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Slegg OG, Willis JA, Wilkinson F, Sparey J, Wild CB, Rossdale J, Ross RM, Pauling JD, Carson K, Kandan SR, Oxborough D, Knight D, Peacock OJ, Suntharalingam J, Coghlan JG, Augustine DX. IMproving PULmonary hypertension Screening by Echocardiography: IMPULSE. Echo Res Pract 2022; 9:9. [PMID: 36258244 PMCID: PMC9580132 DOI: 10.1186/s44156-022-00010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/24/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The world symposium on pulmonary hypertension (PH) has proposed that PH be defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as assessed by right heart catheterisation (RHC). Transthoracic echocardiography (TTE) is an established screening tool used for suspected PH. International guidelines recommend a multi-parameter assessment of the TTE PH probability although effectiveness has not been established using real world data. STUDY AIMS To determine accuracy of the European Society of Cardiology (ESC) and British Society of Echocardiography (BSE) TTE probability algorithm in detecting PH in patients attending a UK PH centre. To identify echocardiographic markers and revised algorithms to improve the detection of PH in those with low/intermediate BSE/ESC TTE PH probability. METHODS TTE followed by RHC (within 4 months after) was undertaken in patients for suspected but previously unconfirmed PH. BSE/ESC PH TTE probabilities were calculated alongside additional markers of right ventricular (RV) longitudinal and radial function, and RV diastolic function. A refined IMPULSE algorithm was devised and evaluated in patients with low and/or intermediate ESC/BSE TTE PH probability. RESULTS Of 310 patients assessed, 236 (76%) had RHC-confirmed PH (average mPAP 42.8 ± 11.7). Sensitivity and specificity for detecting PH using the BSE/ESC recommendations was 89% and 68%, respectively. 36% of those with low BSE/ESC TTE probability had RHC-confirmed PH and BSE/ESC PH probability parameters did not differ amongst those with and without PH in the low probability group. Conversely, RV free wall longitudinal strain (RVFWLS) was lower in patients with vs. without PH in low BSE/ESC probability group (- 20.6 ± 4.1% vs - 23.8 ± 3.9%) (P < 0.02). Incorporating RVFWLS and TTE features of RV radial and diastolic function (RVFAC and IVRT) within the IMPULSE algorithm reduced false negatives in patients with low BSE/ESC PH probability by 29%. The IMPULSE algorithm had excellent specificity and positive predictive value in those with low (93%/80%, respectively) or intermediate (82%/86%, respectively) PH probability. CONCLUSION Existing TTE PH probability guidelines lack sensitivity to detect patients with milder haemodynamic forms of PH. Combining additional TTE makers assessing RV radial, longitudinal and diastolic function enhance identification of milder forms of PH, particularly in those who have a low BSE/ESC TTE PH probability.
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Affiliation(s)
- Oliver Graham Slegg
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA13NG, UK
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | | | - Fiona Wilkinson
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Joseph Sparey
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA13NG, UK
| | | | | | | | - John D Pauling
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA13NG, UK
| | - Kevin Carson
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA13NG, UK
| | | | | | | | | | | | | | - Daniel Xavier Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA13NG, UK.
- Department for Health, University of Bath, Bath, UK.
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Foley RW, Kaneria N, Ross RVM, Suntharalingam J, Hudson BJ, Rodrigues JC, Robinson G. Computed tomography appearances of the lung parenchyma in pulmonary hypertension. Br J Radiol 2021; 94:20200830. [PMID: 32915646 DOI: 10.1259/bjr.20200830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Computed tomography (CT) is a valuable tool in the workup of patients under investigation for pulmonary hypertension (PH) and may be the first test to suggest the diagnosis. CT parenchymal lung changes can help to differentiate the aetiology of PH. CT can demonstrate interstitial lung disease, emphysema associated with chronic obstructive pulmonary disease, features of left heart failure (including interstitial oedema), and changes secondary to miscellaneous conditions such as sarcoidosis. CT also demonstrates parenchymal changes secondary to chronic thromboembolic disease and venous diseases such as pulmonary venous occlusive disease (PVOD) and pulmonary capillary haemangiomatosis (PCH). It is important for the radiologist to be aware of the various manifestations of PH in the lung, to help facilitate an accurate and timely diagnosis. This pictorial review illustrates the parenchymal lung changes that can be seen in the various conditions causing PH.
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Affiliation(s)
- Robert W Foley
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Nirav Kaneria
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Rob V MacKenzie Ross
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Jay Suntharalingam
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Benjamin J Hudson
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Jonathan Cl Rodrigues
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Graham Robinson
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
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Pi H, Kosanovich CM, Handen A, Tao M, Visina J, Vanspeybroeck G, Simon MA, Risbano MG, Desai A, Mathier MA, Rivera-Lebron BN, Nguyen Q, Kliner J, Nouraie M, Chan SY. Outcomes of Pulmonary Arterial Hypertension Are Improved in a Specialty Care Center. Chest 2020; 158:330-340. [PMID: 32109446 DOI: 10.1016/j.chest.2020.01.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 12/22/2019] [Accepted: 01/26/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressures and is managed by vasodilator therapies. Current guidelines encourage PAH management in specialty care centers (SCCs), but evidence is sparse regarding improvement in clinical outcomes and correlation to vasodilator use with referral. RESEARCH QUESTION Is PAH management at SCCs associated with improved clinical outcomes? STUDY DESIGNAND METHODS A single-center, retrospective study was performed at the University of Pittsburgh Medical Center (UPMC; overseeing 40 hospitals). Patients with PAH were identified between 2008 and 2018 and classified into an SCC or non-SCC cohort. Cox proportional hazard modeling was done to compare for all-cause mortality, as was negative binomial regression modeling for hospitalizations. Vasodilator therapy was included to adjust outcomes. RESULTS Of 580 patients with PAH at UPMC, 455 (78%) were treated at the SCC, comprising a younger (58.8 vs 64.8 years; P < .001) and more often female (68.4% vs 51.2%; P < .001) population with more comorbidities without differences in race or income. SCC patients demonstrated improved survival (hazard ratio, 0.68; P = .012) and fewer hospitalizations (incidence ratio, 0.54; P < .001), and provided more frequent disease monitoring. Early patient referral to SCC (< 6 months from time of diagnosis) was associated with improved outcomes compared with non-SCC patients. SCC patients were more frequently prescribed vasodilators (P < .001) and carried more diagnostic PAH coding (P < .001). Vasodilators were associated with improved outcomes irrespective of location but without statistical significance when comparing between locations (P > .05). INTERPRETATION The UPMC SCC demonstrated improved outcomes in mortality and hospitalizations. The SCC benefit was multifactorial, with more frequent vasodilator therapy and disease monitoring. These findings provide robust evidence for early and regular referral of patients with PAH to SCCs.
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Affiliation(s)
- Hongyang Pi
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Chad M Kosanovich
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam Handen
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA
| | - Michael Tao
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jacqueline Visina
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Marc A Simon
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael G Risbano
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Aken Desai
- Division of Cardiovascular Medicine, University of Colorado, Aurora, CO
| | - Michael A Mathier
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Belinda N Rivera-Lebron
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Quyen Nguyen
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer Kliner
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen Y Chan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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