10-year survival of pulmonary arterial hypertension associated with connective tissue disease: insights from a multicentre PAH registry

Cluster analysis reveals three clinical phenotypes of pulmonary artery hypertension associated with connective tissue diseases: insights into inflammation and immunity

BACKGROUND

Inflammation and immune mechanisms play a crucial role in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH), though they remain inadequately understood. This study aimed to identify specific clinical phenotypes in CTD-PAH using inflammatory and immune markers through hierarchical cluster analysis.

METHODS

We conducted a single-center, retrospective cohort study of CTD-PAH patients from 2009 to 2024. Clinical variables, including neutrophil lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complement C3 and C4, were analyzed to form clusters based on baseline characteristics, clinical outcomes, and treatment goals.

RESULTS

Among 184 patients (95.1% female; median age 40.42 years), three distinct clusters were identified: Cluster 1 (vasculopathic phenotype) exhibited lower inflammatory activity but worse hemodynamic outcomes; Cluster 2 (vasculitic phenotype) had higher inflammatory activity with favorable hemodynamics; Cluster 3 (mixed phenotype) showed active inflammation and poor hemodynamic status. Most vasculitic patients were classified as systemic lupus erythematosus-associated PAH (SLE-PAH), which had a shorter course and higher prevalence of autoantibodies. The vasculopathic and mixed phenotypes were common in scleroderma-related PAH (SSc-PAH), undifferentiated CTD- related PAH (UCTD-PAH), and mixed CTD- related PAH (MCTD-PAH), associated with poorer treatment outcomes and survival rate.

CONCLUSION

Distinct clinical phenotypes in CTD-PAH correlate with inflammatory activity and hemodynamic status, influencing treatment responses and prognosis.

The prognostic value of HFA-PEFF score in connective tissue disease-associated PAH: evidence from a cohort study

BACKGROUND

Connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) patients with left heart dysfunction may have worse prognosis. This study was to investigate the prognostic value of HFA-PEFF score in connective tissue disease-associated PAH.

METHODS

This single-center retrospective cohort study enrolled 147 CTD-PAH patients diagnosed via right heart catheterization (RHC), divided into two groups based on their HFA-PEFF scores: < 5 (n = 74) and ≥ 5 (n = 73). The clinical characteristics were compared between the two groups. The primary end point was all-cause mortality, and the secondary end point was clinical worsening events. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards models.

RESULTS

Compared to the HFA-PEFF score < 5 group, the ≥ 5 group exhibited significantly higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), a greater proportion of WHO functional class III-IV, shorter 6-min walk distance (6MWD), larger right ventricular (RV) volume, worse RV function, smaller left ventricular (LV) volume, and higher native T1 values. An HFA-PEFF score ≥ 5 was a predictor for all-cause mortality in CTD-PAH (HR 5.022, P = 0.020) and for clinical worsening events (HR 2.670, P = 0.020). At follow-up, 17.9% of CTD-PAH had an HFA-PEFF score ≥ 5. Patients with follow-up HFA-PEFF scores ≥ 5 had a significantly lower event-free survival rate (P < 0.001).

CONCLUSION

An HFA-PEFF score ≥ 5 was associated with all-cause mortality and clinical worsening events in CTD-PAH patients.

TRIAL REGISTRATION

NCT05980728. Connective Tissue Disease Patients With Pulmonary Hypertension. Oct 17, 2023.

Epidemiology, disease burden of pulmonary arterial hypertension in China: A systematic literature review

INTRODUCTION

Although pulmonary arterial hypertension (PAH) may impose a substantial burden in China, the epidemiology of PAH remains unclear. This systematic literature review (SLR) aims to synthesize the literature on PAH epidemiology and disease burden in China.

METHODS

A systematic literature review was conducted using original publications since 2013. Comprehensive searches were performed in both English (EMBASE, MEDLINE) and Chinese (CNKI, Wanfang) databases. Articles were included when information on epidemiology, natural history, humanistic or economic burden of PAH was available.

RESULTS

Among 4808 abstracts and 333 full-text articles identified, 156 met inclusion/exclusion criteria: natural history (155), epidemiology (17), health-related quality of life (HRQoL) (32), health resource utilization (HCRU) (8) and cost (3). Majority (85.9 %) relied on single-hospital data. No studies reported population-level incidence or prevalence. Congenital heart disease associated PAH (CHD-PAH) was the most common PAH-subtype. Of the 155 studies, 55.5 % focused on connective tissue disease-associated PAH (CTD-PAH). Excluding studies of special groups, the median proportion of female was 74.3 % (range: 55.0 %-95.0 %), the median age was 36.2 years (range: 32.3-55.6 years), and the median 5-year survival rate was 74.1% (range:15.0%-87.6%). For PAH-targeted therapy, monotherapy (primarily phosphodiesterase-5 inhibitors and endothelin receptor antagonists) was prescribed more often than combination therapies. 36-Item Short Form Survey (SF-36) was the most utilized HRQoL instrument. Among 32 studies detailing HRQoL, 14 demonstrated a significant improvement in HRQoL after intervention. One study reported that 70.0 % of PAH patients were hospitalized at least once a year, and 14.0 % were hospitalized 3-5 times a year. One study highlighted substantial economic burden, citing average annual out-of-pocket costs of $10,388 per patient in 2021.

CONCLUSION

In China, PAH is predominantly reported among young females, and the most common reported subtype is CHD-PAH. Population-level studies are needed to better understand the epidemiology, treatment patterns, and disease burden of PAH.

Trends in pulmonary arterial hypertension: insights from Global Burden of Disease 1990-2021

OBJECTIVE

This study aimed to assess the global, regional and national burden of pulmonary arterial hypertension (PAH) from 1990 to 2021 using data from the Global Burden of Disease Study 2021. The focus was on evaluating trends in incidence, prevalence, mortality and disability-adjusted life-years (DALYs) associated with PAH and examining these trends by age, gender and sociodemographic index (SDI).

DESIGN

This is a systematic analysis leveraging data from the Global Burden of Disease Study 2021. The analysis focused on both crude and age-standardised rates to track temporal trends in PAH burden, with data stratified by region and SDI.

SETTING

The study used global, regiona, and national data from 204 countries and regions, spanning from 1990 to 2021.

PARTICIPANTS

The participants in this study include individuals diagnosed with PAH, with data representing populations globally, categorised by age, gender and SDI.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures included global, regional and national incidence, prevalence, mortality and DALYs related to PAH. Secondary outcomes consisted of age-standardised rates (age-standardised incidence rate (ASIR), age-standardised mortality rate (ASMR)) and trends over the study period. A key strength of this study is the detailed stratification by SDI, revealing how PAH burden varies across different socio-economic settings. This extended temporal analysis offers new insights into long-term trends, highlighting the rising burden in lower-SDI regions and significant regional disparities in disease management and outcomes.

RESULTS

From 1990 to 2021, global PAH cases showed substantial increases in both incidence (85.62%) and prevalence (81.46%), while age-standardised rates remained stable. Across SDI levels, high-SDI regions maintained stable ASIRs (0.37 per 100 000) with a slight decline (estimated average percentage change (EAPC) -0.06%), while low-SDI regions demonstrated the most significant reduction (EAPC -0.30%). Deaths increased by 48.36% globally, though the ASMR decreased from 0.35 to 0.27 per 100 000. The disease burden measured by DALYs decreased by 6.59%, with high-SDI regions showing better improvements in age-standardised DALY rates (-1.39% EAPC) compared with other SDI levels. Gender analysis revealed persistent female predominance (female-to-male ratio 1.62:1), particularly pronounced in populations over 50 years across all SDI quintiles.

CONCLUSIONS

While global age-standardised rates have declined, PAH remains a significant global health burden, particularly in low-SDI regions. These findings underscore the need for targeted prevention and intervention strategies, especially for high-risk populations, such as females and the elderly, to reduce the global health impact of PAH.

Fragmented QRS complex could predict all-cause mortality in patients with connective tissue disease-associated pulmonary arterial hypertension

OBJECTIVES

To investigate the prognostic impact and pathophysiological characteristics of fragmented QRS complex (fQRS) on patients with CTD-associated pulmonary arterial hypertension (CTD-PAH).

METHODS

This was a multicentre retrospective study recruiting 141 patients with CTD-PAH diagnosed by right heart catheterization (114 cases in the discovery cohort and 27 cases in the validation cohort). fQRS and ST-T change were detected on conventional 12-lead ECG. Patients were followed up every 3 months to update their status and the primary endpoint was all-cause death. Clinical information and ECG characteristics were compared between survival and death groups and Kaplan-Meier curve was used for survival analysis.

RESULTS

There were significant differences in age, gender, 6-min walk distance, N-terminal pro-brain natriuretic peptide, World Health Organization class, presence of fQRS, and presence of ST-T change in inferior leads between survival group and death group. Inferior fQRS and ST-T change were significantly associated with right ventricular dilatation and reduced right ventricular ejection fraction. Kaplan-Meier curve showed that all-cause mortality was higher in CTD-PAH with fQRS (P = 0.003) and inferior ST-T change (P = 0.012). Low- and intermediate-risk CTD-PAH with inferior ST-T change had higher all-cause mortality (P = 0.005). The prognostic value of fQRS and inferior ST-T change was validated in external validation cohort.

CONCLUSION

The presence of inferior fQRS and ST-T change could predict poor prognosis in CTD-PAH.

CLINICAL TRIAL REGISTRATION

NCT05980728, https://clinicaltrials.gov.

Impact of sodium-glucose cotransporter-2 inhibitors on pulmonary vascular cell function and arterial remodeling

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors represent a cutting-edge class of oral antidiabetic therapeutics that operate through selective inhibition of glucose reabsorption in proximal renal tubules, consequently augmenting urinary glucose excretion and attenuating blood glucose levels. Extensive clinical investigations have demonstrated their profound cardiovascular efficacy. Parallel basic science research has elucidated the mechanistic pathways through which diverse SGLT-2 inhibitors beneficially modulate pulmonary vascular cells and arterial remodeling. Specifically, these inhibitors exhibit promising potential in enhancing pulmonary vascular endothelial cell function, suppressing pulmonary smooth muscle cell proliferation and migration, reversing pulmonary arterial remodeling, and maintaining hemodynamic equilibrium. This comprehensive review synthesizes current literature to delineate the mechanisms by which SGLT-2 inhibitors enhance pulmonary vascular cell function and reverse pulmonary remodeling, thereby offering novel therapeutic perspectives for pulmonary vascular diseases.

Relationships Among the EmPHasis-10 Questionnaire, the Simplified Four-Strata Risk Assessment Tool, and Echocardiographic Parameters in Patients with Precapillary Pulmonary Hypertension

Background/Objectives: Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are complex diseases that require precise diagnosis and management. The ESC risk score has been used in both conditions. We assessed the relationship between the EmPHasis-10 questionnaire (patient subjective evaluation) and objective assessment using endorsed tools (simplified four-strata risk assessment and right ventricular imaging by transthoracic echocardiography). Methods: The present study retrospectively extracted data from 40 adult patients (27 PAH and 13 CTEPH cases) diagnosed in a single center in Romania. The EmPHasis-10 questionnaire and the four-strata risk assessment (FSRA) tool were applied to each patient. Mean pulmonary artery pressure (mPAP), tricuspid annular plane systolic excursion (TAPSE), TAPSE/systolic pulmonary artery pressure (TAPSE/sPAP) ratio, and right ventricular outflow tract acceleration time (RVOT-AT) were assessed. Results: A significant correlation was observed between the EmPHasis-10 scores and the FSRA tool, the WHO functional class, and the 6 min walking distance. Emphasis-10 score did not correlate with any of the echocardiographic parameters. The FSRA tool showed a moderate positive correlation with mPAP (r = 0.42, p = 0.01) and a negative correlation with TAPSE (r = -0.46, p = 0.003); additionally, across the entire cohort, it was moderately negatively correlated with both RVOT-AT (r = -0.42, p = 0.01) and TAPSE/sPAP ratio (r = -0.43, p = 0.005). Conclusions: Our study evidenced the alignment between EmPHasis-10 scores and prognostic risk score, with poorer health-related quality of life corresponding to higher FSRA. The EmPHasis-10 questionnaire proves to be a valuable, easy-to-use instrument, offering meaningful insights into patients' health-related quality of life, underscoring its utility in enhancing comprehensive patient assessment and management.

Pathophysiology of the right ventricle and its pulmonary vascular interaction

The right ventricle and its stress response is perhaps the most important arbiter of survival in patients with pulmonary hypertension of many causes. The physiology of the cardiopulmonary unit and definition of right heart failure proposed in the 2018 World Symposium on Pulmonary Hypertension have proven useful constructs in subsequent years. Here, we review updated knowledge of basic mechanisms that drive right ventricular function in health and disease, and which may be useful for therapeutic intervention in the future. We further contextualise new knowledge on assessment of right ventricular function with a focus on metrics readily available to clinicians and updated understanding of the roles of the right atrium and tricuspid regurgitation. Typical right ventricular phenotypes in relevant forms of pulmonary vascular disease are reviewed and recent studies of pharmacological interventions on chronic right ventricular failure are discussed. Finally, unanswered questions and future directions are proposed.

Can Combination Therapy with Endothelin Receptor Antagonist and PDE5 Inhibitors Prevent Echocardiographic Findings Suspicious for Pulmonary Arterial Hypertension? Description of a Real-Life Case Series

OBJECTIVE

To retrospectively evaluate the incidence rate (IR) of elevated echocardiographic estimated systolic pulmonary artery pressure (sPAP), suspected for pulmonary hypertension (PH), in systemic sclerosis (SSc) patients after the introduction of a combination therapy with bosentan and sildenafil for treatment or prevention of digital ulcers.

METHODS

Patients attending the Scleroderma Unit of the Universital Hospital of Careggi from July 2010 to July 2023 were enrolled. Patients older than 18 years old with a history of digital ulcers, treated with bosentan and sildenafil in combination for at least 12 months, were included. Patients with a diagnosis of PH preceding the introduction of the therapy were excluded. Demographical data, disease duration, laboratoristic, and instrumental data (pulmonary function tests, echocardiographic estimation of sPAP, and ultrasonographic value of renal resistive index) were collected. The IR of echocardiographic signs suspected of pulmonary hypertension and their 95% confidence interval were calculated in events/1000 patients-years.

RESULTS

Thirty-five patients were enrolled; the mean disease duration was 12.82 years (SD 5.92). The mean duration of the combination treatment was 81.03 (SD 43.1.3) months, and the total at-risk time was 2674 months. Two patients (5.7%) presented echocardiographic signs of PH (sPAP 50 mmHg and 40 mmHg); the IR was calculated to be 9/1000 patients-years (95% CI 7.95-10.12). In one of the two patients, right heart catheterism (RHC) excluded PAH, while the other patient refused to undergo RHC, and PAH could not be confirmed/excluded. The stability of PFTs and echocardiographic sPAP was observed during the observation time.

CONCLUSIONS

The results of this retrospective study suggest that combination therapy with endothelin receptor antagonists and phosphodiesterase-5 (PDE5) inhibitors could help in preventing PAH in SSc; prospective case-control studies on a larger population are needed to improve knowledge in this field.

Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis

Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.

Pulmonary Hypertension in Systemic Sclerosis

Systemic sclerosis is a multisystem connective tissue disease that is associated with substantial morbidity and mortality. Visceral organ involvement is common in patients with systemic sclerosis and occurs independently of skin manifestations. Pulmonary hypertension (PH) is an important and prevalent complication of systemic sclerosis. The clinical classification of PH cohorts conditions with similar pathophysiological mechanisms into one of five groups. While patients with systemic sclerosis can manifest with a spectrum of pulmonary vascular disease, notable clinical groups include group 1 pulmonary arterial hypertension (PAH) associated with connective tissues disease, PAH with features of capillary/venous involvement, group 2 PH associated with left heart disease, and group 3 PH associated with interstitial lung disease. Considerable efforts have been made to advance screening methods for PH in systemic sclerosis including the DETECT and ASIG (Australian Scleroderma Interest Group) composite algorithms. Current guidelines recommend annual assessment of the risk of PAH as early recognition may result in attenuated hemodynamic impairment and improved survival. The treatment of PAH associated with systemic sclerosis requires a multidisciplinary team including a PH specialist and a rheumatologist to optimize immunomodulatory and PAH-specific therapies. Several potential biomarkers have been identified and there are several promising PAH therapies on the horizon such as the novel fusion protein sotatercept. This chapter provides an overview of PH in systemic sclerosis, with a specific focus on group 1 PAH.

Pulmonary hypertension

Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.

Anti-MDA5 antibody-associated clinically amyopathic dermatomyositis diagnosed after the onset of pulmonary hypertension

Idiopathic inflammatory myopathies (IIM) are a group of highly heterogeneous systemic autoimmune diseases, of which clinically amyopathic dermatomyositis (CADM) is a distinct sub-type. Pulmonary hypertension (PH) is a life-threatening medical condition that can occur as a complication of connective tissue diseases. Herein, our report first suggests that PH can develop in CADM. A 48-year-old woman came to our hospital due to a 3 months history of facial edema and shortness of breath. Relevant examinations revealed Gottron's sign, normal creatinine kinase levels, elevated levels of mean pulmonary artery pressure, double-positive anti-MDA5 and anti-Ro52 antibodies, and typical pathological changes associated with myositis. The diagnosis of CADM combined with PH was considered. The patient responded well to the immunosuppression therapy and PH-related drug therapy. We provide further insights that patients with IIM need to undergo regular assessment of PH.