1
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Grünig E, Rahaghi F, Elwing J, Vizza CD, Pepke-Zaba J, Shen J, Yao H, Hage A, Rosenkranz S, Vonk M, Balasubramanian V, Yuanhua Y, Yu Z, Lordan J, Cadaret L, Grover R, Ousmanou A, Seaman S, Deng C, Broderick M, White RJ. Oral Treprostinil is Associated with Improved Survival in FREEDOM-EV and its Open-Label Extension. Adv Ther 2024; 41:618-637. [PMID: 38055186 PMCID: PMC10838815 DOI: 10.1007/s12325-023-02711-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/09/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION In the event-driven FREEDOM-EV trial, oral treprostinil delayed clinical worsening in patients with pulmonary arterial hypertension (PAH). Open-label extension studies offer additional data about tolerability, efficacy, and survival, especially for those initially assigned placebo. The aim of the current study was to determine if oral treprostinil changed survival when considering the parent and extension study, if treprostinil provides functional benefits for participants initially assigned to placebo, and if the benefits observed for those treated with treprostinil were durable. METHODS Both active and placebo participants from FREEDOM-EV could enroll in the FREEDOM-EV open-label extension (OLE) study after experiencing an investigator-assessed clinical worsening event or after parent study closure. All participants in the OLE were offered open-label oral treprostinil. Previously assigned placebo participants titrated to maximally tolerated doses; previously assigned treprostinil participants continued dose titration. We repeated assessments including functional class and 6-min walk distance (6MWD) at 12-week intervals and measured N-terminal pro-brain natriuretic peptide (NT-proBNP) at week 48. Survival was estimated by Kaplan-Meier analysis, and we estimated hazard ratio (HR) using Cox proportional hazards. RESULTS Of 690 FREEDOM-EV participants, 470 enrolled in the OLE; vital status was available for 89% of initial Freedom-EV participants. When considering the combined parent and open-label data, initial assignment to oral treprostinil reduced mortality (HR 0.64, 95% confidence interval 0.46-0.91, p = 0.013); absolute risk reduction was 9%. Participants randomized to placebo who initiated oral treprostinil after clinical worsening and tolerated treatment through week 48 demonstrated favorable shifts in functional class (p < 0.0001), 6MWD improvements of + 84 m (p < 0.0001), and a reduction in NT-proBNP of - 778 pg/mL (p = 0.02), compared to OLE baseline. Modest trends toward benefit were measured for those initially assigned placebo who did not have clinical worsening, and 132/144 (92%) of treprostinil assigned participants without clinical worsening remained on drug at week 48 in the OLE study. Adverse events were consistent with FREEDOM-EV. CONCLUSION Initial treprostinil assignment improved survival in the entire data set; those who began treprostinil after a clinical worsening in the placebo arm and tolerated drug to week 48 enjoyed substantial functional gains. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01560637.
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Affiliation(s)
- Ekkehard Grünig
- Thoraxklinik-Heidelberg gGmbH, and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franck Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida, Weston, FL, USA
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza Università di Roma, Rome, Italy
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Yao
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Antoine Hage
- Pulmonary Hypertension Program, Department of Pulmonology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University of Cologne, Cologne, Germany
| | - Madelon Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Yang Yuanhua
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - James Lordan
- Cardiopulmonary Transplantation, Institute of Transplantation, Institute of Cellular Medicine, Newcastle University and the Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Linda Cadaret
- Division of Cardiology, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Rob Grover
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Aliou Ousmanou
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Scott Seaman
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Chunqin Deng
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine and the Mary M. Parkes Center, University of Rochester Medical Center, Rochester, NY, USA.
- Mary M. Parkes Center for Asthma, Allergy, and Pulmonary Care, University of Rochester Medical Center, 400 Red Creek Drive, Rochester, NY, 14623, USA.
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Morland K, Gerges C, Elwing J, Visovatti SH, Weatherald J, Gillmeyer KR, Sahay S, Mathai SC, Boucly A, Williams PG, Harikrishnan S, Minty EP, Hobohm L, Jose A, Badagliacca R, Lau EMT, Jing Z, Vanderpool RR, Fauvel C, Leonidas Alves J, Strange G, Pulido T, Qian J, Li M, Mercurio V, Zelt JGE, Moles VM, Cirulis MM, Nikkho SM, Benza RL, Elliott CG. Real-world evidence to advance knowledge in pulmonary hypertension: Status, challenges, and opportunities. A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative's Real-world Evidence Working Group. Pulm Circ 2023; 13:e12317. [PMID: 38144948 PMCID: PMC10739115 DOI: 10.1002/pul2.12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/26/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
This manuscript on real-world evidence (RWE) in pulmonary hypertension (PH) incorporates the broad experience of members of the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative Real-World Evidence Working Group. We aim to strengthen the research community's understanding of RWE in PH to facilitate clinical research advances and ultimately improve patient care. Herein, we review real-world data (RWD) sources, discuss challenges and opportunities when using RWD sources to study PH populations, and identify resources needed to support the generation of meaningful RWE for the global PH community.
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Affiliation(s)
- Kellie Morland
- Global Medical AffairsUnited Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Christian Gerges
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Scott H. Visovatti
- Division of Cardiovascular MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary MedicineUniversity of AlbertaEdmontonCanada
| | - Kari R. Gillmeyer
- The Pulmonary CenterBoston University Chobian & Avedisian School of MedicineBostonMassachusettsUSA
- Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedfordMassachusettsUSA
| | - Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep MedicineHouston Methodist HospitalHoustonTexasUSA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Athénaïs Boucly
- Faculté de MédecineUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital BicêtreAssistance Publique Hôpitaux de ParisLe Kremlin BicêtreFrance
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Paul G. Williams
- Center of Chest Diseases & Critical CareMilpark HospitalJohannesburgSouth Africa
| | | | - Evan P. Minty
- Department of Medicine & O'Brien Institute for Public HealthUniversity of CalgaryCalgaryCanada
| | - Lukas Hobohm
- Department of CardiologyUniversity Medical Center of the Johannes Gutenberg University MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg University MainzMainzGermany
| | - Arun Jose
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of RomePoliclinico Umberto IRomeItaly
| | - Edmund M. T. Lau
- Department of Respiratory Medicine, Royal Prince Alfred HospitalUniversity of SydneyCamperdownNew South WalesAustralia
- Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Zhi‐Cheng Jing
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | | | - Charles Fauvel
- Service de Cardiologie, Centre de Compétence en Hypertension Pulmonaire 27/76, Centre Hospitalier Universitaire Charles Nicolle, INSERM EnVI U1096Université de RouenRouenFrance
| | - Jose Leonidas Alves
- Pulmonary Division, Heart InstituteUniversity of São Paulo Medical SchoolSão PauloBrazil
| | - Geoff Strange
- School of MedicineThe University of Notre Dame AustraliaPerthWestern AustraliaAustralia
| | - Tomas Pulido
- Ignacio Chávez National Heart InstituteMéxico CityMexico
| | - Junyan Qian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC‐DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical ImmunologyMinistry of EducationBeijingChina
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC‐DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical ImmunologyMinistry of EducationBeijingChina
| | - Valentina Mercurio
- Department of Translational Medical SciencesFederico II UniversityNaplesItaly
| | - Jason G. E. Zelt
- Department of Medicine, Faculty of MedicineUniversity of OttawaOttawaCanada
| | - Victor M. Moles
- Division of Cardiovascular MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical Center MurraySalt Lake CityUtahUSA
| | | | - Raymond L. Benza
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - C. Gregory Elliott
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical Center MurraySalt Lake CityUtahUSA
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Mayer M, Badesch DB, Nielsen KH, Kawut S, Bull T, Ryan JJ, Sager J, Mazimba S, Hemnes A, Klinger J, Runo J, McConnell JW, De Marco T, Chakinala MM, Yung D, Elwing J, Kaplan A, Argula R, Pomponio R, Peterson R, Hountras P. Impact of the COVID-19 pandemic on chronic disease management and patient reported outcomes in patients with pulmonary hypertension: The Pulmonary Hypertension Association Registry. Pulm Circ 2023; 13:e12233. [PMID: 37159803 PMCID: PMC10163321 DOI: 10.1002/pul2.12233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
To better understand the impact of the COVID-19 pandemic on the care of patients with pulmonary hypertension, we conducted a retrospective cohort study evaluating health insurance status, healthcare access, disease severity, and patient reported outcomes in this population. Using the Pulmonary Hypertension Association Registry (PHAR), we defined and extracted a longitudinal cohort of pulmonary arterial hypertension (PAH) patients from the PHAR's inception in 2015 until March 2022. We used generalized estimating equations to model the impact of the COVID-19 pandemic on patient outcomes, adjusting for demographic confounders. We assessed whether insurance status modified these effects via covariate interactions. PAH patients were more likely to be on publicly-sponsored insurance during the COVID-19 pandemic compared with prior, and did not experience statistically significant delays in access to medications, increased emergency room visits or nights in the hospital, or worsening of mental health metrics. Patients on publicly-sponsored insurance had higher healthcare utilization and worse objective measures of disease severity compared with privately insured individuals irrespective of the COVID-19 pandemic. The relatively small impact of the COVID-19 pandemic on pulmonary hypertension-related outcomes was unexpected but may be due to pre-established access to high quality care at pulmonary hypertension comprehensive care centers. Irrespective of the COVID-19 pandemic, patients who were on publicly-sponsored insurance seemed to do worse, consistent with prior studies highlighting outcomes in this population. We speculate that previously established care relationships may lessen the impact of an acute event, such as a pandemic, on patients with chronic illness.
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Affiliation(s)
- Megan Mayer
- Pulmonary Sciences & Critical Care Medicine, University of ColoradoAuroraColoradoUSA
| | - David B. Badesch
- Pulmonary Sciences & Critical Care Medicine, University of ColoradoAuroraColoradoUSA
| | - Kelly H. Nielsen
- Pulmonary Sciences & Critical Care Medicine, University of ColoradoAuroraColoradoUSA
| | - Steven Kawut
- Department of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Todd Bull
- Pulmonary Sciences & Critical Care Medicine, University of ColoradoAuroraColoradoUSA
| | - John J. Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of UtahSalt Lake CityUtahUSA
| | - Jeffrey Sager
- Cottage Health Pulmonary Hypertension CenterSanta BarbaraCaliforniaUSA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of VirginiaCharlottesvilleVirginiaUSA
| | - Anna Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Vanderbilt UniversityNashvilleTennesseeUSA
| | | | - James Runo
- Division of Pulmonary & Critical Care Medicine, University of WisconsinMadisonWisconsinUSA
| | | | - Teresa De Marco
- Division of Cardiology, University of California, San FranciscoSan Francisco Medical CenterCaliforniaUSA
| | - Murali M. Chakinala
- Division of Pulmonary & Critical Care Medicine, Washington University School of MedicineSt. LouisMissouriUSA
| | - Delphine Yung
- Division of Pediatric CardiologyUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jean Elwing
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Adolfo Kaplan
- Department of Internal MedicineUniversity of Texas‐Rio Grande ValleyMcAllenTexasUSA
| | - Rahul Argula
- Division of Pulmonary and Critical care medicine, Medical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Raymond Pomponio
- Department of Biostatistics & Informatics, Colorado School of Public HealthUniversity of Colorado‐Anschutz Medical CampusAuroraColoradoUSA
| | - Ryan Peterson
- Department of Biostatistics & Informatics, Colorado School of Public HealthUniversity of Colorado‐Anschutz Medical CampusAuroraColoradoUSA
| | - Peter Hountras
- Pulmonary Sciences & Critical Care Medicine, University of ColoradoAuroraColoradoUSA
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4
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Nathan SD, Deng C, King CS, DuBrock HM, Elwing J, Rajagopal S, Rischard F, Sahay S, Broderick M, Shen E, Smith P, Tapson VF, Waxman AB. Inhaled Treprostinil Dosage in Pulmonary Hypertension Associated With Interstitial Lung Disease and Its Effects on Clinical Outcomes. Chest 2023; 163:398-406. [PMID: 36115497 PMCID: PMC10083130 DOI: 10.1016/j.chest.2022.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) complicates the course of many patients with fibrotic interstitial lung disease (ILD). Inhaled treprostinil (iTre) has been shown to improve functional ability and to delay clinical worsening in patients with PH resulting from ILD. RESEARCH QUESTION Do higher dosages of iTre have greater benefits in preventing clinical worsening and achieving clinical improvement? STUDY DESIGN AND METHODS Post hoc analysis of the INCREASE study, a 16-week double-blind, randomized, placebo-controlled trial of iTre in patients with PH resulting from ILD. Four groups were identified based on the number of breaths per session (bps; < 9 and ≥ 9 bps) of active drug or placebo attained at 4 weeks. Patients were evaluated for clinical worsening (15% decrease in 6-min walkdistance, cardiopulmonary hospitalization, lung transplantation, or death) or clinical improvement (15% increase in the six-minute walk distance with a concomitant 30% reduction in N-terminal prohormone of brain natriuretic peptide without any clinical worsening event). RESULTS At 4 weeks, 70 patients were at a dose of ≥ 9 bps (high-dosage group) and 79 patients were at a dose of < 9 bps (low-dosage group) in the iTre arm vs 86 patients in the high-dose group and 67 patients in the low-dose group in the placebo arm. Between weeks 4 and 16, 17.1% of patients in the high-dose treprostinil group and 22.8% in the low-dose treatment group experienced a clinical worsening event vs 33.7% and 34.3% of patients in the two placebo arms, respectively (P = .006). By week 16, 15.7% and 12.7% of patients in the high- and low-dose iTre groups, respectively, demonstrated clinical improvement vs 7% and 1.5% patients in the placebo arms (P = .003) INTERPRETATION: Higher dosages of iTre overall show greater benefit in terms of preventing clinical worsening and achieving clinical improvement. These data support the early initiation and uptitration of therapy to a dosage of at least 9 bps four times daily in patients with PH resulting from ILD. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02630316; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
| | - Chunqin Deng
- United Therapeutics Corporation, Research Triangle Park, NC
| | | | | | - Jean Elwing
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Sandeep Sahay
- Houston Methodist Lung Center, Houston Methodist Hospital, Houston, TX
| | | | - Eric Shen
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Peter Smith
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Victor F Tapson
- Cedars-Sinai Medical Center, Los Angeles, CA; Inari Medical, Irvine, CA
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5
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Barbera JA, Kiely D, Gruenig E, Balasubramanian V, Vizza CD, Elwing J, Sood N, Rao Y, Holdstock L, Seaman S, Broderick M, White RJ. Efficacy and dose-response relationship of oral treprostinil in PAH patients on monotherapy or dual background therapy. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
FREEDOM-C and FREEDOM-C2 were randomized, placebo-controlled, double-blinded international, multicenter studies investigating the use of oral treprostinil (TRE) in subjects on mono or dual background pulmonary arterial hypertension (PAH) therapies. Both had a primary endpoint of change in 6-minute walk distance (6MWD) at Week 16 vs baseline. Previous post-hoc analyses combining mono and dual therapy subjects (PDE-5i and/or ERA) from these studies revealed a TRE dose-dependent increase in 6MWD. (1. White & Rao, 2016)
Purpose
This post-hoc analysis was performed to determine if subjects from FREEDOM-C and FREEDOM-C2 derive improvements in 6MWD with increasing doses of TRE when stratified by mono or dual background therapy and to determine if PAH background therapies (mono or dual) impacted 6MWD.
Methods
All active subjects (n=331) from FREEDOM-C and FREEDOM-C2 were grouped into TRE dose tertiles (low-dose: ≤2 mg BID, mid-dose: >2 mg to ≤3.5 mg BID, and high-dose: >3.5 mg BID). Placebo subjects (n=329) were in a separate 0 mg dose group. No data imputation was implemented.
Comparisons of 6MWD change at Weeks 4, 8, 12, and 16 between mono and dual therapy subgroups at any dose group were performed using a two-sample t-test or nonparametric Wilcoxon rank-sum test. The nonparametric Kruskal-Wallis test was conducted with subsequent pairwise comparisons of 6MWD change at Week 16 between the four dose groups through Dunn's approach. Additionally, the Jonckheere-Terpstra test was used to assess the linear trend for 6MWD improvement with higher doses of TRE.
Results
Baseline characteristics of the combined intention to treat (ITT) population and summary of 6MWD for subjects with both baseline and Week 16 data are in Table 1. 6MWD change improved steadily to Week 16 in subjects at higher TRE doses, regardless of the number of PAH background therapies (Figure 1). No statistical differences were found between mono and dual therapy at any time point or for any dose group. At Week 16, there was a significant difference in 6MWD change between the placebo group and high dose group within both mono and dual background therapy subjects. The difference between the low- and high-dose groups was significant for subjects on dual background therapy. There was a significant positive linear trend for TRE doses in 6MWD improvement at Week 16 for both monotherapy subjects (one-sided p-value = 0.0002) and dual therapy subjects (one-sided p-value = 0.0242).
Conclusions
6MWD improved in PAH patients regardless of their background therapy (monotherapy or dual background) and derive greater 6MWD improvements with higher doses of TRE. The observed dose-dependent 6MWD increase supports the use of TRE in sequential combination with background therapies (mono or dual).
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): United Therapeutics Corporation
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Affiliation(s)
- J A Barbera
- Hospital Clinic de Barcelona , Barcelona , Spain
| | - D Kiely
- Sheffield Teaching Hospitals NHS Trust , Sheffield , United Kingdom
| | - E Gruenig
- Thoracic Clinic-Heidelberg , Heidelberg , Germany
| | - V Balasubramanian
- University of California San Francisco , Fresno , United States of America
| | - C D Vizza
- Sapienza University of Rome , Rome , Italy
| | - J Elwing
- University of Cincinnati Medical Center , Cincinnati , United States of America
| | - N Sood
- University of California , Davis , United States of America
| | - Y Rao
- United Therapeutics Corporation , Research Triangle Park , United States of America
| | - L Holdstock
- United Therapeutics Corporation , Research Triangle Park , United States of America
| | - S Seaman
- United Therapeutics Corporation , Research Triangle Park , United States of America
| | - M Broderick
- United Therapeutics Corporation , Research Triangle Park , United States of America
| | - R J White
- University of Rochester Medical Center , Rochester , United States of America
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6
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Majeed RW, Wilkins MR, Howard L, Hassoun PM, Anthi A, Cajigas HR, Cannon J, Chan SY, Damonte V, Elwing J, Förster K, Frantz R, Ghio S, Al Ghouleh I, Hilgendorff A, Jose A, Juaneda E, Kiely DG, Lawrie A, Orfanos SE, Pepe A, Pepke‐Zaba J, Sirenko Y, Swett AJ, Torbas O, Zamanian RT, Marquardt K, Michel‐Backofen A, Antoine T, Wilhelm J, Barwick S, Krieb P, Fuenderich M, Fischer P, Gall H, Ghofrani H, Grimminger F, Tello K, Richter MJ, Seeger W. Pulmonary Vascular Research Institute GoDeep: A meta-registry merging deep phenotyping datafrom international PH reference centers. Pulm Circ 2022; 12:e12123. [PMID: 36034404 PMCID: PMC9399782 DOI: 10.1002/pul2.12123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 11/08/2022] Open
Abstract
The Pulmonary Vascular Research Institute GoDeep meta-registry is a collaboration of pulmonary hypertension (PH) reference centers across the globe. Merging worldwide PH data in a central meta-registry to allow advanced analysis of the heterogeneity of PH and its groups/subgroups on a worldwide geographical, ethnical, and etiological landscape (ClinTrial. gov NCT05329714). Retrospective and prospective PH patient data (diagnosis based on catheterization; individuals with exclusion of PH are included as a comparator group) are mapped to a common clinical parameter set of more than 350 items, anonymized and electronically exported to a central server. Use and access is decided by the GoDeep steering board, where each center has one vote. As of April 2022, GoDeep comprised 15,742 individuals with 1.9 million data points from eight PH centers. Geographic distribution comprises 3990 enrollees (25%) from America and 11,752 (75%) from Europe. Eighty-nine perecent were diagnosed with PH and 11% were classified as not PH and provided a comparator group. The retrospective observation period is an average of 3.5 years (standard error of the mean 0.04), with 1159 PH patients followed for over 10 years. Pulmonary arterial hypertension represents the largest PH group (42.6%), followed by Group 2 (21.7%), Group 3 (17.3%), Group 4 (15.2%), and Group 5 (3.3%). The age distribution spans several decades, with patients 60 years or older comprising 60%. The majority of patients met an intermediate risk profile upon diagnosis. Data entry from a further six centers is ongoing, and negotiations with >10 centers worldwide have commenced. Using electronic interface-based automated retrospective and prospective data transfer, GoDeep aims to provide in-depth epidemiological and etiological understanding of PH and its various groups/subgroups on a global scale, offering insights for improved management.
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Affiliation(s)
- Raphael W. Majeed
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute of Medical InformaticsRWTH Aachen UniversityAachenGermany
| | - Martin R. Wilkins
- National Heart and Lung Institute and Imperial CollegeLondon NHS Healthcare TrustLondonUK
| | - Luke Howard
- National Heart and Lung Institute and Imperial CollegeLondon NHS Healthcare TrustLondonUK
| | - Paul M. Hassoun
- Department of MedicineDivision of Pulmonary and Critical Care Medicine, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Anastasia Anthi
- 1st Department of Critical CareNational & Kapodistrian University of Athens Medical School and Pulmonary Hypertension Clinic, Evangelismos General HospitalAthensGreece
| | - Hector R. Cajigas
- Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterNew YorkUSA
| | - John Cannon
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical CampusCambridgeUK
| | - Stephen Y. Chan
- Department of Medicine, Division of Cardiology, Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine InstituteUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Victoria Damonte
- Hospital de Niños, Hospital Privado Universitario, Clinica Universitaria Reina Fabiola and Instituto Oulton‐Catholic, University of CórdobaCórdobaArgentina
| | - Jean Elwing
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Kai Förster
- Ludwig‐Maximilians University of MunichMunchenGermany
| | - Robert Frantz
- Department of CardiologyMayo ClinicRochesterNew YorkUSA
| | | | - Imad Al Ghouleh
- Department of Medicine, Division of Cardiology, Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine InstituteUniversity of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | | | - Arun Jose
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ernesto Juaneda
- Hospital de Niños, Hospital Privado Universitario, Clinica Universitaria Reina Fabiola and Instituto Oulton‐Catholic, University of CórdobaCórdobaArgentina
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and University of SheffieldSheffieldUK
| | - Allan Lawrie
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and University of SheffieldSheffieldUK
| | - Stylianos E. Orfanos
- 1st Department of Critical CareNational & Kapodistrian University of Athens Medical School and Pulmonary Hypertension Clinic, Evangelismos General HospitalAthensGreece
| | | | - Joanna Pepke‐Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical CampusCambridgeUK
| | - Yuriy Sirenko
- Department of Symptomatic Hypertension“National Scientific Center ‘The M.D. Strazhesko Institute of Cardiology’” of National Academy of Medical ScienceKyivUkraine
| | - Andrew J. Swett
- Division of Pulmonary, Allergy, and Critical Care, and Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford UniversityStanfordCaliforniaUSA
| | - Olena Torbas
- Department of Symptomatic Hypertension“National Scientific Center ‘The M.D. Strazhesko Institute of Cardiology’” of National Academy of Medical ScienceKyivUkraine
| | - Roham T. Zamanian
- Division of Pulmonary, Allergy, and Critical Care, and Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford UniversityStanfordCaliforniaUSA
| | - Kurt Marquardt
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Achim Michel‐Backofen
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Tobiah Antoine
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Jochen Wilhelm
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | | | - Phillipp Krieb
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Meike Fuenderich
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Patrick Fischer
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Henning Gall
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
| | - Hossein‐Ardeschir Ghofrani
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Friedrich Grimminger
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Khodr Tello
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Manuel J. Richter
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
| | - Werner Seeger
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL)GiessenGermany
- Institute for Lung Health (ILH), Cardio‐Pulmonary Institute (CPI)GiessenGermany
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7
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Nathan SD, Tapson VF, Elwing J, Rischard F, Mehta J, Shapiro S, Shen E, Deng C, Smith P, Waxman A. Efficacy of Inhaled Treprostinil on Multiple Disease Progression Events in Patients with Pulmonary Hypertension Due to Parenchymal Lung Disease in the INCREASE Trial. Am J Respir Crit Care Med 2021; 205:198-207. [PMID: 34767495 PMCID: PMC8787243 DOI: 10.1164/rccm.202107-1766oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rationale The INCREASE study of inhaled treprostinil met its primary endpoint of change in 6-minute-walk distance at Week 16. In addition, there were significantly fewer clinical worsening events in patients receiving inhaled treprostinil. However, the incidence of multiple events in the same patient is unknown. Objectives This post hoc analysis evaluated the effect of continued treatment with inhaled treprostinil on the frequency and impact of multiple disease progression events. Methods Patients enrolled in INCREASE were analyzed for disease progression events, defined as at least 15% decline in 6-minute-walk distance, exacerbation of underlying lung disease, cardiopulmonary hospitalization, lung transplantation, at least 10% decline in forced vital capacity, or death during the duration of the 16-week study. Measurements and Main Results In total, 147 disease progression events occurred in the inhaled treprostinil group (89/163 patients, 55%) compared with 215 events (109/163 patients, 67%) in the placebo group (P = 0.018). There was a lower incidence of each disease progression component in the inhaled treprostinil group: 6-minute-walk distance decline (45 vs. 64 events), lung disease exacerbation (48 vs. 72 events), FVC decline (19 vs. 33), cardiopulmonary hospitalization (23 vs. 33 events), and death (10 vs. 12). Fewer patients receiving inhaled treprostinil had multiple progression events compared with those receiving the placebo (35 vs. 58, 22% vs. 36%; P = 0.005). Conclusions Patients who received inhaled treprostinil were significantly less likely to experience further disease progression events after an initial event compared with patients receiving placebo. These results support the continuation of inhaled treprostinil despite the occurrence of disease progression in clinical practice.
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Affiliation(s)
- Steven D Nathan
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Transplant Program, Falls Church, Virginia, United States;
| | - Victor F Tapson
- Cedars Sinai Medical Center, Medicine - Pulmonary, Beverely Hills, California, United States
| | - Jean Elwing
- University of Cincinnati, 2514, Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, Ohio, United States
| | - Franz Rischard
- University of Arizona, Division of Pulmonary and Critical Care Medicine, Tuscon, Arizona, United States
| | - Jinesh Mehta
- Cleveland Clinic Florida, Department of Pulmonary & Critical Care Medicine, Weston, Florida, United States
| | - Shelley Shapiro
- UCLA Medical Center, 21767, Los Angeles, California, United States
| | - Eric Shen
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Chunqin Deng
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Peter Smith
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Aaron Waxman
- Brigham and Women's Hospital, 1861, Pulmonary and Critical Care, Boston, Massachusetts, United States
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8
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Khan S, Windholz J, Olmstead K, Zhou C, Ahmad Y, Alzamora-Schmatz P, Harris D, Gomez-Arroyo J, Elwing J. AORTIC STENOSIS IN PATIENTS WITH SYSTEMIC SCLEROSIS: PREVALENCE, RISK FACTORS AND CLINICAL OUTCOMES. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)03114-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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9
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Min J, Badesch D, Chakinala M, Elwing J, Frantz R, Horn E, Klinger J, Lammi M, Mazimba S, Sager J, Shlobin O, Simon M, Thenappan T, Grinnan D, Ventetuolo C, Al-Naamani N. Prediction of Health-related Quality of Life and Hospitalization in Pulmonary Arterial Hypertension: The Pulmonary Hypertension Association Registry. Am J Respir Crit Care Med 2021; 203:761-764. [PMID: 33211974 DOI: 10.1164/rccm.202010-3967le] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jeff Min
- Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | | | | | | | | | | | - James Klinger
- Rhode Island Hospital Pulmonary Hypertension Center East Providence, Rhode Island
| | | | - Sula Mazimba
- University of Virginia Charlottesville, Virginia
| | - Jeffrey Sager
- Cottage Health Pulmonary Hypertension Center Santa Barbara, California
| | | | - Marc Simon
- University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | | | | | - Corey Ventetuolo
- Alpert Medical School of Brown University Providence, Rhode Island and
| | - Nadine Al-Naamani
- Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
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10
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Cattran A, Elwing J. Successful use of intravenous treprostinil as a bridge to pulmonary thromboendarterectomy. BMJ Case Rep 2021; 14:14/3/e235806. [PMID: 33766958 PMCID: PMC8006775 DOI: 10.1136/bcr-2020-235806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) involves non-resolving thromboemboli in the pulmonary arteries. Treatment for CTEPH includes lifelong anticoagulation and determination of patients who have disease which is operable versus inoperable. Pulmonary arterial hypertension (PAH) targeted therapies are oftentimes used as a bridge to pulmonary thromboendarterectomy (PTE), though riociguat is the only Food and Drug Administration (FDA)-approved therapy for CTEPH. There is a paucity of data regarding the efficacy of other PAH therapies, particularly as a bridge to PTE. Here, we present a case report of severe CTEPH related to ventriculoatrial shunt in which intravenous treprostinil was used as a bridge to PTE.
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Affiliation(s)
- Ashley Cattran
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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11
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Affiliation(s)
- Eric Vick
- From the Departments of Internal Medicine
| | | | - Jean Elwing
- Pulmonology and Critical Care Medicine, University of Cincinnati Medical Center, Cincinnati, OH
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12
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Ahmad Y, Zhou C, Olmstead K, Khan S, Windholz J, Gupta N, Gomez-Arroyo J, Elwing J. SYSTEMIC SCLEROSIS-ASSOCIATED PRECAPILLARY PULMONARY HYPERTENSION WITH AND WITHOUT INTERSTITIAL LUNG DISEASE: OBSERVATIONS FROM A SINGLE REFERRAL CENTER COHORT. Chest 2020. [DOI: 10.1016/j.chest.2020.08.991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Raymond-Forde S, Elwing J, Mcloughlin R. WHAT IS IN HIS RIGHT VENTRICLE? AN UNUSUAL AND LIFE-THREATENING PRESENTATION OF VTE. Chest 2020. [DOI: 10.1016/j.chest.2020.08.1796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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14
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Jose A, Memon HA, Baker R, Elwing J, McCormack F. INCIDENTAL RIGHT VENTRICULAR ABNORMALITIES ON SINGLE PHOTON EMISSION CT SCAN SIGNIFICANTLY PREDICTS DEVELOPMENT OF PULMONARY HYPERTENSION IN BLACK FEMALES. Chest 2020. [DOI: 10.1016/j.chest.2020.08.1874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Olmstead K, Khan S, Windholz J, Zhou C, Ahmad Y, Alzamora P, Harris D, Gomez-Arroyo J, Elwing J. AORTIC STENOSIS IN PATIENTS WITH SYSTEMIC SCLEROSIS: PREVALENCE, SEVERITY, AND RISK FACTORS. Chest 2020. [DOI: 10.1016/j.chest.2020.08.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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Memon HA, Elwing J. AUTOLOGOUS STEM CELL TRANSPLANTATION: A POSSIBLE TREATMENT FOR PULMONARY HYPERTENSION IN POEMS SYNDROME. Chest 2019. [DOI: 10.1016/j.chest.2019.08.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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17
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Bennett S, Ciullo A, Elwing J. EXTRACORPOREAL MEMBRANE OXYGENATION AS A BRIDGE TO RECOVERY IN SEVERE PULMONARY HYPERTENSION PATIENT FOLLOWING CARDIAC ARREST. Chest 2019. [DOI: 10.1016/j.chest.2019.08.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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18
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Alkhawam H, Muskula PR, Effat M, Rahman S, Elwing J, Helmy T. SLOW AND STEADY WINS THE RACE: MANAGEMENT OF PERICARDIAL TAMPONADE IN THE SETTING OF PULMONARY HYPERTENSION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33449-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Wigger G, Elwing J. Troublesome Triad: Fibrosing Mediastinitis, Severe Pulmonary Hypertension, and Pulmonary Vein Stenosis. Chest 2017. [DOI: 10.1016/j.chest.2017.08.1051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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20
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Lee C, Elwing J. Pulse dose steroids in severe pulmonary arterial hypertension secondary to systemic lupus erythematosus. SAGE Open Med Case Rep 2017; 5:2050313X17707153. [PMID: 28515936 PMCID: PMC5423708 DOI: 10.1177/2050313x17707153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/03/2017] [Indexed: 11/23/2022] Open
Abstract
Objective: The pulmonary vascular targeted treatment for systemic lupus erythematosus–associated pulmonary arterial hypertension is similar to other connective tissue disease–associated pulmonary arterial hypertension. In addition, there also appears to be a role for immunosuppression in the overall management. However, the optimal immunosuppressive regimen and what patients will respond to treatments are currently not clearly elucidated given the lack of randomized controlled trials on the subject. Our objective is to highlight the importance of early immunosuppression in systemic lupus erythematosus–associated pulmonary arterial hypertension and the role of pulse dose steroids in management. Methods: This case describes a 23-year-old woman who presented with pulmonary arterial hypertension diagnosed by right heart catheterization with mean pulmonary artery pressure of 74 mmHg, pulmonary capillary wedge pressure of 12 mmHg, and a pulmonary vascular resistance of 1908 dyne s cm−5. Due to the aggressive nature of her disease, she declined despite management with epoprostenol and sildenafil. Because of coexisting systemic lupus erythematosus with hemolytic anemia and worsening pulmonary arterial hypertension, intensive immunosuppressive therapy with pulse dose steroids was initiated. Results: Shortly after initiation of pulse dose steroids and maintenance immunosuppression, she had a dramatic symptomatic and hemodynamic response with a decrease in her pulmonary vascular resistance from 1908 to 136 dyne sec cm−5 and improvement in her mean pulmonary artery pressure from 74 to 27 mmHg on repeat right heart catheterization. Conclusion: Early immunosuppression is important to consider in those with systemic lupus erythematosus–associated pulmonary arterial hypertension. Limited studies are available, but most have focused on the use of cyclophosphamide. Pulse dose steroids may be a potentially less toxic but equally effective manner to aid in the treatment of systemic lupus erythematosus–pulmonary arterial hypertension when intensive immunosuppression is being considered.
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Affiliation(s)
- Cody Lee
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jean Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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21
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Anis M, Harris D, Elwing J. Not Quite a Hero (Hemodialysis Reliable Outflow Graft): A Rare Cause of Dyspnea and Positional Syncope in End Stage Renal Disease (ESRD). Chest 2016. [DOI: 10.1016/j.chest.2016.08.1008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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22
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Lopez-Candales A, Palm D, Mesa M, Lopez F, Elwing J. HEMODYNAMIC SIGNIFICANCE OF THE LEFT VENTRICULAR VELOCITY OF PROPAGATION MEASUREMENTS IN PATIENTS WITH CHRONIC PULMONARY HYPERTENSION. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)32069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Pietras DA, Lopez FR, Peréz R, López-Candales A, Elwing J. Worsening gradient of aortic stenosis with treatment of pulmonary arterial hypertension in scleroderma. Bol Asoc Med P R 2015; 107:41-44. [PMID: 26035984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Systemic sclerosis (SSc) can cause interstitial lung and pulmonary vascular disease that can induce pulmonary arterial hypertension (PAH). It is well known that severe PAH may reduce left ventricluar preload and decrease diastolic filling with the potential of reducing forward flow. We present a case in which a patient with SSc and symptomatic PAH required direct pulmonary vasodilator therapy for treatment of elevated pulmonary pressures. On follow-up echocardiogram, while improvement in right ventricular function and reduction in estimated pulmonary pressures were noted; worsening of aortic valve gradients was also found. Cardiac hemodynamics of pulmonary vasodilator therapy is discussed and the literature is reviewed.
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24
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López-Candales A, Lopez FR, Trivedi S, Elwing J. Right Ventricular Ejection Efficiency: A New Echocardiographic Measure of Mechanical Performance in Chronic Pulmonary Hypertension. Echocardiography 2013; 31:516-23. [DOI: 10.1111/echo.12419] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Angel López-Candales
- Division of Cardiovascular Diseases; University of Cincinnati; College of Medicine; Cincinnati Ohio
| | - Francisco R. Lopez
- Department of Medicine; University of Cincinnati; College of Medicine; Cincinnati Ohio
| | - Setu Trivedi
- Department of Medicine; University of Cincinnati; College of Medicine; Cincinnati Ohio
| | - Jean Elwing
- Division of Pulmonary; Critical Care & Sleep Medicine; University of Cincinnati; College of Medicine; Cincinnati Ohio
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25
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Anjak A, López-Candales A, Lopez FR, Harris D, Elwing J. Objective Measures of Right Ventricular Function during Exercise: Results of a Pilot Study. Echocardiography 2013; 31:508-15. [DOI: 10.1111/echo.12417] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ahmad Anjak
- Department of Medicine; University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Angel López-Candales
- Division of Cardiovascular Medicine; University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Francisco R. Lopez
- Department of Medicine; University of Cincinnati College of Medicine; Cincinnati Ohio
| | - David Harris
- Division of Cardiovascular Medicine; University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Jean Elwing
- Division of Pulmonary; Critical Care & Sleep Medicine; University of Cincinnati College of Medicine; Cincinnati Ohio
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26
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Kelly S, Singhal S, Naz T, Elwing J, Yousuf M, Shizukuda Y. Exercise Characteristics Of Patients With Exercise-induced Arteriovenous Fistula In Pulmonary Circulation And Unexplained Exertional Dyspnea. Med Sci Sports Exerc 2009. [DOI: 10.1249/01.mss.0000355715.76305.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Abstract
Although the prevalence of pulmonary hypertension (PH) in individuals with chronic obstructive pulmonary disease (COPD) is not known precisely, approximately 10%–30% of patients with moderate to severe COPD have elevated pulmonary pressures. The vast majority of PH associated with COPD is mild to moderate and severe PH occurs in <5% of patients. When COPD is associated with PH, both mortality and morbidity are increased. There are no clinical or physical examination findings that accurately identify patients with underlying PH. Radiographic imaging findings are specific but not sensitive indicators of PH. Echocardiography is the principle noninvasive diagnostic test but may be technically limited in a significant proportion of patients with COPD. Right heart catheterization is required for accurate measurement of pulmonary pressures. The combined effects of inflammation, endothelial cell dysfunction, and angiogenesis appear to contribute to the development of PH associated with COPD. Systemic vasodilators have not been found to be effective therapy. Selective pulmonary vasodilators including inhaled nitric oxide and phosphodiesterase inhibitors are promising treatments for patients with COPD associated PH but further evaluation of these medications is needed prior to their routine use.
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Affiliation(s)
- Jean Elwing
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, University of Cincinnati Medical School, Cincinnati, OH, USA
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