Outcomes of lung disease-associated pulmonary hypertension and impact of elevated pulmonary vascular resistance

The clinical impact of acute vasoreactivity testing in patients with severe pulmonary hypertension associated with lung disease: A retrospective exploratory analysis

BACKGROUND

The clinical impact of acute vasoreactivity testing with inhaled nitric oxide (NO testing) in severe pulmonary hypertension associated with lung disease (LD-PH) remains unknown.

METHODS

We retrospectively reviewed 48 consecutive patients with severe LD-PH (73 ± 9 years; male: 81%) who underwent NO testing between 2014 and 2022. We conducted an exploratory analysis of the association between the response to NO testing and both the efficacy of pulmonary vasodilators and prognosis.

RESULTS

NO testing demonstrated a significant improvement in hemodynamics, with an average reduction of 1.8 wood units in pulmonary vascular resistance (PVR) without a decrease of oxygen saturation. Patients were divided into the vasoreactive and non-vasoreactive groups based on the median PVR response (-15%) to NO testing. The vasoreactive group had a higher proportion of patients who initiated pulmonary vasodilators and had better long-term prognosis than that of the non-vasoreactive group (P = 0.03). Among the 36 patients (75%) who initiated pulmonary vasodilators after NO testing, the vasoreactive group demonstrated a significant improvement in the symptom, brain natriuretic peptide level, and hemodynamics at the first follow-up (median 4 months), whereas the non-vasoreactive group did not. Moreover, a correlation was observed between the change in PVR at NO testing and the change in PVR after initiation of pulmonary vasodilators (r = 0.42, P = 0.02).

CONCLUSIONS

The PVR response to NO testing associated with short-term efficacy of pulmonary vasodilators in patients with severe LD-PH. Prospective studies of PVR response to NO testing on the clinical efficacy in large-scale LD-PH cohorts are warranted.

Echocardiographic Changes Related to Pulmonary Hypertension in Preweaned Dairy Calves With Bronchopneumonia: A Case-Control Study in Commercial Dairy Farms

BACKGROUND

Bronchopneumonia (BP) can cause pulmonary hypertension (PH) and secondary cardiovascular changes.

OBJECTIVES

The aim of this study was to describe PH-related transthoracic Doppler echocardiography (TTE) changes in preweaned dairy calves with BP diagnosed by thoracic ultrasonography (TUS).

ANIMALS

One hundred and sixty-four calves were selected from 11 commercial dairy farms.

METHODS

This is a case-control study. The enrolled calves were grouped according to TUS results into either the control group (with normally aerated lungs) or the BP group (calves with lobar BP). Both groups were then subjected to TTE.

RESULTS

Three echocardiographic variables were statistically different between the two groups, which included 104 healthy calves and 60 diagnosed with BP. The internal end-systolic (LVIDs) and end-diastolic diameters of the left ventricle (LVIDd) were significantly (p = 0.033, 0.034, respectively) lower in BP-affected calves (mean ± standard deviation [SD]: LVIDs, 29.65 ± 3.94 mm in healthy calves vs. 28.21 ± 4.44 mm in BP-affected calves; LVIDd, 49.83 ± 4.7 mm in healthy calves vs. 48.11 ± 5.4 in BP-affected calves). The pulmonary artery internal diameter in end-diastole (PAdia) was significantly larger (p = 0.017) in BP-affected calves (16.81 ± 2.68 mm) than in healthy calves (15.75 ± 2.67 mm).

CONCLUSIONS AND CLINICAL IMPORTANCE

The observed differences in the affected calves were within the normal reference ranges and exhibited clinical relevance. The lack of evident cardiac disturbances indicates that the BP diagnosis in our study sample was made without relevant cardiac alterations, highlighting the potential of TUS's early diagnostic capabilities during BP episodes.

Screening and diagnosis of pulmonary hypertension associated with chronic lung disease (PH-CLD): A consensus statement from the pulmonary vascular research institute's innovative drug development initiative-group 3 pulmonary hypertension

Pulmonary hypertension (PH) is a frequent complication of chronic lung disease (CLD). However, PH is difficult to diagnose early since accompanying symptoms overlap and are similar to those of the underlying CLD. In most cases the PH is mild to moderate and therefore physical signs may be absent or subtle. This consensus paper provides insight into the clues that might suggest the presence of occult PH in patients with CLD. An overview of current diagnostic tools and emerging diagnostic technologies is provided as well as guidance for the work-up and diagnosis of PH in patients with CLD.

A composite score based on cardiovascular parameters can predict the mortality risk of patients with newly diagnosed interstitial lung disease: A prospective observational study

BACKGROUND

It is crucial to identify factors that can predict the risk of mortality in patients newly diagnosed with interstitial lung disease (ILD). This study sought to develop and assess a composite scoring system for mortality prediction among ILD patients based on cardiovascular parameters, which were previously reported as predictors of survival.

METHODS

We prospectively enrolled patients with newly diagnosed ILD and monitored their survival status for 24 months. Surviving and deceased patients were compared regarding their baseline characteristics including clinical, pulmonary, and cardiovascular parameters. A system of composite scores was established based on significant cardiovascular parameters and the Gender-Age-Physiology (GAP) score. Receiver operating characteristic curves were generated to identify their optimal cut-off values. Univariate as well as multiple multivariate regression models were built to investigate the mortality prediction of different individual and combined parameters.

RESULTS

Ninety-six patients newly diagnosed with ILD underwent cardiovascular evaluation. In univariate analysis, three cardiovascular parameters were identified as significant predictors of mortality risk in ILD patients, either individually or as a combination of composite scores: tricuspid regurgitation velocity > 3.1 m/s; N-terminal pro-B-type natriuretic peptide level > 300 pg/ml and computed tomography pulmonary artery/ascending aorta diameter ratio > 0.9. In multivariate analysis, a composite score of those parameters [hazard ratio (HR) = 2.37 (confidence interval [CI]:1.06-5.33); p = 0.037; Score 1] and GAP score [HR = 1.62 (CI: 1.11-2.36); p = 0.012] were the most significant predictors for mortality among ILD patients. Combination of Score 1 and GAP score (Score 2) can increase the accuracy of survival predictions (area under the curve 0.83; p < 0.001).

CONCLUSIONS

A composite score based on cardiovascular parameters and the GAP score can be used to predict the risk of mortality of patients with ILD. Such a score achieved better diagnostic accuracy than the GAP score alone. Nevertheless, further larger-scale randomized controlled trials are required for evaluation of the newly proposed score and confirmation of our results.

Severe pulmonary hypertension in chronic obstructive pulmonary disease - From clinical perspective to histological evidence

Severe pulmonary hypertension (PH) in chronic obstructive pulmonary disease (COPD) is currently defined by an elevated mean pulmonary arterial pressure and strongly elevated pulmonary vascular resistance >5 wood units. Clinically, these patients show a male predominance, and usually present with very severe dyspnea, severe hypoxemia, strongly decreased exercise capacity and poor prognosis, even though the clinical picture is frequently associated with less severe airflow obstruction. Explanted lung samples of patients with COPD and severe PH show severe remodeling of small pulmonary arterioles, predominantly in the intima and media of the vessels. In this concise review, we discuss the clinical and histopathological evidence of severe PH in COPD.

Mild elevation of pulmonary vascular resistance predicts mortality regardless of mean pulmonary artery pressure in mild interstitial lung disease

BACKGROUND

Pulmonary hypertension (PH) is defined by elevated mean pulmonary arterial pressure (MPAP), and elevated pulmonary vascular resistance (PVR) reflects pulmonary vascular abnormalities. The clinical significance of non-severe PH in patients with various interstitial lung diseases (ILDs) has not been fully elucidated. We aimed to investigate the clinical significance of MPAP and PVR for mortality in patients with newly diagnosed ILD.

METHODS

We retrospectively analysed consecutive patients with ILD at initial evaluations that included right heart catheterisation from 2007 to 2018. These patients were classified by MPAP and PVR using the 2022 the European Society of Cardiology (ESC)/the European Respiratory Society (ERS) guidelines for PH. The clinical significance of MPAP and PVR for mortality was analysed.

RESULTS

Among 854 patients, 167 (19.6%) had MPAP>20 mm Hg. The proportion of patients with PVR>2 Wood units (WU) among those with MPAP≤20 mm Hg, 202 WU was associated with a higher mortality rate (HR 1.61, 95% CI 1.28 to 2.02, p<0.0001) even in a group with MPAP≤20 mm Hg.

CONCLUSIONS

Mild elevation of PVR was associated with a higher mortality rate in patients with newly diagnosed ILD, even in those with MPAP≤20 mm Hg.

Vasoreactive pulmonary artery hypertension in non-fibrotic hypersensitive pneumonitis

Group III pulmonary hypertension (PH) is common in patients with hypersensitivity pneumonitis (HSP). Group I PH and vasoreactivity in HSP have not been reported. We describe a case of an elderly veterinarian woman who presented with progressive shortness of breath and desaturation on exertion. The patient was diagnosed with non-fibrotic HSP after consistent findings on chest CT, transbronchial biopsy and a positive HSP serological panel. The patient relocated her birds, and prednisone was started. Due to persistent symptoms, she underwent a right heart catheterisation, which showed PH with vasoreactivity; subsequently, nifedipine was started. Over a 9-month follow-up, there was an improvement in symptoms and a complete resolution of PH and CT scan changes. Our case highlights the rare possibility of group I PH in HSP. It illustrates the importance of confirming the aetiology of PH and initiating treatment early to resolve symptoms.

Pathophysiology and new advances in pulmonary hypertension

Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.

Clinical insights into pulmonary hypertension in chronic obstructive pulmonary disease

Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD). Little is known about the prevalence and clinical profiles of patients with COPD-PH. We report the clinical characteristics, hemodynamic profiles, and prognosis in a large population of patients with COPD referred for right heart catheterization (RHC). We extracted data from all patients referred for RHC between 1997 and 2017 in Vanderbilt's deidentified medical record. PH was defined as mean pulmonary artery pressure >20 mmHg. Pre- and postcapillary PH were defined according to contemporary guidelines. COPD was identified using a validated rules-based algorithm requiring international classification of diseases codes relevant to COPD. We identified 6065 patients referred for RHC, of whom 1509 (24.9%) had COPD and 1213 had COPD and PH. Patients with COPD-PH had a higher prevalence of diabetes, atrial fibrillation, and heart failure compared with COPD without PH. Approximately 55% of patients with COPD-PH had elevated left ventricle (LV) filling pressure. Pulmonary function testing data from individuals with COPD-PH revealed subtype differences, with precapillary COPD-PH having lower diffusion capacity of the lungs for carbon monoxide (DLCO) values than the other COPD-PH subtypes. Patients with COPD-PH had significantly increased mortality compared with COPD alone (hazard ratio [HR]: 1.70, 95% confidence interval [CI]: 1.28-2.26) with the highest mortality among the combined pre- and postcapillary COPD-PH subgroup (HR: 2.39; 95% CI: 1.64-3.47). PH is common among patients with COPD referred for RHC. The etiology of PH in patients with COPD is often mixed due to multimorbidity and is associated with high mortality, which may have implications for risk factor management.

Lung Disease-Related Pulmonary Hypertension

Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.

Group 3 Pulmonary Hypertension: A Review of Diagnostics and Clinical Trials

Group 3 pulmonary hypertension (PH) is a known sequelae of chronic lung disease. Diagnosis and classification can be challenging in the background of chronic lung disease and often requires expert interpretation of numerous diagnostic studies to ascertain the true nature of the PH. Stabilization of the underlying lung disease and adjunctive therapies such as oxygen remain the mainstays of therapy, as there are no Food and Drug Administration-approved therapies for group 3 PH. Referral to PH centers for individualized management and clinical trial enrollment is paramount.

ERS International Congress, Madrid, 2019: highlights from the Pulmonary Vascular Diseases Assembly

The 2019 European Respiratory Society (ERS) International Congress, held in Madrid, Spain, had exciting sessions regarding the field of pulmonary vascular disease. The symposia related to the new ERS/European Society of Cardiology (ESC) Guidelines for the diagnosis and management of acute pulmonary embolism were well received, as were sessions on pulmonary hypertension related to lung disease, demonstrating the concept of pulmonary hypertension not being the rarity that it was previously thought to be. The use of risk stratification in relation to pulmonary arterial hypertension (PAH) was heavily featured and the scientific sessions informing the respiratory community of potential biomarkers and targets for future therapies were thought-provoking. This article discusses highlights of the 2019 pulmonary vascular disease sessions as a summary of current knowledge and practice. We have summarised the key points from the sessions pertaining to the new ERS/ESC Guidelines for the management of acute pulmonary embolism. We have also focused on prognostic factors and potential therapies in pulmonary hypertension related to interstitial lung disease. Relating to PAH, we have reviewed the symposia on risk stratification, along with the use of noninvasive measures and the sessions relating to biomarkers in PAH.

Computed Tomography Angiography-Based Pulmonary Artery Volumetry as a Diagnostic Tool for Pulmonary Hypertension

OBJECTIVES

We evaluated use of three-dimensional pulmonary artery volumes derived from computed tomography pulmonary angiography (CTPA) in a group with pulmonary hypertension (PH) compared with healthy controls as a tool for the diagnosis of PH.

METHODS

Retrospective analysis was performed of 40 CTPA scans obtained within 90 days of right heart catheterization demonstrating PH. The CTPA scans of 40 age- and sex-matched patients without cardiopulmonary disease were used as comparison. Diameters and volumes of the pulmonary arteries were compared.

RESULTS

Adjusted total volume of the main, right, and left proximal pulmonary arteries (PAvol) demonstrated area under the curve of 0.918 (95% confidence interval, 0.860-0.975) for detection of PH, comparable to main pulmonary artery diameter measurement. Area under the curve values for PAvol were higher in subgroups divided by sex and PH severity.

CONCLUSIONS

Volumetric analysis of the proximal pulmonary arteries using CTPA is a promising diagnostic tool for PH in a real-world cohort.

Acute Respiratory Failure in Interstitial Lung Disease Complicated by Pulmonary Hypertension

Interstitial lung disease represents a group of diffuse parenchymal lung diseases with overwhelming morbidity and mortality when complicated by acute respiratory failure. Recently, trials investigating outcomes and their determinants have provided insight into these high mortality rates. Pulmonary hypertension is a known complication of interstitial lung disease and there is high prevalence in idiopathic pulmonary fibrosis, connective tissue disease, and sarcoidosis subtypes. Interstitial lung disease associated pulmonary hypertension has further increased mortality with acute respiratory failure, and there is limited evidence to guide management. This review describes investigations and management of interstitial lung disease associated acute respiratory failure complicated by pulmonary hypertension. Despite the emerging attention on interstitial lung disease associated acute respiratory failure and the influence of pulmonary hypertension, critical care management remains a clinical and ethical challenge.

Pulmonary Hypertension in COPD: A Case Study and Review of the Literature

Pulmonary hypertension (PH) is a frequently encountered complication of chronic obstructive pulmonary disease (COPD) and is associated with worsened clinical symptoms and prognosis. The prevalence of PH-COPD is not concretely established as classification criteria vary historically, but the presence of severe disease out of proportion to underlying COPD is relatively rare. Right heart catheterization, the gold standard in diagnosis of PH, is infrequently performed in COPD, and the overlap in the clinical symptoms of PH and COPD presents diagnostic challenges. Proven treatments are limited. Trials exploring the use of vasodilator therapy in this patient group generally demonstrate improvements in hemodynamics accompanied by worsening gas exchange without clearly demonstrated improvements in clinically meaningful outcomes. In-depth workup of underlying pulmonary hypertension and use of pulmonary vasodilator medications may be appropriate on an individual basis. We present a case study and a review and discussion of the pertinent literature on this topic.