Prognostic factors in pulmonary arterial hypertension with Dana Point group 1

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Pulmonary Artery Pulsatility Index Provides No Additional Prognostic Information in Pediatric Pulmonary Arterial Hypertension

BACKGROUND/OBJECTIVES

The pulmonary artery pulsatility index (PAPi, calculated as (SPAP - DPAP)/mRAP) has been suggested as a measure of right ventricular-vascular coupling (RVVC) and as a prognostic parameter in cardiovascular conditions, particularly right ventricular failure. This retrospective study investigated the relationship between the PAPi and its components with disease severity parameters, the RVVC, and clinical outcomes in children with pulmonary arterial hypertension (PAH).

METHODS

We analyzed data from 111 children from the Dutch National Registry with PAH. The PAPi (median 6.0 [3.9-8.3]) was calculated from heart catheterization data and the RVVC was determined as the TAPSE/sPAP ratio via echocardiography (0.25 ± 0.12 mm/mmHg). Disease severity was characterized by clinical, hemodynamic, and laboratory data. Cox proportional hazard modeling assessed the PAPi's predictive value for transplant-free survival.

RESULTS

There was no correlation between the RVVC and PAPi (R = -0.208, p = 0.111, n = 60). The PAPi correlated negatively with uric acid (R = -0.387, p < 0.001) but not with other disease severity parameters. Mean right atrial pressure correlated with multiple disease severity indicators. Transplant-free survival rates at 1, 3, and 5 years were 87%, 79%, and 73%, respectively. Neither the PAPi nor its components correlated with transplant-free survival.

CONCLUSIONS

In conclusion, the PAPi does not correlate with the RVVC and this study could not demonstrate any prognostic value of the PAPi regarding disease severity or outcomes in children with PAH, challenging its utility in this population.

Hospital outcomes for patients with pulmonary arterial hypertension in sepsis and septic shock

Background

Pulmonary arterial hypertension (PAH) is associated with increased morbidity and mortality risk. The risk for adverse outcomes in patients with PAH in sepsis or septic shock (SSS) is uncertain.

Methods

Adult patients diagnosed with SSS were identified in the National Readmissions Database over the years 2016–2017. A 2:1 ratio nearest propensity matching method was employed for several demographic, social, and clinical variables. In-hospital outcomes were compared between patients with PAH and those without, using t-test and chi-squared test as appropriate. Patients with cardiogenic shock were excluded. Relevant ICD-10 codes were used, and statistical significance was set at 0.05.

Results

A total of 1,134 patients with PAH and sepsis/septic shock were identified, with a mean age of 65 years and 67% identifying as females. Patients with PAH had a higher prevalence of some chronic conditions, including chronic pulmonary disease, renal failure, congestive heart failure, coronary artery disease, obesity, coagulation disease. The prevalence of type 2 diabetes mellitus and alcohol use was lower in this cohort. After matching, patients with PAH and SSS, when compared to those with SSS and without PAH, had an increased occurrence of acute heart failure (24.1% vs. 19.6%, p = 0.003), amongst clinical outcomes. The differences in the occurrence of death, vasopressor use, paroxysmal atrial fibrillation, acute myocardial infarction, acute kidney injury, and stroke outcomes were not statistically different between the two groups. Patients with PAH, however, had a longer hospital stay (13.5 days vs. 10.9 days, p < 0.001) and hospital costs ($164,252 vs. $129,185, p < 0.001).

Conclusion

Patients with PAH have worse outcomes for acute heart failure in sepsis or septic shock. Other mortality and morbidity outcomes are not statistically different. PAH is also associated with a longer hospital stay and increased hospital costs. These findings should be interpreted recognizing the inclusion of patients with re-admissions and the administrative nature of the database.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02145-1.

Prevalence, incidence, and survival of pulmonary arterial hypertension: A systematic review for the global burden of disease 2020 study

Pulmonary arterial hypertension (PAH) is characterized by increased resistance in the pulmonary arterioles as a result of remodeled blood vessels. We sought all available epidemiologic data on population‐based prevalence, incidence, and 1‐year survival of PAH as part of the Global Burden of Disease Study. We performed a systematic review searching Global Index Medicus (GIM) for keywords related to PAH between 1980 and 2021 and identified population‐representative sources of prevalence, incidence, and mortality for clinically diagnosed PAH. Of 6772 articles identified we found 65 with population‐level data: 17 for prevalence, 17 for incidence, and 58 reporting case fatality. Reported prevalence ranged from 0.37 cases/100,000 persons in a referral center of French children to 15 cases/100,000 persons in an Australian study. Reported incidence ranged from 0.008 cases/100,000 person‐years in Finland, to 1.4 cases/100,000 person‐years in a retrospective chart review at a clinic in Utah, United States. Reported 1‐year survival ranged from 67% to 99%. All studies with sex‐specific estimates of prevalence or incidence reported higher levels in females than males. Studies varied in their size, study design, diagnostic criteria, and sampling procedures. Reported PAH prevalence, incidence, and mortality varied by location and study. Prevalence ranged from 0.4 to 1.4 per 100,000 persons. Harmonization of methods for PAH registries would improve efforts at disease surveillance. Results of this search contribute to ongoing efforts to quantify the global burden of PAH.

＜Editors' Choice＞ Pulmonary Hypertension: Diagnosis, Management, and Treatment

Pulmonary hypertension (PH) is a hemodynamic state that is characterized by a resting mean pulmonary artery pressure ≧ 25 mmHg. The common forms of PH are pulmonary arterial hypertension (PAH), chronic thromboembolic pulmonary hypertension (CTEPH), PH caused by left-heart disease, and PH due to lung disease. Previously regarded as untreatable, the treatment of PAH has dramatically advanced since the introduction of the drug epoprostenol in 1999, with three-year survival rates improving from 30%-40% to over 85%. Drugs available for the specific treatment of PAH include endothelin-receptor antagonists, phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, prostacyclin analogs, and prostacyclin-receptor agonists. In the past decade, management and treatment of CTEPH have also improved. While pulmonary endarterectomy used to be the only option for the treatment of CTEPH, newer treatments include a soluble guanylate cyclase stimulator, which has proven to be an efficacious targeted therapy. Other cases benefit from balloon pulmonary angioplasty.

Pulmonary Hypertension: The Role of Lung Transplantation

Despite advances in targeted medical therapy, pulmonary arterial hypertension (PAH) remains a fatal disease because of progressive right ventricular dysfunction. For patients who are refractory to medical therapy, heart-lung and lung transplantation are important treatment options. Because of longer waiting time, surgical interventions including extracorporeal lung support and atrial septostomy can be used in PAH patients bridging to transplantation.

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.

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.

New Therapeutic Paradigms and Guidelines in the Management of Pulmonary Arterial Hypertension

BACKGROUND

Recent and ongoing developments in the diagnosis, treatment, and management of pulmonary arterial hypertension (PAH) provide deeper insights into pathogenic mechanisms. Approvals of new pharmacotherapies that improve function and reduce morbidity and mortality risks; advances in clinical trial methods, including long-term, event-driven studies with clinically relevant and patient-centered endpoints; and trial results support a new therapeutic management strategy. This new paradigm involves initial treatment with combined therapies that act through different disease pathways. In addition, 2 new sets of clinical practice guidelines for PAH have been published since June 2014. Despite these advances, major gaps have been documented in the diagnosis, treatment, and management of patients with PAH.

OBJECTIVE

To present current knowledge and evidence on PAH to support managed care professionals and providers in achieving accurate differential diagnosis, promptly referring patients to specialists as necessary, and ensuring that patients receive appropriate, guideline-directed therapies.

SUMMARY

Major gaps in the quality of care provided to patients with PAH include oversights in clinicians' recognition of symptoms, delays in diagnosis, and misdiagnosis ensuing from incomplete evaluations, delays in referral of patients to centers of expertise and initiation of therapy, and inappropriate treatment regimens. To address deficiencies in PAH diagnosis, new practice guidelines emphasize the essential role of right heart catheterization in characterizing and confirming the disease, as well as referral to expert pulmonary hypertension centers to ensure appropriate evaluation and treatment. Updated disease and functional classifications of PAH, along with new research findings on prognostic factors and effects of comorbid conditions, offer key support for making effective therapy and management decisions for patients with PAH at different risk levels and stages of the disease. Since 2013, the U.S. Food and Drug Administration has approved new PAH therapies in the classes of endothelin receptor antagonists, guanylate cyclase stimulators, prostacyclin analogues, and prostacyclin receptor agonists. As demonstrated through phase 3 clinical trials, these generally well-tolerated therapies delay disease progression, improve hemodynamic and functional status, and decrease numbers of hospitalizations. Moreover, 2 sets of recently published guidelines-developed by the American College of Chest Physicians and the European Society of Cardiology/European Respiratory Society-provide evidence-based and expert consensus recommendations for achieving PAH treatment goals. The most recent guidelines include a recommendation for upfront combination therapy for patients with moderate disease, which is supported by new comparative clinical trial evidence. As addressed in this article, these advances in the field of PAH have important implications for managed care and clinical practice, including considerations of cost-benefit outcomes associated with different management strategies.

The Management of Supraventricular Tachyarrhythmias in Patients with Pulmonary Arterial Hypertension

BACKGROUND

Atrial remodelling in pulmonary arterial hypertension (PAH) may lead to higher incidence of supraventricular arrhythmias (SVA). The purpose of this study was to evaluate the efficiency and safety of various methods for treatment of SVA in this group.

METHODS

This was a single centre study. Forty-eight patients (33 women and 15 men) aged 19-77 years (median 49 years) were enrolled. There were 30 patients with idiopathic PAH, 10 had PAH associated with connective tissue disease, and eight with congenital heart disease. A retrospective analysis was performed to estimate the prevalence and type of supraventricular arrhythmias, as well as efficiency and safety of treatment methods. Mean follow-up period was 28.8±17.7 months.

RESULTS

Supraventricular arrhythmias occurred in 17 patients (35%) and appeared to be atrial fibrillation, flutter or tachycardia. Supraventricular arrhythmias coexisted with elevated mean right atrial pressure in 75%. Four patients had more than one type of SVA. A flutter-like macro-reentrant form of atrial tachycardia dependent on cavo-tricuspid isthmus was found in four cases. The treatment of SVA included typical methods: antiarrhythmic drugs, direct current cardioversion (DCC), and radiofrequency (RF) ablation. All of the therapeutic methods were effective in managing acute arrhythmia. Three patients required re-ablation. Overall mortality: 14 patients (29%) in the whole study group, including six in SVA group (35%) and eight without SVA (26%).

CONCLUSIONS

In patients with PAH DCC, pharmacological cardioversion and RF ablation can be applied safely and effectively. Flutter-like macro-reentrant atrial tachycardia dependent on cavo-tricuspid isthmus is observed in this group. It is more challenging, but possible, to successfully treat this arrhythmia with RF ablation.