Causes of pulmonary hypertension in the elderly

Exercise capacity-hemodynamics mismatch in elderly patients with pulmonary hypertension: A nationwide multicenter study from Taiwan Society of Cardiology Pulmonary Hypertension Registry (TAIPANS)

Background

Demographics of pulmonary hypertension (PH) has changed a lot over the past forty years. Several recent registries noted an increase in mean age of PH but only a few of them investigated the characteristics of elderly patients. Thus, we aimed to analyze the characteristics of PH in such a population in this study.

Methods

This multicenter study enrolled patients diagnosed with PH in group 1, 3, 4, and 5 consecutively from January 1, 2019 to December 31, 2020. A total of 490 patients was included, and patients were divided into three groups by age (≤45 years, 45-65 years, and >65 years).

Results

The mean age of PH patients diagnosed with PH was 55.3 ± 16.3 years of age. There was higher proportion of elderly patients classified as group 3 PH (≤45: 1.3, 45-65: 4.5, >65: 8.1 %; p = 0.0206) and group 4 PH (≤45: 8.4, 45-65: 14.5, >65: 31.6 %; p < 0.0001) than young patients. Elderly patients had shorter 6-min walking distance (6 MWD) (≤45 vs. >65, mean difference, 77.8 m [95% confidence interval (CI), 2.1-153.6 m]), lower mean pulmonary arterial pressure (mPAP) (≤45 vs. >65, mean difference, 10.8 mmHg [95% CI, 6.37-15.2 mmHg]), and higher pulmonary arterial wedge pressure (PAWP) (≤45 vs. 45-65, mean difference, -2.1 mmHg [95% CI, -3.9 to -0.3 mmHg]) compared to young patients. Elderly patients had a poorer exercise capacity despite lower mPAP level compared to young population, but they received combination therapy less frequently compared to young patients (triple therapy in group 1 PH, ≤45: 16.7, 45-65: 11.3, >65: 3.8 %; p = 0.0005). Age older than 65 years was an independent predictor of high mortality for PH patients.

Conclusions

Elderly PH patients possess unique hemodynamic profiles and epidemiologic patterns. They had higher PAWP, lower mPAP, and received combination therapy less frequently. Moreover, ageing is a predictor of high mortality for PH patients. Exercise capacity-hemodynamics mismatch and inadequate treatment are noteworthy in the approach of elderly population with PH.

Relationship between obstructive sleep apnea and pulmonary hypertension: past, present and future

INTRODUCTION

Obstructive sleep apnea (OSA) is a widely prevalent condition with consequent multiple organ systems complications. There is consensus that OSA is associated with negative effects on pulmonary hemodynamics but whether it contributes to development of clinical pulmonary hypertension (PH) is unclear.

AREAS COVERED

In this review, we (1) highlight previous studies looking into the possible bidirectional association of OSA and PH, focusing on those that explore clinical prognostic implications, (2) explore potential pathophysiology, (3) discuss the new metrics in OSA, (4) describe endo-phenotyping of OSA, (5) recommend possible risk assessment and screening pathways.

EXPERT OPINION

Relying only on symptoms to consider a sleep study in PH patients is a missed opportunity to detect OSA, which, if present and not treated, can worsen outcomes. The potential prognostic role of sleep study metrics such as oxygen desaturation index (ODI), hypoxic burden (HB) and ventilatory burden (VB) in OSA should be studied in prospective trials to identify patients at risk for PH. AHI alone has not provided clarity. In those with PH, we should consider replacing ambulatory overnight pulse oximetry (OPO) with home sleep studies (HST). In PH patients, mild OSA should be sufficient to consider PAP therapy.

Elderly Patients with Idiopathic Pulmonary Hypertension: Clinical Characteristics, Survival, and Risk Stratification in a Single-Center Prospective Registry

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.

Pulmonary Arterial Hypertension in the Elderly: Peculiar Features and Challenges for a Proper Phenotyping Approach

(1) Introduction. Although pulmonary arterial hypertension (PAH) usually affects young people with a low cardiovascular risk profile, progressive epidemiologic changes have been providing a codified phenotype of elderly subjects with PAH and increased risk predictors for left heart disease. We therefore conducted a systematic review to describe the current knowledge and characteristics of elderly individuals with PAH and further insights concerning their prognostic outcomes and therapeutic response. (2) Methods. A search was conducted in PubMed, Embase, and Cochrane Library for publications evaluating the epidemiology, diagnostic work-up, and treatment of PAH in elderly subjects. (3) Among the 74 publications initially retrieved, 16 full-text articles were selected for the present systematic review. Compared to their younger counterparts, elderly individuals with PAH showed greater clinical deterioration, reduced exercise capacity, and worse prognostic outcomes, as well as less response to PAH-targeted therapy and higher rates of PAH drug discontinuation. (4) Conclusions. Demographic changes over time contributed to define a peculiar PAH phenotype in elderly patients, with an increased burden of cardiovascular comorbidities and distinctive features compared to young patients. Further investigations are needed in order to better clarify the nosologic criteria, and management in this subset population.

Ligustrazine alleviates pulmonary arterial hypertension in rats by promoting the formation of myocardin transcription complex in the nucleus of pulmonary artery smooth muscle cells

Pulmonary arterial hypertension (PAH) is a pathophysiological state of abnormally elevated pulmonary arterial pressure caused by drugs, inflammation, toxins, viruses, hypoxia, and other risk factors. We studied the therapeutic effect and target of tetramethylpyrazine (tetramethylpyrazine [TMP]; ligustrazine) in the treatment of PAH and we speculated that dramatic changes in myocardin levels can significantly affect the progression of PAH. In vivo, the results showed that administration of TMP significantly prolonged the survival of PAH rats by reducing the proliferative lesions, right ventricular systolic pressure (RVSP), mean pulmonary arterial pressure (mPAP), and the Fulton index in the heart and lung of PAH rats. In vitro, TMP can regulate the levels of smooth muscle protein 22-alpha (SM22-α), and myocardin as well as intracellular cytokines such as NO, transforming growth factor beta (TGF-β), and connective tissue growth factor (CTGF) in a dose-dependent manner (25, 50, or 100 μM). Transfection of myocardin small interfering RNA (siRNA) aggravated the proliferation of pulmonary artery smooth muscle cells (PSMCs), and the regulatory effect of TMP on α-smooth muscle actin (α-SMA) and osteopontin (OPN) disappeared. The application of 10 nM estrogen receptor alpha (ERα) inhibitor MPP promoted the proliferation of PSMCs, but it does not affect the inhibition of TMP on PSMCs proliferation. Finally, we found that TMP promoted the nucleation of myocardin-related transcription factor-A (MRTF-A) and combined it with myocardin. In conclusion, TMP can inhibit the transformation of PSMCs from the contractile phenotype to the proliferative phenotype by promoting the formation of the nuclear (MRTF-A/myocardin) transcription complex to treat PAH.

Performance of risk stratification scores and role of comorbidities in older vs younger patients with pulmonary arterial hypertension

BACKGROUND

Risk scores are important tools for the prognostic stratification of pulmonary arterial hypertension (PAH). Their performance and the additional impact of comorbidities across age groups is unknown.

METHODS

Patients with PAH enrolled from 2001 to 2021 were divided in ≥65 years old vs <65 years old patients. Study outcome was 5-year all-cause mortality. French Pulmonary Hypertension Network (FPHN), FPHN noninvasive, Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL 2.0) risk scores were calculated and patients categorized at low, intermediate and high risk. Number of comorbidities was calculated.

RESULTS

Among 383 patients, 152 (40%) were ≥65 years old. They had more comorbidities (number of comorbidities 2, IQR 1-3, vs 1, IQR 0-2 in <65 years patients). Five-year survival was 63% in ≥65 vs 90% in <65 years. Risk scores correctly discriminated the different classes of risk in the overall cohort and in the older and younger groups. REVEAL 2.0 showed the best accuracy in the total cohort (C-index 0.74, standard error-SE- 0.03) and older (C-index 0.69, SE 0.03) patients, whereas COMPERA 2.0 performed better in younger patients (C-index 0.75, SE 0.08). Number of comorbidities was associated with higher 5-year mortality, and consistently increased the accuracy of risk scores, in younger but not in older patients.

CONCLUSIONS

Risk scores have similar accuracy in the prognostic stratification of older vs younger PAH patients. REVEAL 2.0 had the best performance in older patients and COMPERA 2.0 had it in younger patients. Comorbidities increased the accuracy of risk scores only in younger patients.

Use of Levosimendan in Patients with Pulmonary Hypertension: What is the Current Evidence?

Pulmonary hypertension, defined as an increase in mean arterial pressure > 20 mmHg, is a chronic and progressive condition with high mortality and morbidity. Drug therapy of patients with pulmonary hypertension is based on the distinctive pathophysiologic aspect that characterizes the different groups. However, recently, levosimendan, a calcium-sensitizing agent with inotropic, pulmonary vasodilator, and cardioprotective properties, has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension (in addition to specific drugs) and pulmonary hypertension associated with left heart disease (as possible treatment). This review provides a comprehensive overview of the current evidence on the use of levosimendan in patients with pulmonary hypertension.

Left Heart Disease Phenotype in Elderly Patients with Pulmonary Arterial Hypertension: Insights from the Italian PATRIARCA Registry

Pulmonary arterial hypertension (PAH) in the elderly is often associated with left heart disease (LHD), prompting concerns about the use of pulmonary vasodilators. The PATRIARCA registry enrolled ≥70 year-old PAH or chronic thromboembolic pulmonary hypertension (CTEPH) patients at 11 Italian centers from 1 December 2019 through 15 September 2022. After excluding those with CTEPH, post-capillary PH at the diagnostic right heart catheterization (RHC), and/or incomplete data, 23 (33%) of a total of 69 subjects met the criteria proposed in the AMBITION trial to suspect LHD. Diabetes [9 (39%) vs. 6 (13%), p = 0.01] and chronic kidney disease [14 (61%) vs. 12 (26%), p = 0.003] were more common, and the last RHC pulmonary artery wedge pressure [14 ± 5 vs. 10 ± 3 mmHg, p < 0.001] was higher and pulmonary vascular resistance [5.56 ± 3.31 vs. 8.30 ± 4.80, p = 0.02] was lower in LHD than non-LHD patients. However, PAH therapy was similar, with 13 (57%) and 23 (50%) subjects, respectively, taking two oral drugs. PAH medication patterns remained comparable between LHD and non-LHD patients also when the former [37, 54%] were identified by atrial fibrillation and echocardiographic features of LHD, in addition to the AMBITION criteria. In this real-world snapshot, elderly PAH patients were treated with pulmonary vasodilators, including combinations, despite a remarkable prevalence of a LHD phenotype.

Clinical Characteristics of Patients Undergoing Right Heart Catheterizations in Community Hospitals

Background

Recognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals.

Methods and Results

In total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2–3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance.

Conclusions

Older age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

Hypoxia and hemorheological properties in older individuals

Hypoxia is caused by insufficient oxygen availability for the organism leading to reduced oxygen delivery to tissues and cells. It has been regarded as a severe threat to human health and it is indeed implicated in pathophysiological mechanisms involved in the development and progression of many diseases. Nevertheless, the potential of controlled hypoxia interventions (i.e. hypoxia conditioning) for improving cardio-vascular health is gaining increased attention. However, blood rheology is often a forgotten factor for vascular health while aging and hypoxia exposure are both suspected to alter hemorheological properties. These changes in blood rheology may influence the benefits-risks balance of hypoxia exposure in older individuals. The benefits of hypoxia exposure for vascular health are mainly reported for healthy populations and the combined impact of aging and hypoxia on blood rheology could therefore be deleterious in older individuals. This review discusses evidence of hypoxia-related and aging-related changes in blood viscosity and its determinants. It draws upon an extensive literature search on the effects of hypoxia/altitude and aging on blood rheology. Aging increases blood viscosity mainly through a rise in plasma viscosity, red blood cell (RBC) aggregation and a decrease in RBC deformability. Hypoxia also causes an increase in RBC aggregation and plasma viscosity. In addition, hypoxia exposure may increase hematocrit and modulate RBC deformability, depending on the hypoxic dose, i.e, beneficial effect of intermittent hypoxia with moderate dose vs deleterious effect of chronic continuous or intermittent hypoxia or if the hypoxic dose is too high. Special attention is directed toward the risks vs. benefits of hemorheological changes during hypoxia exposure in older individuals, and its clinical relevance for vascular disorders.

Doppler trans-thoracic echocardiography for detection of pulmonary hypertension in adults

BACKGROUND

Pulmonary hypertension (PH) is an important cause of morbidity and mortality, which leads to a substantial loss of exercise capacity. PH ultimately leads to right ventricular overload and subsequent heart failure and early death. Although early detection and treatment of PH are recommended, due to the limited responsiveness to therapy at late disease stages, many patients are diagnosed at a later stage of the disease because symptoms and signs of PH are nonspecific at earlier stages. While direct pressure measurement with right-heart catheterisation is the clinical reference standard for PH, it is not routinely used due to its invasiveness and complications. Trans-thoracic Doppler echocardiography is less invasive, less expensive, and widely available compared to right-heart catheterisation; it is therefore recommended that echocardiography be used as an initial diagnosis method in guidelines. However, several studies have questioned the accuracy of noninvasively measured pulmonary artery pressure. There is substantial uncertainty about the diagnostic accuracy of echocardiography for the diagnosis of PH.

OBJECTIVES

To determine the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH.

SEARCH METHODS

We searched MEDLINE, Embase, Web of Science Core Collection, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform from database inception to August 2021, reference lists of articles, and contacted study authors. We applied no restrictions on language or type of publication.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH, where right-heart catheterisation was the reference standard. We excluded diagnostic case-control studies (two-gate design), studies where right-heart catheterisation was not the reference standard, and those in which the reference standard threshold differed from 25 mmHg. We also excluded studies that did not provide sufficient diagnostic test accuracy data (true-positive [TP], false-positive [FP], true-negative [TN], and false-negative [FN] values, based on the reference standard). We included studies that provided data from which we could extract TP, FP, TN, and FN values, based on the reference standard. Two authors independently screened and assessed the eligibility based on the titles and abstracts of records identified by the search. After the title and abstract screening, the full-text reports of all potentially eligible studies were obtained, and two authors independently assessed the eligibility of the full-text reports.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. We assessed the methodological quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We estimated a summary receiver operating characteristic (SROC) curve by fitting a hierarchical summary ROC (HSROC) non-linear mixed model. We explored sources of heterogeneity regarding types of PH, methods to estimate the right atrial pressure, and threshold of index test to diagnose PH. All analyses were performed using the Review Manager 5, SAS and STATA statistical software.

MAIN RESULTS

We included 17 studies (comprising 3656 adult patients) assessing the diagnostic accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH. The included studies were heterogeneous in terms of patient distribution of age, sex, WHO classification, setting, country, positivity threshold, and year of publication. The prevalence of PH reported in the included studies varied widely (from 6% to 88%). The threshold of index test for PH diagnosis varied widely (from 30 mmHg to 47 mmHg) and was not always prespecified. No study was assigned low risk of bias or low concern in each QUADAS-2 domain assessed. Poor reporting, especially in the index test and reference standard domains, hampered conclusive judgement about the risk of bias. There was little consistency in the thresholds used in the included studies; therefore, common thresholds contained very sparse data, which prevented us from calculating summary points of accuracy estimates. With a fixed specificity of 86% (the median specificity), the estimated sensitivity derived from the median value of specificity using HSROC model was 87% (95% confidence interval [CI]: 78% to 96%). Using a prevalence of PH of 68%, which was the median among the included studies conducted mainly in tertiary hospitals, diagnosing a cohort of 1000 adult patients under suspicion of PH would result in 88 patients being undiagnosed with PH (false negatives) and 275 patients would avoid unnecessary referral for a right-heart catheterisation (true negatives). In addition, 592 of 1000 patients would receive an appropriate and timely referral for a right-heart catheterisation (true positives), while 45 patients would be wrongly considered to have PH (false positives). Conversely, when we assumed low prevalence of PH (10%), as in the case of preoperative examinations for liver transplantation, the number of false negatives and false positives would be 13 and 126, respectively.

AUTHORS' CONCLUSIONS

Our evidence assessment of echocardiography for the diagnosis of PH in adult patients revealed several limitations. We were unable to determine the average sensitivity and specificity at any particular index test threshold and to explain the observed variability in results. The high heterogeneity of the collected data and the poor methodological quality would constrain the implementation of this result into clinical practice. Further studies relative to the accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH in adults, that apply a rigorous methodology for conducting diagnostic test accuracy studies, are needed.

Endothelial Senescence: A New Age in Pulmonary Hypertension

Pulmonary hypertension is an enigmatic, deleterious disease driven by multiple heterogeneous causes with a burgeoning proportion of older patients with complex, chronic comorbidities without adequate treatment options. The underlying endothelial pathophenotypes that direct vasoconstriction and panvascular remodeling remain both controversial and incompletely defined. This review discusses emerging concepts centered on endothelial senescence in pulmonary vascular disease. This principle proposes a more heterogeneous, dynamic pulmonary endothelium in disease; it provides a potentially unifying feature of endothelial dysfunction in pulmonary hypertension irrespective of cause; and it supports a clinically relevant link between aging and pulmonary hypertension like other chronic illnesses. Thus, taking cues from studies on aging and age-related diseases, we present possible opportunities and barriers to diagnostic and therapeutic targeting of senescence in pulmonary hypertension.

An autopsy case of pulmonary arterial hypertension in an elderly patient with multimorbidity: a case report

Background

There is an increasing number of elderly patients with pulmonary arterial hypertension (PAH), and their characteristics differ from those of young or middle-aged patients with this condition.

Case summary

A 73-year-old woman with a history of myocardial infarction and cardiovascular risk factors was admitted to the hospital with 2-week exertional dyspnoea. Her initial diagnosis was heart failure with preserved ejection fraction, but the symptoms persisted despite receiving treatment with diuretics. Additional tests showed a significant decrease in diffusing capacity of carbon monoxide and findings suggestive of severe pulmonary hypertension (PH). Contrast-enhanced computed tomography of the chest, and pulmonary angiography, showed no narrowing or obstruction of the pulmonary arteries. Right heart catheterization revealed haemodynamic data implying pre-capillary PH. Her condition gradually deteriorated to World Health Organization functional class IV, and sequential combination therapy with tadalafil, macitentan, and selexipag was initiated with a PAH diagnosis; however, she died 1 month later. Pathological findings in autopsy were consistent with PAH, and some parts of the lungs revealed the presence of obstructive and interstitial lung disease.

Discussion

The majority of elderly patients with PAH might have multimorbidity. However, there is no specific treatment strategy. It is associated with diagnostic delay and worse prognosis; therefore, early suspicion and comprehensive tests, including right heart catheterization, are essential for better management.

Sex Differences in Ischemic Stroke Outcomes in Patients With Pulmonary Hypertension

Background The association between systemic hypertension and cerebrovascular disease is well documented. However, the impact of pulmonary hypertension (PH) on acute ischemic stroke outcomes is unknown despite PH being recognized as a risk factor for acute ischemic stroke. We aimed to determine the association between PH and adverse in-hospital outcomes after acute ischemic stroke, as well as whether there are sex differences in this association. Methods and Results Acute ischemic stroke admissions from the US National Inpatient Sample between October 2015 and December 2017 were included. The relationship between PH and outcomes (mortality, prolonged hospitalization >4 days, and routine home discharge) was analyzed using logistic regressions adjusting for demographics, comorbidities, and revascularization therapies. Interaction terms between PH and sex and age groups were also included. A total of 221 249 records representative of 1 106 045 admissions were included; 2.9% of patients had co-morbid PH, and 35.34% of those were male. PH was not associated with in-hospital mortality (odds ratio [OR], 0.96; 95% CI, 0.86-1.09) but was associated with increased odds of prolonged hospitalization (OR, 1.15; 95% CI, 1.09-1.22) and decreased odds of routine discharge (OR, 0.87; 95% CI, 0.81-0.94) for both sexes. Older patients with PH were significantly less likely to be discharged routinely (P=0.028) than their younger counterparts. Compared with female patients with PH, men were 31% more likely to die in hospital (P=0.024). Conclusions PH was not significantly associated with in-hospital mortality but was associated with prolonged hospitalization and adverse discharge status. Male patients with PH were more likely to die in hospital than female patients.

Implementation of a systematic comprehensive geriatric assessment for elderly patients suspected of pulmonary hypertension

BACKGROUND

The phenotype of patients seen for a suspicion of pulmonary hypertension has changed, with an increasing age and frequency of comorbidities. Selection of elderly patients, in whom a classical work-up is mandatory, is challenging. Comprehensive geriatric assessment (CGA) has modified the management of elderly patients with cancer. Pulmonary hypertension (PH) shares with cancer a functional impact and may evolve rapidly, depending on the group of PH. We assessed the impact of a systematic CGA in patients over 70 years old referred for a suspicion of PH.

METHODS

A standardised CGA was performed on every patient older than 70 years old, referred for a PH suspicion, before considering invasive tests for diagnosis and treatment, between July 2014 and May 2019. Our primary aim was to describe the impact of CGA on the decision to stop or pursue the recommended diagnostic work-up for PH.

RESULTS

Among the thirty-one patients evaluated [mean age 81,5 (72-91) years], a negative CGA leads to stop the diagnostic work-up in eleven patients. Among the nineteen remaining patients, sixteen had confirmed PH, with half being chronic thromboembolic pulmonary hypertension.

CONCLUSIONS

Our study indicates that comprehensive geriatric assessment could be an excellent first screen for elderly patients referred for a PH suspicion. Involving a geriatric physician stopped the investigations in one third of patients. In patients with a favourable CGA, PH was confirmed in most of the cases, with chronic thromboembolic pulmonary hypertension being the first cause of PH.

Characteristics and Prognostic Associations of Echocardiographic Pulmonary Hypertension With Normal Left Ventricular Systolic Function in Patients ≥90 Years of Age

The high prevalence of pulmonary hypertension (PH) in elderly patients is well known. However, much remains unknown about those population. We sought to find the clinical characteristics of echocardiographic PH and the prognostic factors in patients ≥90 years of age. We retrospectively reviewed 310 patients ≥90 years of age (median age 92 years, 64% women) diagnosed as echocardiographic PH (peak systolic pulmonary arterial pressure ≥40 mm Hg) with normal left ventricular systolic function. We defined left heart disease (LHD) as significant left-sided valve diseases, left ventricular hypertrophy and left ventricular diastolic dysfunction by using echocardiography. The endpoint was all-cause death at 2,000 days after diagnosis. LHD was found in 92% of patients. During the median follow-up of 367 days (interquartile range, 39-1,028 days), 151 all-cause deaths (49%) occurred. Multivariable Cox regression analysis demonstrated that right ventricular fraction area change <35% (adjusted hazard ratio [HR]: 2.31; p <0.001), pericardial effusion (adjusted HR: 2.28; p <0.001), serum albumin <3.5 g/dL (adjusted HR: 1.76; p = 0.001), chronic obstructive pulmonary disease (adjusted HR: 1.93; p = 0.001) and New York Heart Association (NYHA) class ≥II (adjusted HR: 1.73; p = 0.004) were associated with mortality after adjusted for age. In conclusion, LHD was significantly associated with echocardiographic PH in most patients ≥90 years of age. Also, the co-morbid factors at diagnosis (right ventricular systolic dysfunction, pericardial effusion, hypoalbuminemia, chronic obstructive pulmonary disease, and NYHA class ≥II) were independently associated with mortality.

Protective Effect of Statins on Pulmonary Hypertension in Chronic Obstructive Pulmonary Disease Patients: A Nationwide Retrospective, Matched Cohort Study

In Taiwan, patients with pulmonary hypertension (PH) related to chronic obstructive pulmonary disease (COPD) are most common PH population (group 3). However, efficacy of medical treatments and optimal prevention methods in this group remain uncertain. Statins such as indirect RhoA/Rho-kinase inhibitors influence one of key signalling pathways that promote PH onset. In this study, we explored protective effects of statins against PH in COPD patients using database from Taiwan National Health Insurance programme from 2002 to 2017. The main outcome was the risk of PH. The Cox proportional-hazards model and the Fine and Gray model were used to adjust covariate and competing risks to estimate the subdistribution hazard ratios (sHRs). 553,617 newly diagnosed COPD patients were stratified by statin users (n = 41,168) and statin nonusers (n = 512,449). After 1:1 propensity score matching of statin users (n = 41,163), and 41,163 statin nonusers were included for outcome analysis. Statin users had a 22% lower risk of PH than nonusers (sHR: 0.78, 95% confidence interval: 0.65-0.94). During subgroup analysis, taking higher daily doses and for a longer duration displayed a more significantly reduced risk of PH (both P for trend <0.001). Statins may have a protective effect against PH that is dose- and time-dependent.

Gender Differences in Risk Factors Associated With Pulmonary Artery Systolic Pressure, Heart Failure, and Mortality in Blacks: Jackson Heart Study

Background

Pulmonary hypertension is prevalent in black individuals, especially women. Elevated pulmonary artery systolic pressure (PASP) is associated with significant morbidity and mortality.

Methods and Results

We developed linear and proportional hazards models to examine potential gender‐related differences in risk factors for elevated PASP (estimated by transthoracic echocardiography) and PASP‐associated clinical outcomes (incident heart failure admissions and mortality) in JHS (Jackson Heart Study) participants. JHS is a prospective observational cohort study of heart disease in blacks from the Jackson, Mississippi, metropolitan area. The study cohort included participants with measurable transtricuspid gradients (n=3286) at the time of first/baseline examination, 2000–2004. The median age (interquartile range) of patients at baseline was 57.8 years (18.6 years) with 67.5% being women. The median PASP at baseline was higher in women (men: 26 mm Hg [interquartile range 8], women: 27 mm Hg [interquartile range 9]. In multivariate linear regression analyses with PASP, significant gender interactions were noted for age, chronic lung disease, pulse pressure, and obstructive spirometry. In exploratory analyses stratified by gender, body mass index, and obstructive and restrictive spirometry patterns were associated with PASP in women, and chronic lung disease was associated with PASP in men. Age and pulse pressure had stronger associations with PASP in women compared with men. There was a significant interaction between gender and PASP for heart failure admissions but not mortality.

Conclusions

Specific cardiopulmonary risk factors are associated with elevated PASP in women and men. Women with elevated PASP have a higher risk of incident heart failure admissions. Future research is needed to understand associated gender‐specific mechanisms that can help identify targeted prevention and management strategies for patients with elevated PASP.

Management of pulmonary arterial hypertension in patients aged over 65 years

Historically, pulmonary arterial hypertension (PAH) has been considered a disease of young adults, but over the last three decades, the average age at diagnosis has increased, presenting clinicians with some unique challenges. Clinical symptoms of PAH, including shortness of breath and reduced functional capacity, are not specific for the disease and may be present in older patients because of their age or as a result of comorbid conditions. Eliminating other causes for these symptoms can delay PAH diagnosis and initiation of PAH-specific treatment compared with younger patients. Currently, there are no specific guidelines relating to PAH in older patients and existing guidelines for identifying patients at potential risk of PAH may not be appropriate for patients aged over 65 years. Even though older patients tend to be diagnosed with more advanced symptoms, and evidence suggests that they are less responsive to PAH-specific therapies, treatment is often less aggressive than in younger patients. Even after adjusting for age, survival rates remain disproportionately lower in the older vs. younger PAH populations. Specific guidelines for diagnosis and treatment of older patients with PAH are needed to improve care and outcomes in this growing population. This review aims to assess the challenges associated with diagnosing and managing PAH in older patients, based on literature searches, authors' experiences, and expert opinions.

Clinical outcome and survival in 30 pulmonary hypertension patients with high severity indices and advanced functional class

BACKGROUND

Pulmonary hypertension (PH) is an idiopathic or secondary disorder associated with many systemic illnesses. Long-term survival in PH depends on the severity and functional class. Several new drugs are now available to treat PH, but their impact on clinical outcome and survival are not well established.

OBJECTIVES

Evaluate severity parameters and the impact of current recommended therapy on survival in PH.

DESIGN

Cross-sectional.

SETTINGS

Tertiary care center.

PATIENTS AND METHODS

The study included adult patients who had undergone right heart catheterization since 2012 and were diagnosed with pulmonary hypertension. Survival was recorded after 6 years, at the end of the study. Nine severity variables for PH were assessed including right ventricular size by echocardiogram and pulmonary artery diameter (PA diameter) and the ratio of pulmonary artery diameter to ascending aorta diameter (PA/Ao ratio) by CT.

MAIN OUTCOME MEASURES

Evaluation of severity parameters.

SAMPLE SIZE

30 patients.

RESULTS

Twenty-five patients were positive for 8/9 severity parameters. Eight of 30 (26.6%) patients died. In nonsurvivors, right ventricular size was increased by 25% ( P=.427), pulmonary vascular resistance increased by 29.4% in nonsurvivors ( P=.302), the 6-minute walk distance decreased by 21% ( P=.875), median brain natriuretic peptide increased by 96% ( P=.890), median GGT and alkaline phosphatase were 3 times higher in nonsurvivors ( P=.893 and P=.047, respectively) and PA/Ao was nonsignificantly decreased in nonsurvivors ( P=.373), Survival was decreased by a median of 2.3 years in nonsurvivors.

CONCLUSION

Our study identified a subgroup of PH patients with NYHA functional class III and above with worsening severity indicators who were labeled as a high-risk group. These patients showed continuous deterioration in their clinical status despite escalation of therapy with current guidelines. We recommend these high-risk group patients be referred for early lung transplantation.

LIMITATIONS

Low sample size and only a single center. Needs confirmation with a larger multicenter trial.

CONFLICT OF INTEREST

None.

Association of Undifferentiated Dyspnea in Late Life With Cardiovascular and Noncardiovascular Dysfunction: A Cross-sectional Analysis From the ARIC Study

Importance

Undifferentiated dyspnea is common in late life, but the relative contribution of subclinical cardiac dysfunction is unknown. Impairments in cardiac structure and function may be characteristics of undifferentiated dyspnea in elderly people, providing potential insights into occult heart failure (HF).

Objective

To quantify the association of undifferentiated dyspnea with cardiac dysfunction after accounting for other potential contributors.

Design, Setting, and Participants

This cross-sectional study used data from Atherosclerosis Risk in Communities study participants 65 years and older who attended the fifth study visit (from 2011 to 2013) and had not been diagnosed with HF, chronic obstructive pulmonary disease, morbid obesity, or severe kidney disease. Analyses were conducted from October 2017 to June 2018.

Exposures

Dyspnea measured using the modified Medical Research Council scale, with a score less than 2 classified as none to mild and a score of 2 or more classified as moderate to severe.

Main Outcomes and Measures

Using multivariable logistic regression, the association of undifferentiated dyspnea was defined using cardiac structure, systolic and diastolic function, pulmonary pressure (echocardiography), pulmonary function (spirometry), glomerular filtration rate, hemoglobin, body mass index, depression, and physical performance. The population-attributable risk was calculated for each dysfunction metric.

Results

Among 4342 participants (mean [SD] age, 75.9 [5.0] years; 2533 [58.3%] women), 1173 (27.0%) had undifferentiated dyspnea. Moderate to severe dyspnea was present in 574 participants (13.2%) and was associated with left ventricular (LV) hypertrophy (odds ratio [OR], 1.53; 95% CI, 1.25-1.87; P < .001) and LV diastolic (OR, 1.46; 95% CI, 1.20-1.78; P < .001) and systolic (OR, 1.28; 95% CI, 1.05-1.56; P = .02) dysfunction. Moderate to severe dyspnea was also associated with obstructive (OR, 1.59; 95% CI, 1.28-1.99; P < .001) and restrictive (OR, 2.56; 95% CI, 1.99-3.27; P < .001) findings on spirometry, renal impairment (OR, 1.32; 95% CI, 1.08-1.61; P = .01), anemia (OR, 1.72; 95% CI, 1.39-2.12; P < .001), lower (OR, 2.77; 95% CI, 2.18-3.51; P < .001) and upper (OR, 1.82; 95% CI, 1.49-2.23; P < .001) extremity weakness, depression (OR, 3.01; 95% CI, 2.24-4.25; P < .001), and obesity (OR, 2.35; 95% CI, 1.95-2.83; P < .001). After accounting for these, moderate to severe dyspnea was associated with LV hypertrophy (OR, 1.30; 95% CI, 1.01-1.67; P = .04) and was not associated with systolic or diastolic function. In contrast, in the fully adjusted model, other organ system measures were associated with dyspnea, except for glomerular filtration rate and grip strength. The population-attributable risk of dyspnea associated with obesity alone was 22.6% compared with 5.8% for LV hypertrophy.

Conclusions and Relevance

Undifferentiated dyspnea is multifactorial in older adults, and this study showed an association with obesity. When accounting for other relevant organ systems, cardiovascular function poorly discriminated those with vs those without dyspnea. Therefore, dyspnea should not be assumed to represent occult HF in this population.

Retrospective observational analysis of hospital discharge database to characterize primary pulmonary hypertension and its outcomes in Spain from 2004 to 2015

To examine trends in the incidence, characteristics and outcomes, and to identify factors associated with in-hospital mortality (IHM) of patients hospitalized for primary pulmonary hypertension (PPH) in Spain (2004-2015).We included all patients hospitalized with PPH and included in the Spanish National Hospital Discharge Database.We analyzed 46,883 discharges of patients (7.14% with PPH as their primary diagnosis). Incidence rates decreased from 6.15 cases per 100,000 inhabitants in 2004-06 to 3.40 in 2013-15 (P < .001). Mean age rose from 66.43 ± 21.28 to 69.73 ± 21.12 years (P < .001) and the proportion of females increased over the study period (58.44% vs 60.71%; P < .001). Comorbidity using the Charlson Comorbidity Index (CCI) also increased with 16.07% having CCI ≥3 in 2004-06 vs 21.795 in 2013-15. Median length of hospital stay (LOHS) was 1 day longer in period 2004-06, than in 2013-15 (9 vs 8 days; P < .001). The proportion of patients who were considered a readmission and the mean costs increased from 15.7% and 3712.46&OV0556; in the first period to 17.14% and 4040.28&OV0556; in 2013-15 (P < .001). IHM increased from 8.2% in 2004-06 to 9.93% in 2013-15 (P < .001). The predictors' of IHM among PPH patients included comorbidity and use of mechanical ventilation. Primary diagnosis of PPH did not predict higher IHM (OR 1.07; 95%CI 09-1.26).Our data indicates that the incidence of hospitalizations decreased in Spain between 2004 and 2015. Parallel, LOHS also decreased during this period. By contrast, comorbidity increased over time in PPH patients, as well as readmission rates, costs and IHM.

Mortality in US veterans with pulmonary hypertension: a retrospective analysis of survival by subtype and baseline factors

Pulmonary hypertension (PH) occurs when the pulmonary vasculature is itself diseased or becomes affected secondarily by comorbid conditions, commonly left heart or lung disease. The high prevalence of chronic cardiopulmonary conditions among patients served by Veterans Health Administration (VHA) suggests this population may be particularly susceptible to PH. We sought to identify clinical features and outcomes in veterans diagnosed with PH. We utilized the VHA Corporate Data Warehouse to identify veterans diagnosed between January 1, 2003 and September 30, 2015, assess relevant patient characteristics and their survival time. The effects of PH subtype and baseline factors on outcome were estimated by Cox modeling. There were 110,564 veterans diagnosed with PH during the study period. These veterans were predominantly male, had median age 70.2, and had a high burden of comorbid conditions. PH was frequently due to left heart and/or lung disease. Average survival after PH diagnosis was 3.88 years. Compared with other types, PH due to left heart disease, lung disease or both had shorter survival. This large retrospective study of veterans demonstrates the significance of PH due to left heart and/or lung disease which was common and had high risk of death. Multi-comorbidity was common and added to risk. These findings underscore the need for risk assessment tools for subjects with non-Group 1 PH and novel management strategies to improve their outcome. This study details the largest retrospective cohort assembled for evaluation of secondary PH and allows hypothesis-generating inquiries into these common conditions that are rarely prospectively studied.

Pulmonary arterial hypertension in the elderly: Clinical perspectives

Pulmonary hypertension (PH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventric-ular failure and death. Pulmonary arterial hypertension (PAH) (World Health Organization Group I), a subset of PH, and may be idiopathic in nature or associated with other systemic conditions and is thought to most commonly effect women, the majority of whom are of childbearing age. However, PAH in the elderly population is being increasingly diagnosed creating clinical considerations that had once not been considered. Often in an elderly population the diagnosis of PAH may be delayed due to chronic comorbid conditions such as coronary artery disease or other dyspneic conditions. Though survival and clinical outcomes have improved, the elderly population continues to have disproportionately lower survival rates. High clinical suspicion of PAH warrants a complete diagnostic workup with right heart catheterization. Upon diagnosis, PAH specific therapy should be initiated with possible drug interactions in mind. Adjuvant pulmonary rehabilitation should be considered as a conservative measure with definitive results. Finally, psychosomatic aspects of the disease should also be considered in elderly populations.

Features Associated With Discordance Between Pulmonary Arterial Wedge Pressure and Left Ventricular End Diastolic Pressure in Clinical Practice: Implications for Pulmonary Hypertension Classification

BACKGROUND

The measurements used to define pulmonary hypertension (PH) etiology, pulmonary arterial wedge pressure (PAWP), and left ventricular end-diastolic pressure (LVEDP) vary in clinical practice. We aimed to identify clinical features associated with measurement discrepancy between PAWP and LVEDP in patients with PH.

METHODS

We extracted clinical data and invasive hemodynamics from consecutive patients undergoing concurrent right and left heart catheterization at Vanderbilt University between 1998 and 2014. The primary outcome was discordance between PAWP and LVEDP in patients with PH in a logistic regression model.

RESULTS

We identified 2,270 study subjects (median age, 63 years; 53% men). The mean difference between PAWP and LVEDP was -1.6 mm Hg (interquartile range, -15 to 12 mm Hg). The two measurements were moderately correlated by linear regression (R = 0.6, P < .001). Results were similar when restricted to patients with PH. Among patients with PH (n = 1,331), older age (OR, 1.77; 95% CI, 1.23-2.45) was associated with PAWP underestimation in multivariate models, whereas atrial fibrillation (OR, 1.75; 95% CI, 1.08-2.84), a history of rheumatic valve disease (OR, 2.2; 95% CI, 1.36-3.52), and larger left atrial diameter (OR, 1.70; 95% CI, 1.24-2.32) were associated with PAWP overestimation of LVEDP. Results were similar in sensitivity analyses.

CONCLUSIONS

Clinically meaningful disagreement between PAWP and LVEDP is common. Atrial fibrillation, rheumatic valve disease, and larger left atrial diameter are associated with misclassification of PH etiology when relying on PAWP alone. These findings are important because of the fundamental differences in the treatment of precapillary and postcapillary PH.

Safety of right heart catheterization for pulmonary hypertension in very elderly patients

Right heart catheterization (RHC) is the reference test in diagnosing pulmonary hypertension (PH). The increasing age of patients at the time of diagnosis raises the issue of the morbidity of this invasive test in elderly individuals. We hypothesized that the morbidity associated with RHC would be increased in elderly patients and highlight differences in hemodynamic characteristics compared to younger patients. A retrospective study was conducted in a regional referral center for PH. Data for all consecutive RHCs performed during the study period were analyzed. Over a five-year period, 1060 RHCs were performed. Of the patients, 228 (21.5%) were aged ≥75 years and 832 (78.5%) were aged <75 years. Duration of the procedure and site of puncture did not differ according to age group (all P > 0.05). Nine procedures (0.9%) led to complications: three (1.3%) in patients aged >75 years and six (0.7%) in younger patients aged (P = 0.5). Eight were local vascular injuries, directly related to a femoral vein puncture (P < 0.001). Pulmonary arterial pressure and cardiac output were lower in patients aged >75 years than in younger patients (P = 0.001). RHC may be performed regardless of patient age. The rate of RHC complications is not increased in individuals aged >75 years. As most complications were related to femoral vein puncture, this route should be avoided whenever possible.

Impact of age and comorbidity on risk stratification in idiopathic pulmonary arterial hypertension

Recent reports from worldwide pulmonary hypertension registries show a new demographic picture for patients with idiopathic pulmonary arterial hypertension (IPAH), with an increasing prevalence among the elderly.We aimed to investigate the effects of age and comorbidity on risk stratification and outcome of patients with incident IPAH.The study population (n=264) was categorised into four age groups: 18-45, 46-64, 65-74 and ≥75 years. Individual risk profiles were determined according to a risk assessment instrument, based on the European Society of Cardiology and the European Respiratory Society guidelines. The change in risk group from baseline to follow-up (median 5 months) and survival were compared across age groups. In the two youngest age groups, a significant number of patients improved (18-45 years, Z= -4.613, p<0.001; 46-64 years, Z= -2.125, p=0.034), but no significant improvement was found in the older patient groups. 5-year survival was highest in patients aged 18-45 years (88%), while the survival rates were 63%, 56% and 36% for patients in the groups 46-64, 65-74 and ≥75 years, respectively (p<0.001). Ischaemic heart disease and kidney dysfunction independently predicted survival.These findings highlight the importance of age and specific comorbidities as prognostic markers of outcome in addition to established risk assessment algorithms.

Pulmonary Vascular Diseases in the Elderly

Pulmonary hypertension is a pathologic hemodynamic condition defined by a mean pulmonary arterial pressure of 25 mm Hg or greater at rest. Because of age-associated stiffening of the heart and the pulmonary vasculature and the higher prevalence in the elderly of comorbidities associated with the development of pulmonary hypertension, it is an increasingly common finding in this patient population. A right heart catheterization is necessary for the diagnosis and characterization of pulmonary hypertension. The general management is to treat the underlying conditions responsible for the development of the disorder. Pulmonary vasodilators are indicated in patients with pulmonary arterial hypertension.

ANTIBIOGRAM STUDY AND ANTIBIOTIC USE EVALUATION USING GYSSEN METHOD IN PATIENTS WITH DIABETIC FOOT

Foot infection is a common and serious problem in people with diabetes, which require proper management (diagnostic and therapeutic approaches) that can be cured. Empiric antibiotic regimen should be based on clinical data and bacteria pattern that are available, but definitive therapy should be based on the results of the infected tissue culture. The selection of initial antibiotic therapy was difficult and unwise use can lead to antibiotic-resistant. Evaluation is needed for using antibiotics to benefit wisely. The aim of this research is to analyzed the pattern of bacteria in diabetic foot and to its sensitivity test to antibiotics, analyze empiric antibiotics that can be recommended, and analyzed the use of antibiotics by Gyssen method. Data was analyzed with observational studies (descriptive non-experimental), retrospectively and prospectively in patients diabetic foot infection that met inclusion criteria. Retrospective data are used to analyzed bacteria pattern and its sensitivity test, while prospective data are used to evaluated the use of antibiotics based on bacteria pattern, during the period of late March-early August 2015 at Mardi Waluyo Hospital. Evaluation was conducted by Gyssen method. The results, retrospective data samples obtained 30 infection bacteria during August 2014-March 2015. The prevalence of gram-negative bacteria as 53.33% with most types of bacteria E.coli and Klebsiella oxytoca (13.33%), and gram-positive bacteria as 46.67% with the highest bacteria are Staphylococcus spp. and Streptococcus spp. From the prospective data in inclusion criteria, 13 patients with the highest prevalence of gram-negative bacteria are Klebsiella oxytoca (28.57%), and most gram-positive Staphylococcus auerus (35.71%). While the qualitative analysis of antibiotic use was conducted on 50 types of antibiotics. The results of the qualitative analysis using Gyssens method obtained category as 62%, 2%, 14%, 2B category as 26%, 3A category as 10%, 4A category 52%, 4B category as 6%, 4C category as 8% and there are no use of antibiotics in the category V and VI. Conclusions, Gyessen method can show that the use of antibiotics in diabetic foot patients in Mardi Waluyo hospital is dominated by inaccuracy in choice of antibiotic, and inaccuracies in the interval antibiotics.

The Complexity of Characteristics, Diagnoses and Treatment of Older Patients With Pulmonary Hypertension

BACKGROUND

Older patients with pulmonary hypertension (PH) are more likely to have complex comorbidity than younger patients with pulmonary arterial hypertension (PAH). The best approach to the evaluation and management of these patients is unclear.

METHODS

We, retrospectively, reviewed the clinical records of patients older than 60 years referred for evaluation for PAH. We recorded patient demographics, comorbidity, functional classification (FC), right heart catheterization data, echocardiographic data, chest radiographic images and pulmonary function results. We recorded the final diagnoses according to World Health Organization (WHO) subgroups and treatment outcomes based on changes in FC.

RESULTS

Ninety-seven records were reviewed in detail. The mean age was 71.2 ± 7.5 years with 66% women. Cardiovascular disease was the most frequent comorbidity. Mean PA pressure by catheterization was 39.5 ± 12.2mmHg (n = 65). The overall distribution after evaluation included 21 (21.6%) Group 1, 35 (36.1%) Group 2, 16 (16.5%) Group 3, 18 (18.6%) mixed Group 2 and 3, 6 (6.2%) Group 4 and 1 (1%) Group 5 patients. Group 1 patients were treated with PAH specific drug, and 12 patients had an improvement in FC with treatment.

CONCLUSIONS

Older patients with suspected PH often have significant cardiovascular and respiratory comorbidity. Comprehensive evaluations are needed to determine the severity of PH and associated diseases and to initiate treatment focused on FC. Patients in WHO Group 2 and mixed Group 2 and 3 were frequently identified and constituted a diagnostic and treatment challenge in this study. Older patients with PAH may benefit from PAH specific drugs.

Which prognostic factors should be used in pulmonary arterial hypertension in elderly patients?

In recent times, the prevalence of pulmonary arterial hypertension (PAH) is more commonly seen among elderly populations. The increased prevalence of hypertension, diabetes, obesity, arterial stiffness, as well as diastolic dysfunction, may cause endothelial dysfunction and affect pulmonary vasculature. Furthermore, older patients have certain differences in clinical characteristics and outcomes. In this article, the special characteristics of aging in PAH patients have been reviewed, while the risk predictors of elderly patients are also discussed.

Pulmonary arterial hypertension in critically ill elderly patients

Objective:

To assess the incidence, possible risk factors and prognosis of pulmonary arterial hypertension (PAH) in critically ill elderly patients.

Methods:

We selected 122 cases admitted to the ICU, ages 60–93 years old. An echocardiography examination was performed within four days after admission to the ICU. PAH is usually suspected if the patient’s pulmonary artery systolic pressure ≥ 40 mmHg. We collected echocardiography data, relevant clinical data and routine laboratory data; we then used a statistical method to analyze the risk factors for PAH in critically ill elderly patients and examined its impact on the prognosis.

Results:

Total 51 patients were diagnosed with PAH. The prevalence of critically ill elderly patients with PAH was 41.8%. The ANOVA analysis showed that if patients had COPD (P = 0.031) and/or respiratory failure (P = 0.021), they were more prone to PAH. An enlarged left atrium (P = 0.038) and/or right ventricle (P = 0.029), a declining left ventricle fractional shortening rate (P = 0.038), and an elevated amount of the brain natriuretic peptides (P = 0.046) were all associated with the occurrence of PAH. Multivariate regression analysis showed that the left atrial diameter (P = 0.045) was the risk factor in critically ill elderly patients with PAH. The 30-day mortality rate was 33.3% for elderly patients with PAH, which is statistically significant (P = 0.035) when compared with the mortality rate of patients with normal pulmonary artery pressure. Our multivariate regression analysis also showed that, for critically ill elderly patients admitted in the ICU, PAH (P = 0.039) is risk factor for increased mortality.

Conclusions:

A higher incidence of PAH occurs in critically ill elderly patients. PAH is more likely to occur in patients with an enlarged left atrium, and these problems adversely impact the prognosis.

Prognostic Factors in Patients With Pulmonary Hypertension-A Nationwide Cohort Study

Background

Pulmonary hypertension (PH) is a rare but fatal condition. Large‐scale studies to examine the prognostic factors are lacking. In the present study, we aimed to investigate the factors associated with overall mortality in PH patients.

Methods and Results

Based on Taiwan's National Health Insurance Database, we identified 1092 newly identified PH patients between 1999 and 2011. These patients were matched with 8736 healthy subjects based on propensity score calculated with age, sex, and chronic cardiovascular risk factors. Overall mortality, death incidence rate ratio, and hazard ratio were calculated. Patients with PH had a higher mortality than controls (56.45 versus 18.51 per 1000 person‐years, P<0.0001), with hazard ratio at 3.3 (95% CI: 2.92–3.73, P<0.001). The long‐term survival rates of the PH patients at 1, 5, and 10 years were 87.9%, 72.5%, and 62.6%, respectively, which were significantly lower than controls with 98.4%, 90.8%, and 83.6% at 1, 5, and 10 years, respectively. Among patients with PH, the mortality rate was higher in the older and male patients. However, after stratifying by age and sex, the younger (<50 years) and female patients had a higher risk. Regarding different etiologies of PH, chronic obstructive pulmonary disease and pulmonary embolism led to most cases of mortality (adjusted hazard ratio: 3.2, 95% CI: 2.76–3.71 and 4.64, 95% CI: 2.74–7.87, P<0.05).

Conclusions

PH has high mortality, especially in females, and patients with younger age and with chronic diseases. Chronic obstructive pulmonary disease and pulmonary embolism contributed to an increased risk of mortality in PH patients.

Pulmonary Hypertension - New Trends of Diagnostic and Therapy

Pulmonary hypertension is a pathophysiological state hemodynamically defined as the increase of the mean pulmonary arterial pressure above 25, or 30 mmHg at rest, measured by catheterization of the right heart. Laboratory findings usually reveals polycythemia, the ECG right ventricle hypertrophy, and x-ray characteristic of diseased branches (echocardiography and biomarkers such as B-type natriuretic peptide (BNP) and N-terminal pro-BNP hormones are potentially helpful tools in identifying PH). Echocardiography can be found the increase of the right atrium and ventricle, right ventricular hypertrophy, abnormal contraction of the interventricular septum, left ventricular diastolic dysfunction and decreased left ventricular size, with reduced volumes of systole and end diastole. Doppler confirming tricuspid regurgitation. Pharmacological therapy would represent a use: Calcium Channel Blockers, Prostacyclin Analogues, Endothelin Receptor Antagonists and Phosphodiesterase-5 Inhibitors. Alpha adrenergic antagonists, endothelial receptor subtype A (Bosentan, Tracller) with treatment of the underlying disease or anticongestive therapy, are recommended. In case of inadequate response to treatment with a specific drug, guidelines recommend the combined use of drugs from the basic three groups, using their synergism.

Pulmonary hypertension in the elderly: a different disease?

Pulmonary hypertension (PH) is a haemodynamic syndrome defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg determined by right heart catheterisation (RHC) [1, 2]. A lot of ­diseases fulfil this definition, but they differ widely between each other in respect to their pathophysiology, their haemodynamic characteristics, their clinical presentation, their natural prognosis and their potential therapeutic strategies. The current guidelines on PH diagnosis and management make the distinction between five groups of more than 200 causes of PH [2], but these diseases are very different from one another. In the current classification, the first group (group 1) represents a progressive vasculopathy leading to pre-capillary PH called pulmonary arterial hypertension (PAH), characterised by a characteristic small-calibre pulmonary artery remodelling, as a result of proliferation of endothelial and smooth muscle cells as well as medial hypertrophy. So, if we compare PAH (for example idiopathic PAH) from PH due to valvular disease like mitral insufficiency (group 2.3) it is easy to understand that apart from the fact that mean pulmonary arterial pressure (mPAP) exceeds 25 mmHg in both cases, these two entities have very different pathophysiological pathways. In the first case, there is a true pulmonary vasculopathy. In the second, PH is mainly related to the consequences of an increased hydrostatic pressure in the left atrium ­transmitted to the venous compartment of the pulmonary circulation and then back through the capillary bed. If the pathophysiology of these entities is different, the targets of their treatments are too. The main goal of PAH treatment consists in reducing pulmonary vascular resistance (PVR) with specific medication and, when appropriate, with specific treatment of the underlying disease as it is the case for associated-PAH (group 1.4). Alternatively, the management of PH related to a mitral regurgitation would be to improve the ventricular preload, diminish the ventricular afterload and, if necessary, to correct the anatomical anomaly.

The distinction between PH in the elderly and normal ageing might make diagnosis difficulthttp://ow.ly/YYF1Q

Effect of Age on Phenotype and Outcomes in Pulmonary Arterial Hypertension Trials

BACKGROUND

In recent years, the population of patients with pulmonary arterial hypertension (PAH) has changed dramatically, including more advanced age at diagnosis. We hypothesized that older patients have a distinct clinical profile with different disease characteristics and response to intervention.

METHODS

All previously published treatment studies for PAH conducted by United Therapeutics including seven randomized, placebo-controlled trials and one extension study were included and analyzed to assess the association of age with various demographic, functional, hemodynamic, and outcome variables.

RESULTS

A total of 2,627 patients across three age groups were included: ≤ 50 (n = 1,438, 54.7%), 51 to 64 (n = 780, 29.7%), and ≥ 65 years (n = 409, 15.6%). In comparison with the youngest group, the oldest age group had higher proportions of connective tissue disease-associated etiology (range across the studies, 27%-49% vs 13%-21%), higher proportions of New York Heart Association Functional classes III and IV (74%-91% vs 57%-84%), shorter baseline 6-min walk distance (6MWD) (261-316 vs 335-371 m), better hemodynamic measurements including lower baseline mean pulmonary artery pressure (48-51 vs 58-63 mmHg), and smaller changes in 6MWD from baseline to endpoint (-5.6 to 24 vs 14-43 m). Age remained associated with change in 6MWD when adjusting for covariates in multivariate analyses.

CONCLUSIONS

For the first time, using data from large randomized controlled trials, this study characterizes the different phenotype and outcomes of older patients with PAH, which includes different disease etiology, diminished functional status, and decreased response to intervention. This may have significant implications for the management of this patient population and design of future therapy trials.