a delicate balance to affect PH, which results in conflicting conclusions about the role of AMPK in PH. It is still unclear how these subunits interfere with each other and achieve balance to improve or deteriorate PH. Several signaling pathways are related to AMPK in the treatment of PH, including AMPK/eNOS/NO pathway, Nox4/mTORC2/AMPK pathway, AMPK/BMP/Smad pathway, and SIRT3-AMPK pathway. Among these pathways, the role and mechanism of AMPK/eNOS/NO and Nox4/mTORC2/AMPK pathways are clearer than others, while the SIRT3-AMPK pathway remains still unclear in the treatment of PH. There are drugs targeting AMPK to improve PH, such as metformin (MET), MET combination, and rhodiola extract. In addition, several novel factors target AMPK for improving PH, such as ADAMTS8, TUFM, and Salt-inducible kinases. However, more researches are needed to explore the specific AMPK signaling pathways involved in these novel factors in the future. In conclusion, AMPK plays an important role in PH.

Navigating the Sotatercept landscape: A meta-analysis of clinical outcomes

Pulmonary arterial hypertension (PAH) is a widespread condition that affects around 1% of the global population, with a higher prevalence among older individuals. The approach to managing PAH has undergone significant changes, requiring extensive treatment strategies. Sotatercept, an FDA-approved medication, has recently attracted attention for its potential role in PAH therapy. However, information on its safety and effectiveness is scarce. In this study, we performed a meta-analysis of existing randomized clinical trials to assess the impact of Sotatercept on PAH patients. Our findings revealed that those treated with Sotatercept showed greater improvement in pulmonary vascular resistance and World Health Organization functional class compared with placebo recipients. The occurrence of adverse events was similar between both groups. Importantly, the Sotatercept group displayed a considerably higher number of cases with an increase in hemoglobin levels. Considering that about 33% of PAH patients experience anemia and both anemia and polycythemia can adversely affect disease prognosis, additional research is necessary to establish the potential advantages and disadvantages of Sotatercept as a treatment choice, specifically regarding its erythropoietic properties.

Comparative Treatment Persistence and Adherence to Endothelin Receptor Antagonists Among Patients with Pulmonary Arterial Hypertension in Japan: A Real-World Administrative Claims Database Study

INTRODUCTION

Real-world data on the comparative effectiveness of endothelin receptor antagonists (ERAs; macitentan, bosentan, ambrisentan) for pulmonary arterial hypertension (PAH), particularly in Asian countries, are scarce. We evaluated the persistence of these ERAs before and after macitentan approval in Japan (2015).

METHODS

We used real-world data from the Japanese Medical Data Vision administrative claims database between April 2008 and November 2020. Patients with PAH were identified from the dataset. Persistence to ERA treatment before and after approval of macitentan in Japan was defined as the time between start of the index ERA and treatment discontinuation or death. Propensity score adjustment was applied to minimize confounding effects among treatment groups.

RESULTS

In the pre-macitentan approval cohort, 153 and 51 patients received bosentan and ambrisentan, respectively. In the post-macitentan approval cohort, 331, 284, and 91 patients received macitentan, bosentan, and ambrisentan, respectively. Unadjusted median persistence for ambrisentan- and bosentan-treated patients was 19 and 10 months, respectively (adjusted HR 0.87 [95% CI 0.61-1.24]; P = 0.434 [bosentan as reference]). In the post-macitentan approval cohort, unadjusted median persistence was 18 months for macitentan-treated patients versus 6 and 8 months for ambrisentan- and bosentan-treated patients, respectively. Adjusted HRs for ambrisentan and bosentan were 1.48 (95% CI 1.12-1.95; P = 0.006) and 1.63 (95% CI 1.30-2.04; P < 0.001 [macitentan as reference]), respectively.

CONCLUSIONS

Real-world data for Japanese patients with PAH showed that persistence was significantly higher for macitentan, versus ambrisentan and bosentan, since its approval.

Predictors of procedural complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

BACKGROUND

Balloon pulmonary angioplasty (BPA) is an effective treatment for inoperable chronic thromboembolic pulmonary hypertension, with good results reported for residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). However, BPA is associated with complications, such as pulmonary artery perforation and vascular injury, which can lead to critical pulmonary hemorrhage requiring embolization and mechanical ventilation. Furthermore, the risk factors for occurrence of complications in BPA are unclear; therefore, this study aimed to evaluate predictors of procedural complications in BPA.

METHODS

In this retrospective study, we collected clinical data (patient characteristics, details of medical therapy, hemodynamic parameters, and details of the BPA procedure) from 321 consecutive sessions involving 81 patients who underwent BPA. Procedural complications were evaluated as endpoints.

RESULTS

BPA for residual PH after PEA was performed in 141 sessions (43.9 %), which involved 37 patients. Procedural complications were observed in 79 sessions (24.6 %), including severe pulmonary hemorrhage requiring embolization in 29 sessions (9.0 % of all sessions). No patients experienced severe complications requiring intubation with mechanical ventilation or extracorporeal membrane oxygenation. Age ≥ 75 years and mean pulmonary artery pressure ≥ 30 mmHg were independent predictors of procedural complications. Residual PH after PEA was a significant predictor of severe pulmonary hemorrhage requiring embolization (adjusted odds ratio, 3.048; 95 % confidence interval, 1.042-8.914, p = 0.042).

CONCLUSIONS

Older age, high pulmonary artery pressure, and residual PH after PEA increase the risk of severe pulmonary hemorrhage requiring embolization in BPA.

Review of Advances on Management of Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension is rare, underdiagnosed form of pulmonary hypertension. It is caused by intravascular obstruction of pulmonary arteries due to fibrotic transformation of thromboembolic material and microvasculopathy. It is important to diagnose this variant as potentially curative treatment in the form of pulmonary endarterectomy is available. Last two decades have seen rapid advances in targeted medical management and refinement in balloon pulmonary angioplasty technique, which have provided a viable therapeutic option for patients who deemed to be inoperable.

Impact of non-gated computed tomography on the timing of invasive strategy of patients with non-ST-elevation acute coronary syndrome

Background

This study aimed to examine the clinical role of non-gated computed tomography (CT) in ruling out fatal chest pain in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), with a focus on the time of arrival at the hospital to coronary angiography (CAG) and peak creatine kinase (CK) levels.

Methods

We retrospectively examined 196 NSTE-ACS patients who were admitted with urgently diagnosed NSTE-ACS and underwent percutaneous coronary intervention between March 2019 and October 2022. The patients were divided into three groups, namely, non-CT group, CT and defect- group, and CT and defect+ group, based on whether they underwent a CT scan and the presence or absence of perfusion defects on the CT image.

Results

After the initial admission for NSTE-ACS, 40 patients (20.4%) underwent non-gated CT prior to CAG. Among these 40 patients, 27 had a perfusion defect on the CT scan. The incidence of contrast-induced nephropathy was not different among the three groups. The CT and defect+ group had a shorter arrival-to-CAG time than that of the non-CT group. In NSTE-ACS patients with elevated CK levels, the CT and defect+ group had lower peak CK levels than those in the non-CT group.

Conclusion

NSTE-ACS patients with perfusion defects on non-gated CT had a shorter time from arrival to CAG, which might be associated with a lower peak CK. Non-gated CT might be useful for early diagnosis and early revascularization in the clinical setting of NSTE-ACS.

Quantification of pulmonary perfusion using LSIM-CT correlates with pulmonary hemodynamics in patients with CTEPD

Background

Lung subtraction iodine mapping (LSIM)-CT is a clinically useful technique that can visualize pulmonary mal-perfusion in patients with chronic thromboembolic pulmonary disease (CTEPD). However, little is known about the associations of LSIM images with hemodynamic parameters of patients with CTEPD. This study investigates a parameter of LSIM images associated with mean pulmonary arterial pressure (mPAP) and validates the association between pulmonary vascular resistance, right atrial pressure, cardiac index, and exercise capacity in patients with CTEPD.

Methods

This single-center, prospective, observational study involved 30 patients diagnosed with CTEPD using lung perfusion scintigraphy. To examine the correlation of decreased pulmonary perfusion area (DPA) with mPAP, areas with 0-10, 0-15, 0-20, and 0-30 HU in lung subtraction images were adopted in statistical analysis. The DPA to total lung volume ratio (DPA ratio, %) was calculated as the ratio of each DPA volume to the total lung volume. To assess the correlation between DPA ratios of 0-10, 0-15, 0-20, and 0-30 HU and mPAP, Spearman's rank correlation coefficient was used.

Results

The DPA ratio of 0-10 HU had the most preferable correlation with mPAP than DPA ratios of 0-15, 0-20, and 0-30 HU (ρ = 0.440, P = 0.015). The DPA ratio of 0-10 HU significantly correlates with pulmonary vascular resistance (ρ = 0.445, P = 0.015). The receiver operating characteristic curve analysis indicated that the best cutoff value of the DPA ratio of 0-10 HU for the prediction of an mPAP of ≥30 mmHg was 8.5% (AUC, 0.773; 95% CI, 0.572-0.974; sensitivity, 83.3%; specificity, 75.0%). Multivariate linear regression analysis, which was adjusted for the main pulmonary arterial to ascending aortic diameter ratio and right ventricular to left ventricular diameter ratio, indicated that the DPA ratio of 0-10 HU was independently and significantly associated with mPAP (B = 89.7; 95% CI, 46.3-133.1, P < 0.001).

Conclusion

The DPA ratio calculated using LSIM-CT is possibly useful for estimating the hemodynamic status in patients with CTEPD.

Impact of cancer on the prevalence, management, and outcome of patients with chronic thromboembolic pulmonary hypertension

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) results from unresolved thrombotic obstruction of the pulmonary vasculature. Cancer is a known risk factor for CTEPH. This study aimed to determine the impact of cancer on the prevalence, management, and outcomes of patients with CTEPH.

MATERIALS AND METHODS

In this retrospective study involving 99 patients sequentially diagnosed with CTEPH in our hospital, the prevalence of 10 comorbid conditions including a past history of cancer at the time of CTEPH diagnosis were calculated.

RESULTS

Among the 99 patients, 17 (17%) had a history of cancer. Breast cancer (n = 6) was the most common cancer type, followed by gastrointestinal cancer (n = 3), uterine cancer (n = 2), and malignant lymphoma (n = 2). Between patients with and without cancer, there were no differences in the demographics, severity of CTEPH, and management; however, the 5-year survival rate was lower for patients with cancer (65%) than for those without (89%). In addition, patients with cancer had significantly worse survival than those without (p = 0.03 by log-rank test). During follow-up, nine patients developed cancer after the diagnosis of CTEPH. Among the 99 patients, 13 died during follow-up, 6 (46%) of whom died of cancer.

CONCLUSIONS

17% of our patients with CETPH were diagnosed with cancer, with breast and gastrointestinal tract cancers being the most common. Cancer comorbidity was associated with a poor prognosis and contributed to death in 46% of deceased patients. The impact of cancer on CTEPH should be further evaluated in the future.

Histopathological Evaluation of Pulmonary Thromboendarterectomy Specimens of Chronic Thromboembolic Pulmonary Hypertension

AIMS

Chronic thromboembolic pulmonary hypertension (CTEPH) is a condition with a poor prognosis in which the pulmonary arteries are occluded by organized thrombi. Pulmonary thromboendarterectomy (PEA) is an effective treatment for CTEPH; however, the literature on its histopathological examination is lacking. This study aimed to investigate the histopathological findings and protein and gene expression in PEA specimens, establish an optimal histopathological evaluation method, and clarify the mechanisms of thrombus organization and disease progression in CTEPH.

METHODS

In total, 50 patients with CTEPH who underwent PEA were analyzed. The patients were categorized according to their clinical data into two groups: good and poor postoperative courses. The relationship between their histopathological findings and the clinical course was examined. Immunohistochemical studies confirmed the expression of oxidants, antioxidants, and smooth muscle cell (SMC) differentiation markers and their changes during the progression of thrombus organization. The mRNA expression analysis of 102 samples from 27 cases included oxidants, antioxidants, and vasoconstrictor endothelin-1.

RESULTS

In the PEA specimens, colander-like lesions (aggregations of recanalized blood vessels with well-differentiated SMCs) were significantly more common in the good postoperative course group than in the poor postoperative course group; analysis of proteins and genes proposed that oxidative and antioxidant mechanisms were involved. In the colander-like lesions, there was an increase in endothelin-1 mRNA and protein expression of endothelin receptor A.

CONCLUSIONS

Colander-like lesions in PEA specimens must be identified. Additionally, SMC differentiation in recanalized vessels and the expression of vasoconstrictors and their receptors may contribute to the progression of CTEPH.

Pressure stress delays cyclooxygenase-2 expression induced by interleukin-1β in cultured human pulmonary artery smooth muscle cells

Introduction

Pulmonary artery smooth muscle cells (PASMCs) play an important role in the sequence of events leading to the formation of pulmonary hypertension (PH). However, little is known about the direct effects of high pressure on the function and intercellular signaling pathways of PASMCs. The aim of this study was to evaluate the effect of pressure stress that simulates PH on interleukin (IL)-1β- or angiotensin II-induced cyclooxygenase-2 (COX-2) expression in cultured human PASMCs.

Methods

Either 20 or 60 mmHg atmospheric pressure was applied to PASMCs by a pressure-loading apparatus. Protein expression and phosphorylation were analyzed by western blotting. mRNA expression was analyzed by quantitative real-time reverse transcription-polymerase chain reaction.

Results

IL-1β-induced COX-2 protein expression peaked at 6 h in non-pressurized cells, whereas COX-2 expression was delayed, peaking at 12 h, in 20 and 60 mmHg pressurized cells. Both pressures also delayed the time to peak COX-2 mRNA expression induced by IL-1β. In addition, pressure stress delayed the time to peak mitogen-activated protein kinase (MAPK) phosphorylation induced by IL-1β. In contrast, angiotensin II-induced transient COX-2 mRNA expression and MAPK phosphorylation were not affected by pressure stress.

Conclusion

These results suggest that pressure stress delays IL-1β-induced COX-2 expression via the delayed activation of MAPKs in PASMCs, and the effects of pressure stress differ according to the bioactive substance being stimulated. Our results demonstrate that the application of pressure stress to PASMCs directly alters cell function, which may provide a basic insight into our understanding of the pathogenesis of PH.

Symptom-based portopulmonary hypertension screening questionnaire in Japanese patients with chronic liver disease

Background and Aim

As the exact prevalence of portopulmonary hypertension (PoPH) and the etiology of chronic liver disease (CLD) remain unknown, the present study aimed to clarify these points in Japanese patients with CLD using symptom-based questionnaire screening.

Methods

Patients with CLD were asked to complete an eight-item written questionnaire on pulmonary hypertension (PH) symptoms. If at least one item response was "yes," the patient was offered ultrasonic echocardiography (UCG). Patients identified as having an intermediate or high risk of PH by UCG were referred to a cardiologist for further evaluation, whereby a definitive diagnosis of PoPH was made using right heart catheterization (RHC) findings.

Results

A total of 1111 patients with CLD completed the survey. Of the 566 symptomatic patients with at least one question answered as "yes," approximately half agreed to undergo UCG (n = 267). Compared with asymptomatic patients, symptomatic patients were significantly older, predominantly female, and more frequently exhibited cirrhosis. Based on UCG findings, 228, 12, and 8 patients had a low, intermediate, or high risk for PH, respectively. Intermediate-/high-risk patients showed significantly more advanced disease progression status than low-risk patients. The frequencies of answer to the eight questions were comparable. Ultimately, three patients were diagnosed as having PoPH (1.1% of UCG cases), one with underlying hepatitis C virus (HCV) infection and two with primary biliary cholangitis (PBC).

Conclusion

This symptom-based PoPH screening study clarified the prevalence of PoPH in CLD patients according to a PH symptom questionnaire, UCG, and RHC. Patients with HCV and PBC may have a higher risk of PoPH.

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function

The current treatment algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) as depicted in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines on the diagnosis and treatment of pulmonary hypertension (PH) includes a multimodal approach of combinations of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapies to target major vessel pulmonary vascular lesions, and microvasculopathy. Today, BPA of >1700 patients has been reported in the literature from centers in Asia, the US, and also Europe; many more patients have been treated outside literature reports. As BPA becomes part of routine care of patients with CTEPH, benchmarks for safe and effective care delivery become increasingly important. In light of this development, the ESC Working Group on Pulmonary Circulation and Right Ventricular Function has decided to publish a document that helps standardize BPA to meet the need of uniformity in patient selection, procedural planning, technical approach, materials and devices, treatment goals, complications including their management, and patient follow-up, thus complementing the guidelines. Delphi methodology was utilized for statements that were not evidence based. First, an anatomical nomenclature and a description of vascular lesions are provided. Second, treatment goals and definitions of complete BPA are outlined. Third, definitions of complications are presented which may be the basis for a standardized reporting in studies involving BPA. The document is intended to serve as a companion to the official ESC/ERS guidelines.

Estimation of the effect of atezolizumab plus bevacizumab on pulmonary arterial hypertension using computed tomography in HCC patients

The effect of the combination of atezolizumab and bevacizumab (Atez/Bev) for hepatocellular carcinoma (HCC) on pulmonary arterial hypertension (PAH) is unknown. Estimation of PAH by using computed tomography (CT) has recently been proposed. Thus, we aimed to estimate the effect of Atez/Bev on PAH using CT. Altogether, 113 patients who received Atez/Bev for HCC were enrolled. Probable PAH was defined as the diameter of the main pulmonary artery (mPA-D) ≥ 33 mm, whereas suspicious PAH was defined as mPA-D ≥ 29 mm or mPA-D/the diameter of the ascending aorta (aAo-D) ≥ 1.0. Before treatment, probable/suspicious PAH were diagnosed in 7 (6.7%)/22 (21.0%) patients, respectively. mPA-D and mPA-D/aAo-D significantly increased after induction of Atez/Bev. The increment of mPA-D was correlated with the occurrence of post-treatment respiratory/heart failure. In analysis of 55 patients who underwent CT at 3 months after the last dose of Atez/Bev, mPA-D and mPA-D/aAo-D significantly decreased. However, in the group with continuous treatment of other molecular-targeted drugs after Atez/Bev, mPA-D and mPA-D/aAo-D showed no significant change. In conclusion, PAH may not be a rare complication in patients with HCC and should be managed carefully because of the possible negative effect of Atez/Bev on PAH.

Protocol for a multicentre, double-blind, randomised, placebo-controlled trial of riociguat on peak cardiac index during exercise in patients with chronic thromboembolic pulmonary hypertension after balloon pulmonary angioplasty (THERAPY-HYBRID-BPA trial)

OBJECTIVES

Balloon pulmonary angioplasty (BPA) and medical therapy, such as soluble guanylate cyclase stimulators, are recommended treatments for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy (PEA). However, monotherapy with BPA or medical therapy cannot always eliminate symptoms such as exertional dyspnoea. Thus, this study aims to clarify the efficacy of continuous treatment with riociguat in inoperable CTEPH patients with normalised haemodynamics after BPA.

METHODS AND ANALYSIS

This is a double-blind, multicentre, randomised, placebo-controlled trial. Participants with CTEPH who are ineligible for PEA will receive riociguat followed by BPA. Subsequently, participants will be randomised (1:1) into either riociguat continuing or discontinuing groups and will be observed for 16 weeks after randomisation. The primary endpoint will be the change in peak cardiac index (CI) during the cardiopulmonary exercise test. In the primary analysis, the least square mean differences and 95% CIs for the change in peak CI at 16 weeks between the groups will be estimated by a linear mixed-effects model with baseline value as a covariate, treatment group as a fixed effect and study institution as a random effect.

ETHICS AND DISSEMINATION

National Hospital Organisation Review Board for Clinical Trials (Nagoya) and each participating institution approved this study and its protocols. Written informed consent will be obtained from all participants. The results will be disseminated at medical conferences and in journal publications.

REGISTRATION DETAILS

Japan Registry of Clinical Trials: jRCT no. 041200052.

CLINICALTRIALS

gov by National Library of Medicine Registry ID: NCT04600492.

TRIAL REGISTRATION NUMBER

NCT04600492.