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Fiorentù G, Bernardinello N, Giulianelli G, Cocconcelli E, Balestro E, Spagnolo P. Pulmonary Hypertension Associated with Interstitial Lung Disease (PH-ILD): Back to the Future. Adv Ther 2025; 42:1627-1641. [PMID: 39969780 PMCID: PMC11929637 DOI: 10.1007/s12325-025-03129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Accepted: 01/27/2025] [Indexed: 02/20/2025]
Abstract
Pulmonary hypertension (PH) is a progressive syndrome characterized by increased pulmonary artery pressure. PH often complicates chronic lung diseases, thus contributing to a substantial disease burden and poor prognosis. The WHO Group 3 Pulmonary Hypertension has many subcategories, including sleep-hypoventilation PH, high altitude-PH, chronic obstructive pulmonary disease (COPD)-PH, and interstitial lung disease (PH-ILD), the latter carrying the worst prognosis. ILD is a heterogeneous group of disorders characterized by cough and shortness of breath and, in progressive forms, irreversible loss of function and respiratory failure. The development of PH in patients with ILD worsens exercise capacity and exertional dyspnea and impairs quality of life. Thus, suspicion and early detection of PH following thorough cardiologic evaluation (i.e., echocardiography, pro-BNP, and right heart catheterization) is paramount for appropriate patient management. For PH secondary to chronic respiratory diseases, current guidelines recommend optimizing the treatment of the underlying respiratory condition and offering long-term oxygen therapy. In recent years, several clinical trials have failed to identify drugs beneficial for group 3 PH. Conversely, the INCREASE trial of inhaled treprostinil has recently provided hope for treating PH-ILD. In this review, we summarize and critically discuss the present and future of the pharmacological management of PH-ILD.
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Affiliation(s)
- Giordano Fiorentù
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Nicol Bernardinello
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy.
| | - Giacomo Giulianelli
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Elisabetta Cocconcelli
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Elisabetta Balestro
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Paolo Spagnolo
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
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Gayen S, Pescatore J, Bittner M, Naranjo M, Criner GJ, Weaver S. Development of the pulmonary fibrosis, pulmonary vascular resistance, six minute walk distance, B-type natriuretic peptide, age (PVD-B65) risk score for patients with chronic lung disease and pulmonary hypertension. BMC Pulm Med 2025; 25:69. [PMID: 39923026 PMCID: PMC11807298 DOI: 10.1186/s12890-025-03538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Accepted: 01/29/2025] [Indexed: 02/10/2025] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) confers increased mortality in patients with chronic lung disease, yet there remains a lack of validated risk assessment tools to prognosticate these patients. We aimed to create a risk assessment tool to stratify patients with chronic lung disease and PH by risk of one-year mortality from time of PH diagnosis. METHODS This was a retrospective cohort study of patients with chronic lung disease and PH. We identified predictors of one-year mortality via multivariable Cox regression and assigned point values to the identified predictors based on their hazard ratios to comprise the risk score. Patients were stratified into low, intermediate, and high-risk based on total scores. Kaplan-Meier survival analysis comparing the stratified groups was performed. Internal statistical validation was performed via Cox regression with bootstrapping. RESULTS The identified predictors of one-year mortality that comprised our risk assessment tool were pulmonary fibrosis without emphysema, pulmonary vascular resistance > 5 WU, six-minute walk distance < 150 m, BNP > 200 pg/mL, and age > 65 years (PVD-B65). Once patients were stratified into the three risk groups, Kaplan-Meier survival analysis demonstrated significant differences in one-year survival between the subgroups (logrank p = 0.002). The risk assessment model demonstrated internal validation via bootstrapping (p < 0.05). CONCLUSION The PVD-B65 risk assessment tool is a novel, internally validated one-year mortality risk calculator for patients with chronic lung disease and PH that encompasses factors related to pulmonary parenchymal and vascular remodeling. It may help risk stratify and guide therapeutic interventions in patients with chronic lung disease and PH.
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Affiliation(s)
- Shameek Gayen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA.
| | - Jay Pescatore
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA
| | - Matthew Bittner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA
| | - Mario Naranjo
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA
| | - Sheila Weaver
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA, 19140, USA
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Boucly A, Bertoletti L, Fauvel C, Dewavrin MG, Gerges C, Grynblat J, Guignabert C, Hascoet S, Jaïs X, Jutant EM, Lamblin N, Meyrignac O, Riou M, Savale L, Tromeur C, Turquier S, Valentin S, Simonneau G, Humbert M, Sitbon O, Montani D. Evidence and unresolved questions in pulmonary hypertension: Insights from the 5th French Pulmonary Hypertension Network Meeting. Respir Med Res 2024; 86:101123. [PMID: 38972109 DOI: 10.1016/j.resmer.2024.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/28/2024] [Accepted: 06/18/2024] [Indexed: 07/09/2024]
Abstract
Pulmonary hypertension (PH) continues to present significant challenges to the medical community, both in terms of diagnosis and treatment. The advent of the updated 2022 European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines has introduced pivotal changes that reflect the rapidly advancing understanding of this complex disease. These changes include a revised definition of PH, updates to the classification system, and treatment algorithm. While these guidelines offer a critical framework for the management of PH, they have also sparked new discussions and questions. The 5th French Pulmonary Hypertension Network Meeting (Le Kremlin-Bicêtre, France, 2023), addressed these emergent questions and fostering a deeper understanding of the disease's multifaceted nature. These discussions were not limited to theoretical advancements but extended into the practical realms of patient management, highlighting the challenges and opportunities in applying the latest guidelines to clinical practice.
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Affiliation(s)
- Athénaïs Boucly
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Laurent Bertoletti
- Département of Médecine Vasculaire et Thérapeutique, Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Étienne, INSERM, SAINBIOSE U1059, CIC 1408, Saint-Étienne, France
| | - Charles Fauvel
- Normandie Univ, UNIROUEN, U1096, CHU Rouen, Department of Cardiology, F-76000 Rouen, France
| | | | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julien Grynblat
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Sébastien Hascoet
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Hôpital Marie Lannelongue, Faculté de Médecine, Paris-Saclay, Université Paris-Saclay, Le Plessis Robinson, France
| | - Xavier Jaïs
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Etienne-Marie Jutant
- Respiratory Department, CHU de Poitiers, INSERM CIC 1402, IS-ALIVE Research Group, University of Poitiers, Poitiers, France
| | - Nicolas Lamblin
- Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, Lille, France
| | - Olivier Meyrignac
- Assistance Publique - Hôpitaux de Paris (AP-HP) - Biomaps - Laboratoire d'Imagerie Multimodale - CEA - INSERM - CNRS, DMU 14 Smart Imaging - Department of Radiology, Bicetre Hospital, Le Kremlin-Bicêtre, France
| | - Marianne Riou
- Department of Physiology and Functional Exploration, Nouvel Hôpital Civil, University Hospital of Strasbourg, Strasbourg, France
| | - Laurent Savale
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Cécile Tromeur
- Department of Internal Medicine and Pulmonology, CHU Brest, France. INSERM 1304 GETBO (groupe d'étude de thrombose et de bretagne occidentale), Brest, France
| | - Ségolène Turquier
- Department of Physiology and Functional Exploration, Hôpital Louis Pradel, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Simon Valentin
- Université de Lorraine, CHRU-Nancy, Pôle des Spécialités Médicales/Département de Pneumologie- IADI, INSERM U1254, Nancy, France
| | - Gérald Simonneau
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Marc Humbert
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - Olivier Sitbon
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France
| | - David Montani
- University of Paris-Saclay, School of Medicine, le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Bicêtre Hospital, le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Marie Lannelongue Hospital and Bicêtre Hospital, France.
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Brownstein AJ, Mura M, Ruffenach G, Channick RN, Saggar R, Kim A, Umar S, Eghbali M, Yang X, Hong J. Dissecting the lung transcriptome of pulmonary fibrosis-associated pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2024; 327:L520-L534. [PMID: 39137526 PMCID: PMC11482468 DOI: 10.1152/ajplung.00166.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/15/2024] [Accepted: 08/09/2024] [Indexed: 08/15/2024] Open
Abstract
Integrative multiomics can help elucidate the pathophysiology of pulmonary fibrosis (PF)-associated pulmonary hypertension (PH) (PF-PH). Weighted gene coexpression network analysis (WGCNA) was performed on a transcriptomic dataset of explanted lung tissue from 116 patients with PF. Patients were stratified by pulmonary vascular resistance (PVR), and differential gene expression analysis was conducted. Gene modules were correlated with hemodynamics at the time of transplantation and tested for enrichment in the lung transcriptomics signature of an independent pulmonary arterial hypertension (PAH) cohort. We found 1,250 differentially expressed genes between high and low PVR groups. WGCNA identified that black and yellowgreen modules negatively correlated with PVR, whereas the tan and darkgrey modules are positively correlated with PVR in PF-PH. In addition, the tan module showed the strongest enrichment for an independent PAH gene signature, suggesting shared gene expression patterns between PAH and PF-PH. Pharmacotranscriptomic analysis using the Connectivity Map implicated the tan and darkgrey modules as potentially pathogenic in PF-PH, given their combined module signature demonstrated a high negative connectivity score for treprostinil, a medication used in the treatment of PF-PH, and a high positive connectivity score for bone morphogenetic protein (BMP) loss of function. Pathway enrichment analysis revealed that inflammatory pathways and oxidative phosphorylation were downregulated, whereas epithelial-mesenchymal transition was upregulated in modules associated with increased PVR. Our integrative systems biology approach to the lung transcriptome of PF with and without PH identified several PH-associated coexpression modules and gene targets with shared molecular features with PAH warranting further investigation to uncover potential new therapies for PF-PH.NEW & NOTEWORTHY An integrative systems biology approach that included transcriptomic analysis of explanted lung tissue from patients with pulmonary fibrosis (PF) with and without pulmonary hypertension (PH) undergoing lung transplantation, combined with hemodynamic correlation and pharmacotranscriptomics, identified modules of genes associated with pulmonary vascular disease severity. Comparison with an independent pulmonary arterial hypertension (PAH) dataset identified shared gene expression patterns between PAH and PF-PH.
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Grants
- R01HL147586,R01HL159865 HHS | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- K08169982 HHS | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- K08 HL141995 NHLBI NIH HHS
- UL1TR001881 HHS | NIH | National Center for Advancing Translational Sciences (NCATS)
- K08 HL169982 NHLBI NIH HHS
- R01 HL159507 NHLBI NIH HHS
- R01HL16038,K08HL141995 HHS | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- R01 HL161038 NHLBI NIH HHS
- R01 HL159865 NHLBI NIH HHS
- R01 NS117148 NINDS NIH HHS
- R01NS117148,R01NS111378 HHS | NIH | National Institute of Neurological Disorders and Stroke (NINDS)
- UL1 TR001881 NCATS NIH HHS
- R01HL159507 HHS | NIH | National Heart, Lung, and Blood Institute (NHLBI)
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Affiliation(s)
- Adam J Brownstein
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, California, United States
| | - Marco Mura
- Division of Respirology, Western University, London, Ontario, Canada
| | - Gregoire Ruffenach
- Division of Molecular Medicine, Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Richard N Channick
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, California, United States
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, California, United States
| | - Airie Kim
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, California, United States
| | - Soban Umar
- Division of Molecular Medicine, Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Mansoureh Eghbali
- Division of Molecular Medicine, Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Xia Yang
- Department of Integrative Biology and Physiology, University of California, Los Angeles, California, United States
| | - Jason Hong
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, California, United States
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Vitulo P, Piccari L, Wort SJ, Shlobin OA, Kovacs G, Vizza CD, Hassoun PM, Olschewski H, Girgis RE, Nikkho SM, Nathan SD. 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. Pulm Circ 2024; 14:e70005. [PMID: 39659477 PMCID: PMC11629413 DOI: 10.1002/pul2.70005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/19/2024] [Accepted: 10/07/2024] [Indexed: 12/12/2024] Open
Abstract
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.
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Affiliation(s)
- P. Vitulo
- Department of Pulmonary MedicineIRCCS Mediterranean Institute for Transplantation and Advanced Specialized, TherapiesPalermoSiciliaItaly
| | - L. Piccari
- Department of Pulmonary MedicineHospital del Mar, Pulmonary Hypertension UnitBarcelonaCatalunyaSpain
| | - S. J. Wort
- National Pulmonary Hypertension Service at the Royal Brompton Hospital, London, UK and National Heart and Lung InstituteImperial CollegeLondonUK
| | - O. A. Shlobin
- Advanced Lung Disease and Transplant ProgramInova Heart and Vascular InstituteFalls ChurchVirginiaUSA
| | - G. Kovacs
- Department of Internal Medicine, Division of PulmonologyMedical University of GrazGrazAustria
| | - C. D. Vizza
- University of Rome La Sapienza, Cardiovascular and Respiratory ScienceRomeItaly
| | - P. M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - H. Olschewski
- Department of Internal Medicine, Division of PulmonologyMedical University of GrazGrazSteiermarkAustria
| | - R. E. Girgis
- Corewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - S. M. Nikkho
- Global Clinical DevelopmentBayer AGBerlinGermany
| | - S. D. Nathan
- Advanced Lung Disease and Transplant ProgramInova Heart and Vascular InstituteFalls ChurchVirginiaUSA
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Ang HL, Schulte M, Chan RK, Tan HH, Harrison A, Ryerson CJ, Khor YH. Pulmonary Hypertension in Interstitial Lung Disease: A Systematic Review and Meta-Analysis. Chest 2024; 166:778-792. [PMID: 38821182 DOI: 10.1016/j.chest.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a key complication in interstitial lung disease (ILD), with recent therapeutic advances. RESEARCH QUESTION What are the diagnostic evaluation, epidemiologic features, associated factors, prognostic significance, and outcome measures in interventional trials for PH in patients with ILD in the current literature? STUDY DESIGN AND METHODS The Ovid MEDLINE, Embase, and CENTRAL databases were searched for original research evaluating PH in participants with ILD of any cause. The definition of PH was based on the investigators' criteria. RESULTS Three hundred two studies were included, with varying diagnostic evaluations used to define PH. Commonly used diagnostic tests were right heart catheterization (56%) and transthoracic echocardiography (50%). The pooled prevalence for PH in general populations with ILD was 36% (95% CI, 30%-42%) using right heart catheterization and 34% (95% CI, 29%-38%) using transthoracic echocardiography. Lower diffusion capacity of the lungs for carbon monoxide, worse oxygenation status, reduced exercise capacity, increased pulmonary artery to aorta ratio and pulmonary artery diameter, and elevated serum brain natriuretic peptide consistently were associated with the presence of PH in at least 60% of reported studies. The presence of PH was associated with increased symptom burden and worse prognosis. Outcome measures in interventional trials of PH in ILD focused on changes in pulmonary vascular hemodynamics and 6-min walk distance. INTERPRETATION PH is a common complication in ILD with significant health impacts. A standardized definition with prospective evaluation of risk-stratified assessments for PH using identified associated risk factors is warranted. Our findings provide an evidence base for validation as surrogate end points in future PH interventional trials in ILD. TRIAL REGISTRY International Prospective Register of Systematic Reviews; No.: CRD42021255394; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Hui Li Ang
- Royal Melbourne Hospital, VIC, Australia; Institute for Breathing and Sleep, VIC, Australia
| | - Max Schulte
- Institute for Breathing and Sleep, VIC, Australia
| | | | | | - Amelia Harrison
- Department of Respiratory and Sleep Disorders Medicine, Western Health, St. Albans, VIC, Australia
| | - Christopher J Ryerson
- University of British Columbia, Vancouver, BC, Canada; Centre for Heart Lung Innovation, Vancouver, BC, Canada
| | - Yet Hong Khor
- Institute for Breathing and Sleep, VIC, Australia; School of Translational Medicine, Monash University, Melbourne, VIC, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia.
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Shlobin OA, Adir Y, Barbera JA, Cottin V, Harari S, Jutant EM, Pepke-Zaba J, Ghofrani HA, Channick R. Pulmonary hypertension associated with lung diseases. Eur Respir J 2024; 64:2401200. [PMID: 39209469 PMCID: PMC11525344 DOI: 10.1183/13993003.01200-2024] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 09/04/2024]
Abstract
Pulmonary hypertension (PH) associated with chronic lung disease (CLD) is both common and underrecognised. The presence of PH in the setting of lung disease has been consistently shown to be associated with worse outcomes. Recent epidemiological studies have advanced understanding of the heterogeneity of this patient population and shown that defining both the specific type of CLD as well as the severity of PH (i.e. deeper phenotyping) is necessary to inform natural history and prognosis. A systematic diagnostic approach to screening and confirmation of suspected PH in CLD is recommended. Numerous uncontrolled studies and one phase 3 randomised, controlled trial have suggested a benefit in treating PH in some patients with CLD, specifically those with fibrotic interstitial lung disease (ILD). However, other studies in diseases such as COPD-PH showed adverse outcomes with some therapies. Given the expanding list of approved pharmacological treatments for pulmonary arterial hypertension, developing a treatment algorithm for specific phenotypes of CLD-PH is required. This article will summarise existing data in COPD, ILD and other chronic lung diseases, and provide recommendations for classification of CLD-PH and approach to the diagnosis and management of these challenging patients.
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Affiliation(s)
- Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Schar Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Yochai Adir
- Pulmonary Division, Lady Davis Carmel Medical Center, Faculty of Medicine Technion Institute of Technology, Haifa, Israel
| | - Joan A Barbera
- Department of Pulmonary Medicine, Hospital Clínic-IDIBAPS, University of Barcelona; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon and UMR 754, INRAE, Claude Bernard University Lyon 1, Lyon, France
| | - Sergio Harari
- Unità Operativa di Pneumologia e Terapia Semi-Intensiva Respiratoria, MultiMedica IRCCS, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Etienne-Marie Jutant
- Respiratory Department, Centre Hospitalier Universitaire de Poitiers, INSERM CIC 1402, IS-ALIVE Research Group, University of Poitiers, Poitiers, France
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Hossein-Ardeschir Ghofrani
- Justus-Liebig University Giessen, ECCPS, Kerckhoff-Klinik Bad Nauheim, Giessen, Germany
- Imperial College London, London, UK
| | - Richard Channick
- Pulmonary Vascular Disease Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Lawrence A, Myall KJ, Mukherjee B, Marino P. Converging Pathways: A Review of Pulmonary Hypertension in Interstitial Lung Disease. Life (Basel) 2024; 14:1203. [PMID: 39337985 PMCID: PMC11433497 DOI: 10.3390/life14091203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 09/10/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Pulmonary hypertension (PH) in interstitial lung disease (ILD) is relatively common, affecting up to 50% of patients with idiopathic pulmonary fibrosis (IPF). It occurs more frequently in advanced fibrotic ILD, although it may also complicate milder disease and carries significant clinical implications in terms of morbidity and mortality. Key pathological processes driving ILD-PH include hypoxic pulmonary vasoconstriction and pulmonary vascular remodelling. While current understanding of the complex cell signalling pathways and molecular mechanisms underlying ILD-PH remains incomplete, there is evidence for an interplay between the disease pathogenesis of fibrotic ILD and PH, with interest in the role of the pulmonary endothelium in driving pulmonary fibrogenesis more recently. This review examines key clinical trials in ILD-PH therapeutics, including recent research showing promise for the treatment of both ILD-PH and the underlying pulmonary fibrotic process, further supporting the hypothesis of interrelated pathogenesis. Other important management considerations are discussed, including the value of accurate phenotyping in ILD-PH and the success of the "pulmonary vascular" phenotype. This article highlights the close and interconnected nature of fibrotic ILD and PH disease pathogenesis, a perspective likely to improve our understanding and therapeutic approach to this complex condition in the future.
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Affiliation(s)
| | - Katherine Jane Myall
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
- King's College Hospital, London SE5 9RS, UK
| | - Bhashkar Mukherjee
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London SW3 6NP, UK
| | - Philip Marino
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
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Yoshikawa K, Nishiyama O, Yamazaki R, Kunita Y, Nishikawa Y, Sano A, Matsumoto H. Selexipag for patients with pulmonary hypertension associated with lung disease: A preliminary study. Respir Investig 2024; 62:850-855. [PMID: 39067258 DOI: 10.1016/j.resinv.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/25/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH)-specific therapies are generally ineffective in patients with pulmonary hypertension associated with lung disease (PH-LD). The aim of this preliminary study was to evaluate the potential efficacy of selexipag, titrated according to individual tolerance, in patients with PH-LD. METHODS Consecutive patients diagnosed with PH-LD between October 2016 and March 2019, who received selexipag treatment, were retrospectively evaluated. Specific parameters, including changes in hemodynamic parameters, 6-min walk distance (6MWD), and partial pressure of atrial oxygen/fraction of inspiratory oxygen (PaO2/FiO2) were evaluated. Patients whose 6MWD improved ≥20 m were defined as responders. RESULTS Eight patients with PH-LD were included, comprising four with chronic obstructive pulmonary disease (COPD), two with interstitial lung disease (ILD) related to rheumatoid arthritis, one with ILD related to systemic sclerosis, and one with pulmonary Langerhans cell histiocytosis. No statistically significant improvements in hemodynamic parameters and 6MWD were noted following selexipag treatment. However, four patients showed improvements in 6MWD ≥20 m at follow-up and were considered responders. They had a higher body mass index (BMI) and lower PaO2/FiO2 at baseline than non-responders (p = 0.02 and p = 0.04, respectively). No Grade 3 or 4 adverse events were observed. CONCLUSIONS Selexipag was effective in half of the PH-LD cases, emphasizing higher BMI and lower PaO2/FiO2 as possible indicators for favorable response. Since selexipag starting at a low dose with subsequent titration may reduce the risk of early adverse events, it can be considered a treatment option for PH-LD. Further large-scale studies are warranted to confirm these findings.
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MESH Headings
- Humans
- Male
- Female
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Aged
- Pyrazines/administration & dosage
- Pyrazines/adverse effects
- Middle Aged
- Retrospective Studies
- Acetamides/administration & dosage
- Treatment Outcome
- Lung Diseases/etiology
- Lung Diseases/drug therapy
- Walk Test
- Pulmonary Disease, Chronic Obstructive/drug therapy
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Lung Diseases, Interstitial/drug therapy
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/physiopathology
- Lung Diseases, Interstitial/complications
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Affiliation(s)
- Kazuya Yoshikawa
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Ryo Yamazaki
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yuki Kunita
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yusaku Nishikawa
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Akiko Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Hisako Matsumoto
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
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10
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Tanabe N, Kumamaru H, Tamura Y, Kondoh Y, Nakayama K, Kinukawa N, Kimura T, Nishiyama O, Tsujino I, Shigeta A, Morio Y, Inoue Y, Kuraishi H, Hirata KI, Tanaka K, Kuwana M, Nagaoka T, Handa T, Sugimura K, Sakamaki F, Naito A, Taniguchi Y, Matsubara H, Hanaoka M, Inami T, Hayama N, Nishimura Y, Kimura H, Miyata H, Tatsumi K, JRPHS Group. Pulmonary Hypertension With Interstitial Pneumonia: Initial Treatment Effectiveness and Severity in a Japan Registry. JACC. ASIA 2024; 4:403-417. [PMID: 38765657 PMCID: PMC11099821 DOI: 10.1016/j.jacasi.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 05/22/2024]
Abstract
Background Recent guidelines discourage the use of pulmonary arterial hypertension (PAH)-targeted therapies in patients with pulmonary hypertension (PH) associated with respiratory diseases. Therefore, stratifications of the effectiveness of PAH-targeted therapies are important for this group. Objectives The authors aimed to identify phenotypes that might benefit from initial PAH-targeted therapies in patients with PH associated with interstitial pneumonia and combined pulmonary fibrosis and emphysema. Methods We categorized 270 patients with precapillary PH (192 interstitial pneumonia, 78 combined pulmonary fibrosis and emphysema) into severe and mild PH using a pulmonary vascular resistance of 5 WU. We investigated the prognostic factors and compared the prognoses of initial (within 2 months after diagnosis) and noninitial treatment groups, as well as responders (improvements in World Health Organization functional class, pulmonary vascular resistance, and 6-minute walk distance) and nonresponders. Results Among 239 treatment-naive patients, 46.0% had severe PH, 51.8% had mild ventilatory impairment (VI), and 40.6% received initial treatment. In the severe PH with mild VI subgroup, the initial treatment group had a favorable prognosis compared with the noninitial treatment group. The response rate in this group was significantly higher than the others (48.2% vs 21.8%, ratio 2.21 [95% CI: 1.17-4.16]). In multivariate analysis, initial treatment was a better prognostic factor for severe PH but not for mild PH. Within the severe PH subgroup, responders had a favorable prognosis. Conclusions This study demonstrated an increased number of responders to initial PAH-targeted therapy, with a favorable prognosis in severe PH cases with mild VI. A survival benefit was not observed in mild PH cases. (Multi-institutional Prospective Registry in Pulmonary Hypertension associated with Respiratory Disease; UMIN000011541).
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Affiliation(s)
- Nobuhiro Tanabe
- Pulmonary Hypertension Center, Saiseikai Narashino Hospital, Narashino, Chiba, Japan
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | | | - Naoko Kinukawa
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Ichizo Tsujino
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshiteru Morio
- Center for Pulmonary Diseases and Respiratory Disease Division, National Hospital Organization Tokyo National Hospital, Kiyose, Tokyo, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Hiroshi Kuraishi
- Department of Respiratory Medicine, Nagano Red Cross Hospital, Nagano, Nagano, Japan
| | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kensuke Tanaka
- Department of Chest Medicine, Japan Railway Tokyo General Hospital, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Tetsutaro Nagaoka
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomohiro Handa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Sugimura
- Department of Cardiology, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Fumio Sakamaki
- Division of Respiratory Disease, Department of Medicine, Tokai University Hachioji Hospital, Hchioji, Japan
| | - Akira Naito
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiromi Matsubara
- Department of Cardiology, Okayama Medical Center, Okayama, Japan
| | - Masayuki Hanaoka
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Takumi Inami
- Division of Cardiology Department of Medicine, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Naoki Hayama
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Yoshihiro Nishimura
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kimura
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - JRPHS Group
- Pulmonary Hypertension Center, Saiseikai Narashino Hospital, Narashino, Chiba, Japan
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
- Department of Cardiovascular Medicine, Shinko Hospital, Kobe, Japan
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Center for Pulmonary Diseases and Respiratory Disease Division, National Hospital Organization Tokyo National Hospital, Kiyose, Tokyo, Japan
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
- Department of Respiratory Medicine, Nagano Red Cross Hospital, Nagano, Nagano, Japan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Chest Medicine, Japan Railway Tokyo General Hospital, Tokyo, Japan
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Cardiology, International University of Health and Welfare Narita Hospital, Narita, Japan
- Division of Respiratory Disease, Department of Medicine, Tokai University Hachioji Hospital, Hchioji, Japan
- Department of Cardiology, Okayama Medical Center, Okayama, Japan
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
- Division of Cardiology Department of Medicine, Kyorin University Hospital, Mitaka, Tokyo, Japan
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan
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11
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Weatherald J, Nathan SD, El-Kersh K, Argula RG, DuBrock HM, Rischard FP, Cassady SJ, Tarver J, Levine DJ, Tapson VF, Deng C, Shen E, Das M, Waxman AB. Inhaled treprostinil in patients with pulmonary hypertension associated with interstitial lung disease with less severe haemodynamics: a post hoc analysis of the INCREASE study. BMJ Open Respir Res 2024; 11:e002116. [PMID: 38519114 PMCID: PMC10961504 DOI: 10.1136/bmjresp-2023-002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/14/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Inhaled treprostinil (iTre) is the only treatment approved for pulmonary hypertension due to interstitial lung disease (PH-ILD) to improve exercise capacity. This post hoc analysis evaluated clinical worsening and PH-ILD exacerbations from the 16-week INCREASE study and change in 6-minute walking distance (6MWD) in the INCREASE open-label extension (OLE) in patients with less severe haemodynamics. METHODS Patients were stratified by baseline pulmonary vascular resistance (PVR) of <4 Wood units (WU) versus ≥4 WU and <5 WU versus ≥5 WU. Exacerbations of underlying lung disease, clinical worsening and change in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) in INCREASE were evaluated. For the OLE, patients previously assigned to placebo were considered to have a 16-week treatment delay. 6MWD and clinical events in the OLE were evaluated by PVR subgroup. RESULTS Of the 326 patients enrolled in INCREASE, patients with less severe haemodynamics receiving iTre had fewer exacerbations of underlying lung disease and clinical worsening events. This was supported by the Bayesian analysis of the risk of disease progression (HR<1), and significant decreases in NT-proBNP levels. In the OLE, patients without a treatment delay had improved exercise capacity after 1-year compared with those with a 16-week treatment delay (22.1 m vs -10.3 m). Patients with a PVR of ≤5 WU without a treatment delay had a change of 5.5 m compared with -8.2 m for those with a treatment delay. Patients without a treatment delay had a prolonged time to hospitalisation, lung disease exacerbation and death. CONCLUSION Treatment with iTre led to consistent benefits in clinical outcomes in patients with PH-ILD and less severe haemodynamics. Earlier treatment in less severe PH-ILD may lead to better exercise capacity long-term, however, the subgroup analyses in this post hoc study were underpowered and confirmation of these findings is needed.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven D Nathan
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Karim El-Kersh
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Rahul G Argula
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - Steven J Cassady
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James Tarver
- AdventHealth Central Florida, Orlando, Florida, USA
| | | | | | - Chunqin Deng
- United Therapeutics Corp Research Triangle Park, Research Triangle Park, North Carolina, USA
| | - Eric Shen
- United Therapeutics Corp Research Triangle Park, Research Triangle Park, North Carolina, USA
| | - Manisit Das
- United Therapeutics Corp Research Triangle Park, Research Triangle Park, North Carolina, USA
| | - Aaron B Waxman
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
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12
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Kitahara K, Omura J, Wada S, Kim SW. Patient and Therapeutic Profiles of Pulmonary Hypertension in Chronic Lung Diseases in Japan: A Cohort Study Using a Claims Database. Pulm Ther 2024; 10:21-49. [PMID: 37950789 PMCID: PMC10881911 DOI: 10.1007/s41030-023-00243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 11/13/2023] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is often complicated by chronic lung diseases (CLDs) such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Differentiating between PH associated with CLD (group 3 PH) and pulmonary arterial hypertension (PAH) in CLD is often difficult and reporting on the efficacy of PAH-specific therapies is inconsistent as a result of the lack of understanding of the heterogeneity of patients with PH. METHODS A retrospective observational cohort study was conducted to understand the baseline characteristics, comorbidities, and treatment profiles of patients with PH in CLD in a real-world setting using a large-scale claims database (Medical Data Vision). Administrative and clinical data for patients admitted to acute-care hospitals in Japan between April 2008 and January 2021 were analyzed. RESULTS A total of 115,921 patients with CLD (109,578 with COPD and 6343 with ILD, of whom 569 and 176 had PH, respectively) were analyzed. This study found lower PH diagnosis rates among patients with COPD and patients with ILD than in previous studies. The majority of PH with CLD patients were elderly (mean age 75.7 years) and male (80.81%). Among patients with CLD prescribed PAH-specific therapies (105 patients with COPD; 64 patients with ILD), most received these as monotherapy (COPD, 84.76%; ILD, 75.56%); the most common were phosphodiesterase 5 inhibitors (COPD, 42.70%; ILD, 18.37%), prostacyclins (oral; COPD, 48.31%; ILD, 24.49%), and endothelin receptor antagonists (ERA) (COPD, 8.99%; ILD, 18.37%). Comorbidities (e.g., pulmonary, cardiac, kidney), home oxygen therapy (HOT), and echocardiography (ECHO) were factors associated with the diagnosis of PH. CONCLUSION This is the first study using an administrative database that provides real-world data on patients with PH in CLD in Japan. Our results indicate that PH may be misdiagnosed or underdiagnosed in Japan which may lead to suboptimal treatment for patients, and supports the need for further evidence to guide appropriate treatment.
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Affiliation(s)
- Kazuki Kitahara
- Medical Affairs, Janssen Pharmaceutical K.K., 3-5-2 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan.
| | - Junichi Omura
- Medical Affairs, Janssen Pharmaceutical K.K., 3-5-2 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Shingo Wada
- Real World Evidence Solutions, IQVIA Solutions Japan K.K., 4-10-18 Takanawa, Minato-ku, Tokyo, 108-0074, Japan
| | - Seok-Won Kim
- Real World Evidence Solutions, IQVIA Solutions Japan K.K., 4-10-18 Takanawa, Minato-ku, Tokyo, 108-0074, Japan
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13
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Provencher S, Mai V, Bonnet S. Managing Pulmonary Arterial Hypertension With Cardiopulmonary Comorbidities. Chest 2024; 165:682-691. [PMID: 38461018 DOI: 10.1016/j.chest.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/10/2023] [Accepted: 08/25/2023] [Indexed: 03/11/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) and pulmonary hypertension associated with left-sided heart and lung diseases are most commonly easily discriminated and treated accordingly. With the changing epidemiology of PAH, however, a growing proportion of patients at the time of diagnosis present with comorbidities of varying severity. In addition to classical PAH, two distinct phenotypes have emerged: a heart failure with preserved ejection fraction-like phenotype and a lung phenotype. Importantly, the evidence supporting the currently proposed treatment algorithm for PAH has been generated mainly from PAH trials in which patients with cardiopulmonary comorbidities have been underrepresented or excluded. As a consequence, the best therapeutic approach for patients with common PAH with cardiopulmonary comorbidities remains largely unknown and requires further investigation. The present article reviews the relevant literature on the topic and describes the authors' views on the current therapeutic approach for these patients.
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Affiliation(s)
- Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada.
| | - Vicky Mai
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Sebastien Bonnet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
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14
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Panagiotidou E, Βoutou A, Fouka E, Papakosta D, Chatzopoulos E, Sourla E, Markopoulou A, Kioumis I, Stanopoulos I, Pitsiou G. Phenotyping exercise limitation of patients with Interstitial Fibrosing Lung Disease: the importance of exercise hemodynamics. Pulmonology 2024; 30:104-112. [PMID: 35568651 DOI: 10.1016/j.pulmoe.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Left-heart dysfunction and pulmonary vasculopathy are increasingly recognized as contributing factors of exercise capacity limitation in interstitial fibrosing lung disease (IFLD). Moreover, the clinical significance of exercise pulmonary hypertension (ePH) in pulmonary and cardiac diseases has been documented, representing a risk factor for decreased exercise capacity and survival, progression to resting pulmonary hypertension (PH) and overall clinical worsening. We conducted a prospective study aiming at: (a) assessing the prevalence of PH and ePH in a cohort of 40 functionally limited patients with IFLD, (b) determining the post-capillary (postC) or pre-capillary (preC) etiology of either PH or ePH in this cohort, and (c) examining the correlations between invasively and non-invasively measured exercise variables among hemodynamic groups. PATIENTS AND METHODS 40 IFLD patients underwent cardiopulmonary evaluation, including: clinical examination, lung function tests, 6-minute walking test, heart ultrasonography, cardiopulmonary exercise test and, finally, right heart catheterization (RHC). Resting hemodynamic evaluation was followed by the exercise protocol proposed by Herve et al, using a bedside cycle ergometer in the supine position. Abnormal elevation of mean pulmonary artery pressure (mPAP) above 30mmHg during exercise, with respect to abnormal elevation of cardiac output (CO) below 10 L/min (mPAP-CO ratio ⩾3 mmHg·min·L-1) was used to define ePH (Herve et al, 2015). Secondary hemodynamic evaluation involved detection of abnormal pulmonary arterial wedge pressure (PAWP) increase at peak exercise in relation to CO. Specifically, ΔPAWP/ΔCO >2 mmHg/L per minute determined an abnormal PAWP elevation (Bentley et al, 2020). RESULTS Among the 40-patient cohort, 25% presented postC PH, 37.5% preC PH, 27.5% ePH, with the remaining 10% recording normal hemodynamics. PAWP evaluation during exercise revealed a postC etiology in 4 out of the 11 patients presenting ePH, and a postC etiology in 6 out of the 15 patients presenting resting preC PH. Mean values of non-invasive variables did not display statistically significant differences among hemodynamic groups, except for: diffusing capacity for carbon monoxide (DLCO), carbon monoxide transfer coefficient (KCO) and the ratio of functional vital capacity to DLCO (FVC%/DLCO%), which were lower in both ePH and PH groups (p < 0.05). Resting values of CO, cardiac index (CI), stroke volume (SV) and pulmonary vascular compliance (PVC) were significantly impaired in ePH, preC-PH and postC-PH groups when compared to the normal group. CONCLUSIONS Both PH and ePH were highly prevalent within the IFLD patient group, suggesting that RHC should be offered more frequently in functionally limited patients. Diffusion capacity markers must thus guide decision making, in parallel to clinical evaluation. ePH was associated to lower resting CO and PVC, in a similar way to resting PH, indicating the relevance of cardiopulmonary function to exercise limitation. Finally, the use of the ΔPAWP/ΔCO>2 criterion further uncovered PH of postcapillary etiology, highlighting the complexity of hemodynamics in IFLD. CLINICALTRIALS gov ID: NCT03706820.
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Affiliation(s)
- E Panagiotidou
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - A Βoutou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - E Fouka
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Papakosta
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Chatzopoulos
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Sourla
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Markopoulou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - I Kioumis
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - I Stanopoulos
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - G Pitsiou
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Parikh R, Thomas A, Sharofi A, Moallem N, Fiscus G, Farber HW. Severe pulmonary hypertension-interstitial lung disease presenting as right ventricular failure: stabilisation with intravenous prostacyclin and maintenance with inhaled prostacyclin. ERJ Open Res 2024; 10:00659-2023. [PMID: 38288084 PMCID: PMC10823367 DOI: 10.1183/23120541.00659-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/05/2023] [Indexed: 01/31/2024] Open
Abstract
Background Pulmonary hypertension (PH) leads to increased morbidity and mortality in interstitial lung disease (ILD). While the INCREASE trial highlighted the use of inhaled prostacyclin in PH-ILD patients, such therapy may be inadequate when right ventricular failure (RVF) is also present. In this study, we report the use of intravenous prostacyclin in three PH-ILD patients to stabilise right ventricular (RV) function, with a subsequent transition to maintenance therapy with inhaled prostacyclin. Methods We evaluated three consecutive PH-ILD patients with RVF. RV afterload and pulmonary vascular resistance (PVR) were treated with intravenous prostacyclin during the induction phase of the therapy. Patients transitioned from intravenous prostacyclin to the maintenance phase of the treatment with inhaled prostacyclin once three transition criteria were met: cardiac index (CI) >2 L·min-1·m-2, PVR <7 Wood units (WU) and tricuspid annular plane systolic excursion (TAPSE) change >1 mm or TAPSE >1.6 cm. Results Pre-treatment parameters for the three patients were a mean PVR of 14.3 WU, a mean Fick CI of 1.8 L·min-1·m-2 and a mean TAPSE of 1.4 cm. The average intravenous prostacyclin dose at the time of transition to maintenance therapy was 20.7 ng·kg-1·m-2 of treprostinil. At 3-months follow-up, the mean PVR was 6.3 WU, Fick CI 2.2 L·min-1·m-2 and TAPSE 1.7 cm. Conclusion This case series of three PH-ILD patients with RVF introduces the concept of an initial intravenous prostacyclin induction phase, followed by a transition to maintenance therapy with inhaled prostacyclin. Further development of this treatment algorithm with a refinement of the transition criteria, potential testing in a clinical trial and a longer-term follow-up period is warranted to improve the outcomes of advanced PH-ILD patients with concomitant RVF.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep, Hartford Hospital, Hartford, CT, USA
| | - Alysse Thomas
- A.T. Still University Osteopathic Medical School, Mesa, AZ, USA
| | | | - Niala Moallem
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Garrett Fiscus
- Division of Pulmonary, Critical Care and Sleep, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical Center, Boston, MA, USA
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16
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Blanco I, Hernández-González F, García A, Torres-Castro R, Barberà JA. Management of Pulmonary Hypertension Associated with Chronic Lung Disease. Semin Respir Crit Care Med 2023; 44:826-839. [PMID: 37487524 DOI: 10.1055/s-0043-1770121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of chronic lung diseases, particularly in chronic obstructive pulmonary disease (COPD) and interstitial lung diseases (ILD) and especially in advanced disease. It is associated with greater mortality and worse clinical course. Given the high prevalence of some respiratory disorders and because lung parenchymal abnormalities might be present in other PH groups, the appropriate diagnosis of PH associated with respiratory disease represents a clinical challenge. Patients with chronic lung disease presenting symptoms that exceed those expected by the pulmonary disease should be further evaluated by echocardiography. Confirmatory right heart catheterization is indicated in candidates to surgical treatments, suspected severe PH potentially amenable with targeted therapy, and, in general, in those conditions where the result of the hemodynamic assessment will determine treatment options. The treatment of choice for these patients who are hypoxemic is long-term oxygen therapy and pulmonary rehabilitation to improve symptoms. Lung transplant is the only curative therapy and can be considered in appropriate cases. Conventional vasodilators or drugs approved for pulmonary arterial hypertension (PAH) are not recommended in patients with mild-to-moderate PH because they may impair gas exchange and their lack of efficacy shown in randomized controlled trials. Patients with severe PH (as defined by pulmonary vascular resistance >5 Wood units) should be referred to a center with expertise in PH and lung diseases and ideally included in randomized controlled trials. Targeted PAH therapy might be considered in this subset of patients, with careful monitoring of gas exchange. In patients with ILD, inhaled treprostinil has been shown to improve functional ability and to delay clinical worsening.
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Affiliation(s)
- Isabel Blanco
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Fernanda Hernández-González
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Agustín García
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Rodrigo Torres-Castro
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Joan A Barberà
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
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17
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Halank M, Zeder KE, Sommer N, Ulrich S, Held M, Köhler T, Foris V, Heberling M, Neurohr C, Ronczka J, Holt S, Skowasch D, Kneidinger N, Behr J. [Pulmonary hypertension associated with lung disease]. Pneumologie 2023; 77:916-925. [PMID: 37963481 DOI: 10.1055/a-2145-4756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Lung diseases and hypoventilation syndromes are often associated with pulmonary hypertension (PH). In most cases, PH is not severe. This is defined hemodynamically by a mean pulmonary arterial pressure (PAPm) > 20 mmHg, a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance of ≤ 5 Wood units (WU). Both the non-severe (PVR ≤ 5 WU) and much more the severe PH (PVR > 5 WU) have an unfavorable prognosis.If PH is suspected, it is recommended to primarily check whether risk factors for pulmonary arterial hypertension (PAH, group 1 PH) or chronic thromboembolic pulmonary hypertension (CTEPH, group 4 PH) are present. If risk factors are present or there is a suspicion of severe PH in lung patients, it is recommended that the patient should be presented to a PH outpatient clinic promptly.For patients with severe PH associated with lung diseases, personalized, individual therapy is recommended - if possible within the framework of therapy studies. Currently, a therapy attempt with PH specific drugs should only be considered in COPD patients if the associated PH is severe and a "pulmonary vascular" phenotype (severe precapillary PH, but typically only mild to moderate airway obstruction, no or mild hypercapnia and DLCO < 45 % of predicted value) is present. In patients with severe PH associated with interstitial lung disease phosphodiesterase-5-inhibitors may be considered in individual cases. Inhaled treprostinil may be considered also in non-severe PH in this patient population.
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Affiliation(s)
- Michael Halank
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Katarina E Zeder
- Klinische Abteilung für Pulmonologie, Med. Universität Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Natascha Sommer
- Justus-Liebig-Universitätsklinikum Gießen, Medizinische Klinik II, Pneumologie
- Excellence Cluster Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC)
| | | | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin
| | - Thomas Köhler
- Universitätsklinikum Freiburg, Department Innere Medizin, Klinik für Pneumologie, Freiburg, Deutschland
| | - Vasile Foris
- Klinische Abteilung für Pulmonologie, Med. Universität Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Melanie Heberling
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Claus Neurohr
- RBK Lungenzentrum Stuttgart am Robert-Bosch-Krankenhaus, Abteilung Pneumologie und Beatmungsmedizin, Stuttgart, Deutschland
| | - Julia Ronczka
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | | | - Dirk Skowasch
- Universitätsklinikum Bonn, Med. Klinik und Poliklinik II, Sektion Pneumologie, Bonn, Deutschland
| | - Nikolaus Kneidinger
- Medizinische Klinik und Poliklinik V, LMU Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, LMU Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
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18
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Haynes ZA, Chandel A, King CS. Pulmonary Hypertension in Interstitial Lung Disease: Updates in Disease, Diagnosis, and Therapeutics. Cells 2023; 12:2394. [PMID: 37830608 PMCID: PMC10572438 DOI: 10.3390/cells12192394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/15/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
Pulmonary hypertension is a debilitating condition that frequently develops in the setting of interstitial lung disease, likely related to chronic alveolar hypoxemia and pulmonary vascular remodeling. This disease process is likely to be identified more frequently by providers given recent advancements in definitions and diagnostic modalities, and provides practitioners with emerging opportunities to improve patient outcomes and quality of life. Despite years of data suggesting against the efficacy of pulmonary vasodilator therapy in patients with pulmonary hypertension due to interstitial lung disease, new data have emerged identifying promising advancements in therapeutics. The authors present to you a comprehensive review of pulmonary hypertension in interstitial lung disease, reviewing our current understanding of pathophysiology, updates in diagnostic approaches, and highlights of recent clinical trials which provide an effective approach for medical management.
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Affiliation(s)
- Zachary A. Haynes
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Fairfax, VA 22031, USA;
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19
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Olsson KM, Corte TJ, Kamp JC, Montani D, Nathan SD, Neubert L, Price LC, Kiely DG. Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:820-835. [PMID: 37591300 DOI: 10.1016/s2213-2600(23)00259-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/19/2023]
Abstract
Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.
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Affiliation(s)
- Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany.
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Jan C Kamp
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, INSERM Unité Mixte de Recherche 999, Université Paris-Saclay, Paris, France
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; NIHR Biomedical Research Centre, Sheffield, UK
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20
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Kacprzak A, Tomkowski W, Szturmowicz M. Pulmonary Hypertension in the Course of Interstitial Lung Diseases-A Personalised Approach Is Needed to Identify a Dominant Cause and Provide an Effective Therapy. Diagnostics (Basel) 2023; 13:2354. [PMID: 37510098 PMCID: PMC10378268 DOI: 10.3390/diagnostics13142354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
The prevalence of pulmonary hypertension (PH) complicating interstitial lung diseases (ILDs) is 3.5-15% at an early stage, and up to 90% in ILD patients listed for lung transplantation. In addition, other types of PH may occur in patients with ILDs due to concomitant conditions. Therefore, any significant PH occurring in the setting of ILD requires a proper differential workup. PH increases morbidity and mortality in ILDs. The pathomechanisms underlying PH due to ILD (PH-ILD) are not fully known, and there is no straightforward correlation between the presence or severity of PH-ILD and the severity of ILD. Severe PH in mild ILD without other explanatory causes constitutes a dilemma of differentiating between PH due to ILD and pulmonary arterial hypertension coexisting with ILDs. The heterogeneity and poor prognosis of patients with ILDs coexisting with PH necessitate an individualised approach to the management of this condition. This review presents recent advances in understanding and treatment options in PH-ILD. It also addresses practical issues, such as when to suspect and how to screen for PH in ILD, what are the indications for right heart catheterisation, and how to approach an individual ILD patient to determine the dominant PH cause and apply adequate management.
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Affiliation(s)
- Aneta Kacprzak
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
| | - Witold Tomkowski
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
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21
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Waxman A, Restrepo-Jaramillo R, Thenappan T, Engel P, Bajwa A, Ravichandran A, Feldman J, Hajari Case A, Argula RG, Tapson V, Smith P, Deng C, Shen E, Nathan SD. Long-term inhaled treprostinil for pulmonary hypertension due to interstitial lung disease: INCREASE open-label extension study. Eur Respir J 2023; 61:2202414. [PMID: 37080567 PMCID: PMC10307984 DOI: 10.1183/13993003.02414-2022] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION The 16-week randomised, placebo-controlled INCREASE trial (RCT) met its primary end-point by improving 6-min walk distance (6MWD) in patients receiving inhaled treprostinil for pulmonary hypertension due to interstitial lung disease (PH-ILD). The open-label extension (OLE) evaluated long-term effects of inhaled treprostinil in PH-ILD. METHODS Of 258 eligible patients, 242 enrolled in the INCREASE OLE and received inhaled treprostinil. Assessments included 6MWD, pulmonary function testing, N-terminal pro-brain natriuretic peptide (NT-proBNP), quality of life and adverse events. Hospitalisations, exacerbations of underlying lung disease and death were recorded. RESULTS At INCREASE OLE baseline, patients had a median age of 70 years and a mean 6MWD of 274.2 m; 52.1% were male. For the overall population, the mean 6MWD at week 52 was 279.1 m and the mean change from INCREASE RCT baseline was 3.5 m (22.1 m for the prior inhaled treprostinil arm and -19.5 m for the prior placebo arm); the median NT-proBNP decreased from 389 pg·mL-1 at RCT baseline to 359 pg·mL-1 at week 64; and the absolute (% predicted) mean forced vital capacity change from RCT baseline to week 64 was 51 mL (2.8%). Patients who received inhaled treprostinil versus placebo in the RCT had a 31% lower relative risk of exacerbation of underlying lung disease in the OLE (hazard ratio 0.69 (95% CI 0.49-0.97); p=0.03). Adverse events leading to drug discontinuation occurred in 54 (22.3%) patients. CONCLUSIONS These results support the long-term safety and efficacy of inhaled treprostinil in patients with PH-ILD, and are consistent with the results observed in the INCREASE RCT.
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Affiliation(s)
| | | | | | - Peter Engel
- Carl and Edyth Lindner Research Center at the Christ Hospital, Cincinnati, OH, USA
| | | | | | | | | | - Rahul G Argula
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Peter Smith
- United Therapeutics, Research Triangle Park, NC, USA
| | - Chunqin Deng
- United Therapeutics, Research Triangle Park, NC, USA
| | - Eric Shen
- United Therapeutics, Research Triangle Park, NC, USA
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22
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Piccari L, Allwood B, Antoniou K, Chung JH, Hassoun PM, Nikkho SM, Saggar R, Shlobin OA, Vitulo P, Nathan SD, Wort SJ. Pathogenesis, clinical features, and phenotypes of pulmonary hypertension associated with interstitial lung disease: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative - Group 3 Pulmonary Hypertension. Pulm Circ 2023; 13:e12213. [PMID: 37025209 PMCID: PMC10071306 DOI: 10.1002/pul2.12213] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a frequent complication of interstitial lung disease (ILD). Although PH has mostly been described in idiopathic pulmonary fibrosis, it can manifest in association with many other forms of ILD. Associated pathogenetic mechanisms are complex and incompletely understood but there is evidence of disruption of molecular and genetic pathways, with panvascular histopathologic changes, multiple pathophysiologic sequelae, and profound clinical ramifications. While there are some recognized clinical phenotypes such as combined pulmonary fibrosis and emphysema and some possible phenotypes such as connective tissue disease associated with ILD and PH, the identification of further phenotypes of PH in ILD has thus far proven elusive. This statement reviews the current evidence on the pathogenesis, recognized patterns, and useful diagnostic tools to detect phenotypes of PH in ILD. Distinct phenotypes warrant recognition if they are characterized through either a distinct presentation, clinical course, or treatment response. Furthermore, we propose a set of recommendations for future studies that might enable the recognition of new phenotypes.
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Affiliation(s)
- Lucilla Piccari
- Department of Pulmonary Medicine Hospital del Mar Barcelona Spain
| | - Brian Allwood
- Department of Medicine, Division of Pulmonology Stellenbosch University & Tygerberg Hospital Cape Town South Africa
| | - Katerina Antoniou
- Department of Thoracic Medicine University of Crete School of Medicine Heraklion Crete Greece
| | - Jonathan H Chung
- Department of Radiology The University of Chicago Medicine Chicago Illinois USA
| | - Paul M Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care Medicine Johns Hopkins University Baltimore Maryland USA
| | | | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs University of California Los Angeles David Geffen School of Medicine Los Angeles California USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Health System Falls Church Virginia USA
| | - Patrizio Vitulo
- Department of Pulmonary Medicine IRCCS Mediterranean Institute for Transplantation and Advanced Specialized Therapies Palermo Sicilia Italy
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Health System Falls Church Virginia USA
| | - Stephen John Wort
- National Pulmonary Hypertension Service at the Royal Brompton Hospital London UK
- National Heart and Lung Institute, Imperial College London UK
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23
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Biener L, Pizarro C, Skowasch D. Pulmonale Hypertonie bei Lungenerkrankungen. AKTUELLE KARDIOLOGIE 2023. [DOI: 10.1055/a-1989-1785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
ZusammenfassungDie pulmonale Hypertonie (PH) ist eine häufige Komorbidität von Lungenerkrankungen wie der chronisch obstruktiven Lungenerkrankung oder der idiopathischen pulmonalen Fibrose und geht mit
einer erhöhten Letalität einher. Die pulmonalarterielle Hypertonie (PAH) ist hingegen eine seltene Erkrankung, ebenfalls mit hoher Letalität. Durch das häufig ältere und komorbide
Patientengut der PAH ergeben sich Subgruppen, die sich hinsichtlich ihres Therapieansprechens und der Letalität von typischen PAH-Patienten unterscheiden. In den letzten Jahren hat sich
gezeigt, dass sich neben dem kardialen bzw. Linksherzphänotyp auch ein pulmonaler bzw. kardiopulmonaler Phänotyp abgrenzen lässt. Die Differenzierung zu einer schwergradigen PH bei
Lungengrunderkrankung kann schwierig sein und ist aufgrund der unterschiedlichen Therapiestrategien Expertenzentren vorbehalten.
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Affiliation(s)
- Leonie Biener
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Carmen Pizarro
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Dirk Skowasch
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Deutschland
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24
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Alamri AK, Shelburne NJ, Mayeux JD, Brittain E. Pulmonary Hypertension Association's 2022 International Conference Scientific Sessions Overview. Pulm Circ 2023; 13:e12182. [PMID: 36644322 PMCID: PMC9832865 DOI: 10.1002/pul2.12182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The considerable progress made in recent years in the diagnosis, risk stratification, and treatment of pulmonary hypertension was highlighted during the most recent edition of the Pulmonary Hypertension Association Scientific Sessions, which was held in Atlanta, Georgia from June 9 to 11, 2022, with the theme: Vision for the PHuture: The Evolving Science and Management of PH. Content presented over the 3-day conference focused on scientific and management updates since the last sessions were held in 2018 and included didactic talks, debates, and roundtable discussions across a broad spectrum of topics related to pulmonary hypertension. This article aims to summarize the key messages from each of the session talks.
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Affiliation(s)
- Ayedh K. Alamri
- Department of MedicineUniversity of UtahSalt Lake CityUtahUSA,Department of Medicine, College of MedicineNorthern Border UniversityArarSaudi Arabia
| | - Nicholas J. Shelburne
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennalyn D. Mayeux
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Evan Brittain
- Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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25
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:2200879. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 811] [Impact Index Per Article: 405.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1744] [Impact Index Per Article: 581.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Parikh R, Konstantinidis I, O'Sullivan DM, Farber HW. Pulmonary hypertension in patients with interstitial lung disease: a tool for early detection. Pulm Circ 2022; 12:e12141. [PMID: 36225536 PMCID: PMC9531548 DOI: 10.1002/pul2.12141] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension (PH) complicates the treatment of interstitial lung disease (ILD) patients resulting in poor functional status and worse outcomes. Early recognition of PH in ILD is important for initiating therapy and considering lung transplantation. However, no standard exists regarding which patients to screen for PH-ILD or the optimal method to do so. The aim of this study was to create a risk assessment tool that could reliably predict PH in ILD patients. We developed a PH-ILD Detection tool that incorporated history, exam, 6-min walk distance, diffusion capacity for carbon monoxide, chest imaging, and cardiac biomarkers to create an eight-component score. This tool was analyzed retrospectively in 154 ILD patients where each patient was given a score ranging from 0 to 12. The sensitivity (SN) and specificity (SP) of the PH-ILD Detection tool and an area-under-the-curve (AUC) were calculated. In this cohort, 74 patients (48.1%) had PH-ILD. A score of ≥6 on the PH-ILD Detection tool was associated with a diagnosis of PH-ILD (SN: 86.5%; SP: 86.3%; area-under-the-curve: 0.920, p < 0.001). The PH-ILD Detection tool provides high SN and SP for detecting PH in ILD patients. With confirmation in larger cohorts, this tool could improve the diagnosis of PH in ILD and may suggest further testing with right heart catheterization and earlier intervention with inhaled treprostinil and/or lung transplant evaluation.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care, and SleepHartford HospitalHartfordConnecticutUSA
| | | | - David M. O'Sullivan
- Department of Research AdministrationHartford HealthCareHartfordConnecticutUSA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care MedicineTufts Medical CenterBostonMassachusettsUSA
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Cottin V, Bonniaud P, Cadranel J, Crestani B, Jouneau S, Marchand-Adam S, Nunes H, Wémeau-Stervinou L, Bergot E, Blanchard E, Borie R, Bourdin A, Chenivesse C, Clément A, Gomez E, Gondouin A, Hirschi S, Lebargy F, Marquette CH, Montani D, Prévot G, Quetant S, Reynaud-Gaubert M, Salaun M, Sanchez O, Trumbic B, Berkani K, Brillet PY, Campana M, Chalabreysse L, Chatté G, Debieuvre D, Ferretti G, Fourrier JM, Just N, Kambouchner M, Legrand B, Le Guillou F, Lhuillier JP, Mehdaoui A, Naccache JM, Paganon C, Rémy-Jardin M, Si-Mohamed S, Terrioux P. [French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]. Rev Mal Respir 2022; 39:e35-e106. [PMID: 35752506 DOI: 10.1016/j.rmr.2022.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.
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Affiliation(s)
- V Cottin
- Centre national coordonnateur de référence des maladies pulmonaires rares, service de pneumologie, hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), Lyon, France; UMR 754, IVPC, INRAE, Université de Lyon, Université Claude-Bernard Lyon 1, Lyon, France; Membre d'OrphaLung, RespiFil, Radico-ILD2, et ERN-LUNG, Lyon, France.
| | - P Bonniaud
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et soins intensifs respiratoires, centre hospitalo-universitaire de Bourgogne et faculté de médecine et pharmacie, université de Bourgogne-Franche Comté, Dijon ; Inserm U123-1, Dijon, France
| | - J Cadranel
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et oncologie thoracique, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Tenon, Paris ; Sorbonne université GRC 04 Theranoscan, Paris, France
| | - B Crestani
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie A, AP-HP, hôpital Bichat, Paris, France
| | - S Jouneau
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie, hôpital Pontchaillou, Rennes ; IRSET UMR1085, université de Rennes 1, Rennes, France
| | - S Marchand-Adam
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, hôpital Bretonneau, service de pneumologie, CHRU, Tours, France
| | - H Nunes
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie, AP-HP, hôpital Avicenne, Bobigny ; université Sorbonne Paris Nord, Bobigny, France
| | - L Wémeau-Stervinou
- Centre de référence constitutif des maladies pulmonaires rares, Institut Cœur-Poumon, service de pneumologie et immuno-allergologie, CHRU de Lille, Lille, France
| | - E Bergot
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie et oncologie thoracique, hôpital Côte de Nacre, CHU de Caen, Caen, France
| | - E Blanchard
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie, hôpital Haut Levêque, CHU de Bordeaux, Pessac, France
| | - R Borie
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie A, AP-HP, hôpital Bichat, Paris, France
| | - A Bourdin
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, département de pneumologie et addictologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, Montpellier ; Inserm U1046, CNRS UMR 921, Montpellier, France
| | - C Chenivesse
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et d'immuno-allergologie, hôpital Albert Calmette ; CHRU de Lille, Lille ; centre d'infection et d'immunité de Lille U1019 - UMR 9017, Université de Lille, CHU Lille, CNRS, Inserm, Institut Pasteur de Lille, Lille, France
| | - A Clément
- Centre de ressources et de compétence de la mucoviscidose pédiatrique, centre de référence des maladies respiratoires rares (RespiRare), service de pneumologie pédiatrique, hôpital d'enfants Armand-Trousseau, CHU Paris Est, Paris ; Sorbonne université, Paris, France
| | - E Gomez
- Centre de compétence pour les maladies pulmonaires rares, département de pneumologie, hôpitaux de Brabois, CHRU de Nancy, Vandoeuvre-les Nancy, France
| | - A Gondouin
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Jean-Minjoz, Besançon, France
| | - S Hirschi
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, Nouvel Hôpital civil, Strasbourg, France
| | - F Lebargy
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Maison Blanche, Reims, France
| | - C-H Marquette
- Centre de compétence pour les maladies pulmonaires rares, FHU OncoAge, département de pneumologie et oncologie thoracique, hôpital Pasteur, CHU de Nice, Nice cedex 1 ; Université Côte d'Azur, CNRS, Inserm, Institute of Research on Cancer and Aging (IRCAN), Nice, France
| | - D Montani
- Centre de compétence pour les maladies pulmonaires rares, centre national coordonnateur de référence de l'hypertension pulmonaire, service de pneumologie et soins intensifs pneumologiques, AP-HP, DMU 5 Thorinno, Inserm UMR S999, CHU Paris-Sud, hôpital de Bicêtre, Le Kremlin-Bicêtre ; Université Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France
| | - G Prévot
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Larrey, Toulouse, France
| | - S Quetant
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie et physiologie, CHU Grenoble Alpes, Grenoble, France
| | - M Reynaud-Gaubert
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, AP-HM, CHU Nord, Marseille ; Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - M Salaun
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, oncologie thoracique et soins intensifs respiratoires & CIC 1404, hôpital Charles Nicole, CHU de Rouen, Rouen ; IRIB, laboratoire QuantiIF-LITIS, EA 4108, université de Rouen, Rouen, France
| | - O Sanchez
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | | | - K Berkani
- Clinique Pierre de Soleil, Vetraz Monthoux, France
| | - P-Y Brillet
- Université Paris 13, UPRES EA 2363, Bobigny ; service de radiologie, AP-HP, hôpital Avicenne, Bobigny, France
| | - M Campana
- Service de pneumologie et oncologie thoracique, CHR Orléans, Orléans, France
| | - L Chalabreysse
- Service d'anatomie-pathologique, groupement hospitalier est, HCL, Bron, France
| | - G Chatté
- Cabinet de pneumologie et infirmerie protestante, Caluire, France
| | - D Debieuvre
- Service de pneumologie, GHRMSA, hôpital Emile-Muller, Mulhouse, France
| | - G Ferretti
- Université Grenoble Alpes, Grenoble ; service de radiologie diagnostique et interventionnelle, CHU Grenoble Alpes, Grenoble, France
| | - J-M Fourrier
- Association Pierre-Enjalran Fibrose Pulmonaire Idiopathique (APEFPI), Meyzieu, France
| | - N Just
- Service de pneumologie, CH Victor-Provo, Roubaix, France
| | - M Kambouchner
- Service de pathologie, AP-HP, hôpital Avicenne, Bobigny, France
| | - B Legrand
- Cabinet médical de la Bourgogne, Tourcoing ; Université de Lille, CHU Lille, ULR 2694 METRICS, CERIM, Lille, France
| | - F Le Guillou
- Cabinet de pneumologie, pôle santé de l'Esquirol, Le Pradet, France
| | - J-P Lhuillier
- Cabinet de pneumologie, La Varenne Saint-Hilaire, France
| | - A Mehdaoui
- Service de pneumologie et oncologie thoracique, CH Eure-Seine, Évreux, France
| | - J-M Naccache
- Service de pneumologie, allergologie et oncologie thoracique, GH Paris Saint-Joseph, Paris, France
| | - C Paganon
- Centre national coordonnateur de référence des maladies pulmonaires rares, service de pneumologie, hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), Lyon, France
| | - M Rémy-Jardin
- Institut Cœur-Poumon, service de radiologie et d'imagerie thoracique, CHRU de Lille, Lille, France
| | - S Si-Mohamed
- Département d'imagerie cardiovasculaire et thoracique, hôpital Louis-Pradel, HCL, Bron ; Université de Lyon, INSA-Lyon, Université Claude-Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France
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Cottin V, Selman M, Inoue Y, Wong AW, Corte TJ, Flaherty KR, Han MK, Jacob J, Johannson KA, Kitaichi M, Lee JS, Agusti A, Antoniou KM, Bianchi P, Caro F, Florenzano M, Galvin L, Iwasawa T, Martinez FJ, Morgan RL, Myers JL, Nicholson AG, Occhipinti M, Poletti V, Salisbury ML, Sin DD, Sverzellati N, Tonia T, Valenzuela C, Ryerson CJ, Wells AU. Syndrome of Combined Pulmonary Fibrosis and Emphysema: An Official ATS/ERS/JRS/ALAT Research Statement. Am J Respir Crit Care Med 2022; 206:e7-e41. [PMID: 35969190 PMCID: PMC7615200 DOI: 10.1164/rccm.202206-1041st] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The presence of emphysema is relatively common in patients with fibrotic interstitial lung disease. This has been designated combined pulmonary fibrosis and emphysema (CPFE). The lack of consensus over definitions and diagnostic criteria has limited CPFE research. Goals: The objectives of this task force were to review the terminology, definition, characteristics, pathophysiology, and research priorities of CPFE and to explore whether CPFE is a syndrome. Methods: This research statement was developed by a committee including 19 pulmonologists, 5 radiologists, 3 pathologists, 2 methodologists, and 2 patient representatives. The final document was supported by a focused systematic review that identified and summarized all recent publications related to CPFE. Results: This task force identified that patients with CPFE are predominantly male, with a history of smoking, severe dyspnea, relatively preserved airflow rates and lung volumes on spirometry, severely impaired DlCO, exertional hypoxemia, frequent pulmonary hypertension, and a dismal prognosis. The committee proposes to identify CPFE as a syndrome, given the clustering of pulmonary fibrosis and emphysema, shared pathogenetic pathways, unique considerations related to disease progression, increased risk of complications (pulmonary hypertension, lung cancer, and/or mortality), and implications for clinical trial design. There are varying features of interstitial lung disease and emphysema in CPFE. The committee offers a research definition and classification criteria and proposes that studies on CPFE include a comprehensive description of radiologic and, when available, pathological patterns, including some recently described patterns such as smoking-related interstitial fibrosis. Conclusions: This statement delineates the syndrome of CPFE and highlights research priorities.
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Affiliation(s)
- Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City, Mexico
| | | | | | - Tamera J. Corte
- Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | | | | | - Joseph Jacob
- University College London, London, United Kingdom
| | - Kerri A. Johannson
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Joyce S. Lee
- University of Colorado Denver Anschutz Medical Campus, School of Medicine, Aurora, CO, USA
| | - Alvar Agusti
- Respiratory Institute, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Katerina M. Antoniou
- Laboratory of Molecular and Cellular Pneumonology, Department of Respiratory Medicine, University of Crete, Heraklion, Greece
| | | | - Fabian Caro
- Hospital de Rehabilitación Respiratoria "María Ferrer", Buenos Aires, Argentina
| | | | - Liam Galvin
- European idiopathic pulmonary fibrosis and related disorders federation
| | - Tae Iwasawa
- Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | | | | | | | - Andrew G. Nicholson
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | | | - Don D. Sin
- University of British Columbia, Vancouver, Canada
| | - Nicola Sverzellati
- Scienze Radiologiche, Department of Medicine and Surgery, University of Parma, Italy
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Claudia Valenzuela
- Pulmonology Department, Hospital Universitario de la Princesa, Departamento Medicina, Universidad Autónoma de Madrid, 28049 Madrid, Spain
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French practical guidelines for the diagnosis and management of idiopathic pulmonary fibrosis - 2021 update. Full-length version. Respir Med Res 2022; 83:100948. [PMID: 36630775 DOI: 10.1016/j.resmer.2022.100948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Since the latest 2017 French guidelines, knowledge about idiopathic pulmonary fibrosis has evolved considerably. METHODS Practical guidelines were drafted on the initiative of the Coordinating Reference Center for Rare Pulmonary Diseases, led by the French Language Pulmonology Society (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of the entire OrphaLung network, pulmonologists practicing in various settings, radiologists, pathologists, a general practitioner, a health manager, and a patient association. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS), including an online vote using a Likert scale. RESULTS After a literature review, 54 guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease: epidemiology, diagnostic procedures, quality criteria and interpretation of chest CT scans, lung biopsy indication and procedures, etiological workup, methods and indications for family screening and genetic testing, assessment of the functional impairment and prognosis, indication and use of antifibrotic agents, lung transplantation, management of symptoms, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION These evidence-based guidelines are intended to guide the diagnosis and practical management of idiopathic pulmonary fibrosis.
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Yu S, Wang Y, Fan Y, Ma R, Wang Y, Ye Q. Pulmonary hypertension in patients with pneumoconiosis with progressive massive fibrosis. Occup Environ Med 2022; 79:oemed-2021-108095. [PMID: 35654579 DOI: 10.1136/oemed-2021-108095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 05/13/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study aims to explore the prevalence and clinical features of pulmonary hypertension (PH) in patients with progressive massive fibrosis (PMF) and its correlation with large opacities on CT scans. METHODS This retrospective study collected 235 patients with PMF, and 199 were eligible for analysis. The probability of PH development was estimated based on tricuspid regurgitation velocity measured by echocardiogram. The size and the location of large opacities on chest CT were recorded. Potential risk factors for PH secondary to PMF were analysed using regression analysis. RESULTS The prevalence of a high or intermediate probability of PH was 39.7% in patients with PMF. Type C of large opacities (OR 6.99, 95% CI 2.34 to 23.00, p<0.001) and central type of the large opacities (OR 8.12, 95% CI 2.89 to 24.71, p<0.001) were identified as the risk factors for PH secondary to PMF. Over a median follow-up of 32.8 months, the survival rate was 73.3% in the PH group, significantly lower than that in the non-PH group (96.6%, p<0.001). CONCLUSIONS Over one-third of patients with PMF developed PH. The increased size and the central distribution of large opacities were identified as the risk factors.
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Affiliation(s)
- Shiwen Yu
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Yiran Wang
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Yali Fan
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Ruimin Ma
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Yuanying Wang
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Qiao Ye
- Department of Occupational Medicine and Toxicology, Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
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Sanna L, Todea A. Risk assessment tools for survival prognosis: An era of new surrogacy endpoints for clinical outcome measurement in pulmonary arterial hypertension clinical trials? Respir Med Res 2022; 81:100893. [PMID: 35523041 DOI: 10.1016/j.resmer.2022.100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 11/19/2022]
Abstract
Developing a new medication in a rare disease indication like pulmonary arterial hypertension (PAH) is very challenging. This is especially true now that clinical trials often employ time to clinical worsening (TTCW) as an endpoint (thus requiring a relatively large and lengthy trial) and since patients are more frequently prescribed combination therapy. During the last few decades, several tools have been developed to predict mortality in PAH and have demonstrated generally good discrimination. The objective of this review article is to assess the available data on the different tools and methods described in the literature and identify potential candidates that could be used as surrogate endpoints in pivotal randomized clinical trials in future. Some of these tools have been validated in various registries and in post-hoc analyses of clinical trial data, but none have been assessed in a prospective clinical trial and we still lack the evidence necessary for endorsement by health authorities. In this review, we identify several promising options that warrant further investigation as potential surrogate endpoints in clinical trials to replace TTCW or 6-minute walk distance. Prospective inclusion of such tools in new clinical trials may help build a stronger surrogacy for prognosis of disease progression and mortality.
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Affiliation(s)
- Lilian Sanna
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland.
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Abstract
Pulmonary hypertension (PH) because of chronic lung disease is categorized as Group 3 PH in the most recent classification system. Prevalence of these diseases is increasing over time, creating a growing need for effective therapeutic options. Recent approval of the first pulmonary arterial hypertension therapy for the treatment of Group 3 PH related to interstitial lung disease represents an encouraging advancement. This review focuses on molecular mechanisms contributing to pulmonary vasculopathy in chronic hypoxia, the pathology and epidemiology of Group 3 PH, the right ventricular dysfunction observed in this population and clinical trial data that inform the use of pulmonary vasodilators in Group 3 PH.
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Affiliation(s)
- Navneet Singh
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI
| | - Peter Dorfmüller
- Department of Pathology, Universities of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University, Germany (P.D.).,German Center for Lung Research (DZL), Giessen, Germany (P.D.)
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA (O.A.S.)
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI.,Department of Health Services, Policy and Practice (C.E.V.), Brown University, Providence, RI
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Dominating Cause of Pulmonary Hypertension May Change Over Time-Diagnostic and Therapeutic Considerations in a Patient with Pulmonary Hypertension Due to Rheumatoid Arthritis with Lung Involvement. Diagnostics (Basel) 2021; 11:diagnostics11101931. [PMID: 34679629 PMCID: PMC8534521 DOI: 10.3390/diagnostics11101931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic lung diseases are one of the most frequent causes of pulmonary hypertension (PH). The diagnostic challenge is to differentiate PH due to chronic lung disease from pulmonary arterial hypertension (PAH) with coexisting chronic lung disease. Moreover, the dominating cause of PH may change over time, requiring the implementation of new diagnostic procedures and new treatment modalities. We present a 68-year-old female, initially diagnosed with PH in the course of interstitial lung disease, with restrictive impairment of lung function. Therapy with immunosuppressive drugs resulted in significant clinical, radiological and functional improvement. However, five years later, arthritis symptoms developed, with PH worsening, despite stable lung disease. The patient was diagnosed with PAH in the course of rheumatoid arthritis. The introduction of sildenafil resulted in marked clinical and hemodynamic responses. Long-term survival (eleven years from PH onset and five years from PAH confirmation) has been achieved, and the patient remains in good functional condition. As the differential diagnosis of PH in patients with lung diseases is complex, the cooperation of pulmonologists and cardiologists is mandatory to obtain therapeutic success.
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Shifting gears: the search for group 3 pulmonary hypertension treatment. Curr Opin Pulm Med 2021; 27:296-302. [PMID: 34175858 DOI: 10.1097/mcp.0000000000000788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Treatment options for Group 3 pulmonary hypertension, characterized as secondary to chronic hypoxia or lung disease, remain an elusive holy grail for physicians and patients alike. Despite increasing identification and investigation into this pulmonary vasculopathy group with the second-highest frequency and highest mortality, there are no therapeutic interventions that offer the significant improvements in morbidity and mortality comparable to those benefiting other pulmonary hypertension groups including pulmonary arterial hypertension. This review examines the data on available and emerging Group 3 pulmonary hypertension treatments. RECENT FINDINGS Pulmonary vasodilators have yielded equivocal results in this patient population, although recent evidence shows modestly improved outcomes with inhaled treprostinil in interstitial lung disease-associated pulmonary hypertension. With pulmonary vasodilators providing limited benefit, emerging data support the right ventricle as a potential treatment target in Group 3 pulmonary hypertension. SUMMARY Group 3 pulmonary hypertension is associated with significant morbidity and mortality. Pulmonary vasodilators offer only limited haemodynamic and exertional benefits, and lung transplantation remains the only cure for this deadly disease. The right ventricle may provide a novel intervention target.
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Pulmonary hypertension in interstitial lung disease: screening, diagnosis and treatment. Curr Opin Pulm Med 2021; 27:396-404. [PMID: 34127619 DOI: 10.1097/mcp.0000000000000790] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Pulmonary vascular disease resulting in pulmonary hypertension in the context of interstitial lung disease (PH-ILD) is a common complication that presents many challenges in clinical practice. Despite recent advances, the pathogenetic interplay between parenchymal and vascular disease in ILD is not fully understood. This review provides an overview of the current knowledge and recent advances in the field. RECENT FINDINGS Clinical trials employing the phosphodiesterase-5-inhibitor sildenafil delivered negative results whereas riociguat showed harmful effects in the PH-ILD population. More recently, inhaled treprostinil showed positive effects on the primary endpoint (six-min walk-distance) in the largest prospective randomized placebo-controlled trial to date in this patient population. Additionally, a pilot trial of ambulatory inhaled nitric oxide suggests beneficial effects based on the novel endpoint of actigraphy. SUMMARY In view of these novel developments this review provides an overview of the status quo of screening, diagnosis and management of pulmonary vascular disease and PH in patients with ILD.
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Abstract
PURPOSE OF REVIEW Despite worse outcomes associated with the development of pulmonary hypertension in chronic lung disease, there are no approved treatments for this population. The present review summarizes the recent clinical trials in World Symposium on Pulmonary Hypertension (WSPH) Group 3 pulmonary hypertension, with a particular focus on the study of pulmonary arterial hypertension (PAH)-targeted therapy. RECENT FINDINGS Multiple recent randomized controlled trials have studied a host of PAH-specific medications in the treatment of WSPH Group 3 pulmonary hypertension, including endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins. In pulmonary hypertension associated with chronic obstructive lung disease (PH-COPD) and with interstitial lung disease (PH-ILD), most trials have shown conflicting or negative results, although they have been limited by variable patient populations and small sample sizes. Recent large-scale trial data demonstrate that inhaled treprostinil is associated with improved outcomes in the PH-ILD population. SUMMARY Although most PAH medications have not shown consistent benefit in the WSPH Group 3 population, recent work suggests that inhaled treprostinil has an important role in the treatment of PH-ILD. Efforts are ongoing to evaluate the efficacy of other medications, identify optimal treatment candidates, and define clinically meaningful endpoints in WSPH Group 3 pulmonary hypertension.
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Saggar R, Giri PC, Deng C, Johnson D, McCloy MK, Liang L, Shaikh F, Hong J, Channick RN, Shapiro SS, Lynch JP, Belperio JA, Weigt SS, Ramsey AL, Ross DJ, Sayah DM, Shino MY, Derhovanessian A, Sherman AE, Saggar R. Significance of autoimmune disease in severe pulmonary hypertension complicating extensive pulmonary fibrosis: a prospective cohort study. Pulm Circ 2021; 11:20458940211011329. [PMID: 33996029 PMCID: PMC8108092 DOI: 10.1177/20458940211011329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/23/2021] [Indexed: 12/01/2022] Open
Abstract
The association of autoimmune disease (AI) with transplant-free survival in the setting of severe Group 3 pulmonary hypertension and extensive pulmonary fibrosis remains unclear. We report cases of severe pulmonary hypertension (mean pulmonary artery pressure ≥35 mmHg and right ventricular dysfunction) and extensive pulmonary fibrosis after pulmonary arterial hypertension-specific therapy. We used multivariate regression to determine the clinical variables associated with transplant-free survival. Of 286 screened patients, 55 demonstrated severe pulmonary hypertension and extensive pulmonary fibrosis and were treated with parenteral prostacyclin therapy. The (+)AI subgroup (n = 34), when compared to the (-)AI subgroup (n = 21), was more likely to be female (77% versus 19%) and younger (58.7 ± 12.1 versus 66.0 ± 10.7 years), and revealed lower forced vital capacity (absolute) (1.9 ± 0.7 versus 2.9 ± 1.1 L), higher DLCO (% predicted) (31.1 ± 15.2 versus 23.2 ± 8.0), and increased unadjusted transplant-free survival (1 year (84.6 ± 6.3% versus 45 ± 11.1%)), 3 years (71 ± 8.2% versus 28.6 ± 11.9%), and 5 years (47.6 ± 9.6% versus 6.4 ± 8.2%); (p = 0.01)). Transplant-free survival was unchanged after adjusting for age and gender. The pulmonary hemodynamic profiles improved after parenteral prostacyclin therapy, independent of AI status. The baseline variables associated with mortality included age at pulmonary hypertension diagnosis (heart rate (HR) 1.23 (confidence interval (CI) 1.03-1.47); p = 0.02) and presence of AI (HR 0.26 (confidence interval (CI) 0.10-0.70); p < 0.01). Gas exchange was not adversely affected by parenteral prostacyclin therapy. In the setting of severe Group 3 pulmonary hypertension and extensive pulmonary fibrosis treated with pulmonary arterial hypertension-specific therapy, AI is independently associated with increased transplant-free survival. Pulmonary hypertension/pulmonary fibrosis associated with AI should be considered in future clinical trials of pulmonary arterial hypertension-specific therapy in Group 3 pulmonary hypertension.
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Affiliation(s)
| | - Paresh C. Giri
- Division of Pulmonary and Critical Care Medicine, Loma Linda University School of Medicine, Loma Linda, USA
| | | | | | - Mary K. McCloy
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Lloyd Liang
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Faisal Shaikh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Jason Hong
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Richard N. Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Shelley S. Shapiro
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Joseph P. Lynch
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - John A. Belperio
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Samuel S. Weigt
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Allison L. Ramsey
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | | | - David M. Sayah
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Michael Y. Shino
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Ariss Derhovanessian
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Alexander E. Sherman
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Rajan Saggar
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
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Mandoli GE, De Carli G, Pastore MC, Cameli P, Contorni F, D'Alessandro M, Bargagli E, Mondillo S, Cameli M. Right cardiac involvement in lung diseases: a multimodality approach from diagnosis to prognostication. J Intern Med 2021; 289:440-449. [PMID: 32996153 DOI: 10.1111/joim.13179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/12/2020] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
Lung diseases are amongst the main healthcare issues in the general population, having a high burden of morbidity and mortality. The cardiovascular system has a key role in patients affected by respiratory disorders. More specifically, the right ventricle (RV) enables the impaired lung function to be overcome in an initial stage of disease process, reducing the severity of dyspnoea. In addition, two of the main causes of death in this setting are RV failure and sudden cardiac death (SCD). Echocardiography is regarded as a useful and easily available tool in assessing RV function. Several noninvasive echocardiographic parameters of elevated pulmonary pressures and RV function have been proposed. The combination of different parameters and imaging methods is paramount and researches regarding RV impairment using these indices has been specifically addressed in relation to the chronic obstructive and restrictive lung disease in order to guide the clinicians in the management of these patients. Cardiac involvement in lung diseases is often observed, and RV changes are reported also in early stages of pulmonary diseases. The role of right ventricle in chronic respiratory disease patients has to be evaluated in detail to describe the response to therapy and the degree of disease progression through multimodality and advanced imaging techniques. The aim of this review is to describe the different pathophysiological mechanisms of cardiac impairment in primary lung disease (such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF) and sarcoidosis) and to summarize the role of cardiac multimodality imaging in the diagnosis and the prognosis of these diseases.
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Affiliation(s)
- G E Mandoli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - G De Carli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M C Pastore
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - P Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - F Contorni
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M D'Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - E Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, Siena University Hospital, Siena, Italy
| | - S Mondillo
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- From the, Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Tanabe N, Kumamaru H, Tamura Y, Taniguchi H, Emoto N, Yamada Y, Nishiyama O, Tsujino I, Kuraishi H, Nishimura Y, Kimura H, Inoue Y, Morio Y, Nakatsumi Y, Satoh T, Hanaoka M, Kusaka K, Sumitani M, Handa T, Sakao S, Kimura T, Kondoh Y, Nakayama K, Tanaka K, Ohira H, Nishimura M, Miyata H, Tatsumi K. Multi-Institutional Prospective Cohort Study of Patients With Pulmonary Hypertension Associated With Respiratory Diseases. Circ J 2021; 85:333-342. [PMID: 33536399 DOI: 10.1253/circj.cj-20-0939] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is limited evidence for pulmonary arterial hypertension (PAH)-targeted therapy in patients with pulmonary hypertension associated with respiratory disease (R-PH). Therefore, we conducted a multicenter prospective study of patients with R-PH to examine real-world characteristics of responders by evaluating demographics, treatment backgrounds, and prognosis. METHODS AND RESULTS Among the 281 patients with R-PH included in this study, there was a treatment-naïve cohort of 183 patients with normal pulmonary arterial wedge pressure and 1 of 4 major diseases (chronic obstructive pulmonary diseases, interstitial pneumonia [IP], IP with connective tissue disease, or combined pulmonary fibrosis with emphysema); 43% of patients had mild ventilatory impairment (MVI), whereas 52% had a severe form of PH. 68% received PAH-targeted therapies (mainly phosphodiesterase-5 inhibitors). Among patients with MVI, those treated initially (i.e., within 2 months of the first right heart catheterization) had better survival than patients not treated initially (3-year survival 70.6% vs. 34.2%; P=0.01); there was no significant difference in survival in the group with severe ventilatory impairment (49.6% vs. 32.1%; P=0.38). Responders to PAH-targeted therapy were more prevalent in the group with MVI. CONCLUSIONS This first Japanese registry of R-PH showed that a high proportion of patients with MVI (PAH phenotype) had better survival if they received initial treatment with PAH-targeted therapies. Responders were predominant in the group with MVI.
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Affiliation(s)
- Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University
- Pulmonary Hypertension Center, Saiseikai Narashino Hospital
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
| | | | - Noriaki Emoto
- Department of Clinical Pharmacy, Kobe Pharmaceutical University
| | - Yoshihito Yamada
- Department of Chest Medicine, Japan Railway Tokyo General Hospital
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Kindai University
| | - Ichizo Tsujino
- First Department of Medicine, Hokkaido University Hospital
| | | | - Yoshihiro Nishimura
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiroshi Kimura
- Department of Advanced Medicine for Pulmonary Circulation and Respiratory Failure and Department of Respiratory Medicine, Nippon Medical School Graduate School of Medicine
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA)
- Second Department of Internal Medicine, Nara Medical University
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center
| | - Yoshiteru Morio
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine
- Center for Pulmonary Diseases and Respiratory Disease Division, National Hospital Organization Tokyo National Hospital
| | | | - Toru Satoh
- Division of Cardiology Department of Medicine, Kyorin University Hospital
| | - Masayuki Hanaoka
- First Department of Medicine, Shinshu University School of Medicine
| | - Kei Kusaka
- Center for Pulmonary Diseases and Respiratory Disease Division, National Hospital Organization Tokyo National Hospital
| | | | - Tomohiro Handa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University
| | - Seiicihiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital
| | - Kazuhiko Nakayama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kensuke Tanaka
- Department of Chest Medicine, Japan Railway Tokyo General Hospital
| | - Hiroshi Ohira
- First Department of Medicine, Hokkaido University Hospital
| | | | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University
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Pulmonary hypertension in fibrosing idiopathic interstitial pneumonia: Uncertainties, challenges and opportunities. J Heart Lung Transplant 2021; 40:872-881. [PMID: 33832831 DOI: 10.1016/j.healun.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/14/2021] [Accepted: 03/02/2021] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is a serious complication of chronic fibrosing idiopathic interstitial pneumonia (PH-fIIP) leading to greater morbidity and mortality. The pathophysiologic basis for PH in fIIP is not completely understood, but microvascular rarefaction may play a key role. Severe hypoxemia and reduced diffusion capacity are characteristic. Doppler echocardiography has limited diagnostic utility and right heart catheterization is required to confirm the diagnosis. Lung volumes can be minimally affected, and radiographic findings can be subtle, making the distinction from pulmonary arterial hypertension challenging. Several randomized controlled trials of pulmonary arterial hypertension targeted therapies have recently been completed. Endothelin-receptor antagonists have shown either no benefit or harm. Sildenafil may have some favorable short-term effects but does not appear to impact long-term outcomes. Riociguat treatment increased hospitalizations and mortality. A recent trial of inhaled treprostinil demonstrated improved exercise capacity, but the impact on long-term morbidity and mortality are unknown. Currently, the only viable option for improved survival is lung transplantation. Early referral is imperative to optimize post-transplant outcomes.
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The Challenge to Decide between Pulmonary Hypertension Due to Chronic Lung Disease and PAH with Chronic Lung Disease. Diagnostics (Basel) 2021; 11:diagnostics11020311. [PMID: 33671914 PMCID: PMC7918977 DOI: 10.3390/diagnostics11020311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic lung diseases are strongly associated with pulmonary hypertension (PH), and even mildly elevated pulmonary arterial pressures are associated with increased mortality. Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease, but few of these patients develop severe PH. Not all these pulmonary pressure elevations are due to COPD, although patients with severe PH due to COPD may represent the largest subgroup within patients with COPD and severe PH. There are also patients with left heart disease (group 2), chronic thromboembolic disease (group 4, CTEPH) and pulmonary arterial hypertension (group 1, PAH) who suffer from COPD or another chronic lung disease as co-morbidity. Because therapeutic consequences very much depend on the cause of pulmonary hypertension, it is important to complete the diagnostic procedures and to decide on the main cause of PH before any decision on PAH drugs is made. The World Symposia on Pulmonary Hypertension (WSPH) have provided guidance for these important decisions. Group 2 PH or complex developmental diseases with elevated postcapillary pressures are relatively easy to identify by means of elevated pulmonary arterial wedge pressures. Group 4 PH can be identified or excluded by perfusion lung scans in combination with chest CT. Group 1 PAH and Group 3 PH, although having quite different disease profiles, may be difficult to discern sometimes. The sixth WSPH suggests that severe pulmonary hypertension in combination with mild impairment in the pulmonary function test (FEV1 > 60 and FVC > 60%), mild parenchymal abnormalities in the high-resolution CT of the chest, and circulatory limitation in the cardiopulmonary exercise test speak in favor of Group 1 PAH. These patients are candidates for PAH therapy. If the patient suffers from group 3 PH, the only possible indication for PAH therapy is severe pulmonary hypertension (mPAP ≥ 35 mmHg or mPAP between 25 and 35 mmHg together with very low cardiac index (CI) < 2.0 L/min/m2), which can only be derived invasively. Right heart catheter investigation has been established nearly 100 years ago, but there are many important details to consider when reading pulmonary pressures in spontaneously breathing patients with severe lung disease. It is important that such diagnostic procedures and the therapeutic decisions are made in expert centers for both pulmonary hypertension and chronic lung disease.
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Teramachi R, Taniguchi H, Kondoh Y, Kimura T, Kataoka K, Yokoyama T, Furukawa T, Yagi M, Sakamoto K, Hashimoto N, Hasegawa Y. Impact of post-capillary pulmonary hypertension on mortality in interstitial lung disease. Respir Investig 2021; 59:342-349. [PMID: 33579646 DOI: 10.1016/j.resinv.2020.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/02/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) influences mortality in patients with interstitial lung disease (ILD). Almost all studies on patients with ILD, have focused on the clinical impact of pre-capillary PH on survival. Therefore, little is known about the influence of post-capillary PH. We aimed to assess the prevalence of post-capillary PH and its clinical impact on survival in patients with ILD, followed by comparison with pre-capillary PH. METHODS This retrospective study enrolled 1152 patients with ILD who were diagnosed with PH using right heart catheterization between May 2007 and December 2015. We analyzed the demographics and composite outcomes (defined as death from any cause or lung transplantation) of patients with post-capillary PH and compared them with patients with pre-capillary PH. RESULTS Thirty-two (20%) of the 157 patients with ILD-PH were diagnosed with post-capillary PH. Patients with post-capillary PH had significantly lower modified Medical Research Council scores, higher diffusion capacity for carbon monoxide, higher resting PaO2, lower pulmonary vascular resistance (PVR), and higher lowest oxygen saturation during the 6-min walk test compared to those with pre-capillary PH. Cardiovascular diseases were associated with a higher risk of mortality in patients with post-capillary PH. Multivariate Cox proportional hazards analysis demonstrated no significant difference between the composite outcomes in pre-capillary and post-capillary PH, while PVR and the ILD Gender-Age-Physiology Index were significantly associated with the composite outcome. CONCLUSIONS We found that approximately one-fifth of patients with ILD-PH were diagnosed with post-capillary PH, and that PVR and not post-capillary PH was associated with mortality.
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Affiliation(s)
- Ryo Teramachi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshiki Yokoyama
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Taiki Furukawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Department of Medical IT Center, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Mitsuaki Yagi
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, Nagoya, Aichi, Japan
| | - Koji Sakamoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Naozumi Hashimoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshinori Hasegawa
- National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
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Hoeper MM, Pausch C, Grünig E, Klose H, Staehler G, Huscher D, Pittrow D, Olsson KM, Vizza CD, Gall H, Benjamin N, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Rosenkranz S, Ewert R, Kaemmerer H, Lange TJ, Kabitz HJ, Skowasch D, Skride A, Jureviciene E, Paleviciute E, Miliauskas S, Claussen M, Behr J, Milger K, Halank M, Wilkens H, Wirtz H, Pfeuffer-Jovic E, Harbaum L, Scholtz W, Dumitrescu D, Bruch L, Coghlan G, Neurohr C, Tsangaris I, Gorenflo M, Scelsi L, Vonk-Noordegraaf A, Ulrich S, Held M. Idiopathic pulmonary arterial hypertension phenotypes determined by cluster analysis from the COMPERA registry. J Heart Lung Transplant 2020; 39:1435-1444. [DOI: 10.1016/j.healun.2020.09.011] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
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Alhamad EH, Cal JG, Alrajhi NN, Alharbi WM. Predictors of Mortality in Patients with Interstitial Lung Disease-Associated Pulmonary Hypertension. J Clin Med 2020; 9:E3828. [PMID: 33255999 PMCID: PMC7760529 DOI: 10.3390/jcm9123828] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a well-established complication in interstitial lung disease (ILD) patients. The aim of this study is to investigate the physiological and hemodynamic parameters that predict mortality in patients with ILD-PH. METHODS Consecutive ILD patients who underwent right heart catheterization (n = 340) were included. The information analyzed included demographics and physiological and hemodynamic parameters. Cox regression models were used to identify independent predictors of survival. RESULTS In total, 96 patients had PH and an additional 56 patients had severe PH. The overall survival of idiopathic pulmonary fibrosis (IPF) patients with PH was significantly worse than the survival of patients with other types of ILD with PH (p < 0.0001 by log-rank analysis). Patients with a reduced diffusing capacity of the lung for carbon monoxide (DLco) (<35% predicted), six-minute walk test final oxygen saturation by pulse oximetry (SpO2) <88% and pulmonary vascular resistance ≥4.5 Wood units in the ILD-PH cohort had significantly worse survival. IPF diagnosis, forced vital capacity, DLco, systolic pulmonary artery pressure and cardiac index were identified as independent predictors of survival among the ILD-PH cohort. CONCLUSIONS Patients with ILD-PH have poor prognosis. Physiological and hemodynamic parameters were important factors independently associated with outcome.
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Affiliation(s)
- Esam H. Alhamad
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (J.G.C.); (N.N.A.)
| | - Joseph G. Cal
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (J.G.C.); (N.N.A.)
| | - Nuha N. Alrajhi
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (J.G.C.); (N.N.A.)
| | - Waleed M. Alharbi
- Department of Cardiac Science, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia;
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Alhamad EH, Cal JG. Predictors of mortality in interstitial lung disease patients without pulmonary hypertension. Ann Thorac Med 2020; 15:238-243. [PMID: 33381239 PMCID: PMC7720737 DOI: 10.4103/atm.atm_438_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/12/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND: There is a paucity of information regarding prognostic factors associated with reduced survival in interstitial lung disease (ILD) patients without pulmonary hypertension (PH). AIMS: The aim of this study was to determine physiological and hemodynamic parameters that impact survival among ILD patients without PH based on right heart catheterization (RHC). METHODS: Consecutive ILD patients who underwent RHC (n = 169) at one center were included. The information analyzed included demographics and physiological and hemodynamic parameters. Cox regression models were used to identify independent predictors of survival. RESULTS: The mean age was 55.0 years, and 49.7% of the patients were females. Thirty-three patients died, and two underwent transplantation. Patients with predicted diffusion capacity of the lung for carbon monoxide <35%, walking distance <300 m, and 6-min walk test (6MWT) final oxygen saturation measured by pulse oximetry (SpO
2) <85% were significantly associated with an increased mortality risk (P = 0.022, P < 0.0001, and P = 0.049, respectively; all by log-rank analysis). Advanced age, idiopathic pulmonary fibrosis diagnosis, reduced forced vital capacity, and low cardiac index were independent predictors of increased mortality in the ILD cohort. CONCLUSIONS: Our study demonstrates that parameters obtained from baseline pulmonary function tests and 6MWTs are important determinants of survival in ILD patients without PH. Importantly, cardiac index was the only hemodynamic variable independently associated with survival. Thus, in the absence of PH, when ILD patients perform poorly during the 6MWT manifested as reduced walking distance and desaturation at the end of the test, cardiovascular impairment must be ruled out.
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Affiliation(s)
- Esam H Alhamad
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Joseph G Cal
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Sobiecka M, Lewandowska K, Kober J, Franczuk M, Skoczylas A, Tomkowski W, Kuś J, Szturmowicz M. Can a New Scoring System Improve Prediction of Pulmonary Hypertension in Newly Recognised Interstitial Lung Diseases? Lung 2020; 198:547-554. [PMID: 32206858 PMCID: PMC7242254 DOI: 10.1007/s00408-020-00346-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a well-recognised complication of interstitial lung diseases (ILD), which worsens prognosis and impairs exercise capacity. Echocardiography is the most widely used, non-invasive method for PH assessment. The aim of our study was to identify the factors predictive for echocardiographic signs of PH in newly recognised ILD patients. METHODS Ninety-three consecutive patients (28F/65M) with different ILD were prospectively evaluated from January 2009 to March 2014. Pulmonary function testing, 6-min walk distance (6MWD), initial and sixth minute room air oxygen saturation, NT-proBNP and echocardiography were assessed in each patient. Echocardiographic PH probability was determined according to the 2009 ESC/ERS guidelines. RESULTS In 41 patients (Group B) increased PH possibility has been diagnosed on echocardiography, in 52 patients (Group A)-low PH probability. Most pronounced differences (p ≤ 0.0005) between groups B and A concerned: age, 6MWD, room air oxygen saturation at 6 min, DLCO and TLC/DLCO index (57.6 vs 43.8 years; 478 vs 583 m; 89.1% vs 93.4%; 54.8% predicted vs 70.5% predicted and 1.86 vs 1.44; respectively). Univariate analysis showed four-fold increased probability of PH when TLC/DLCO exceeded 1.67. A scoring system incorporating age, TLC/DLCO index, 6MWD and room air oxygen saturation at 6 min provided high diagnostic utility, AUC 0.867 (95% CI 0.792-0.867). CONCLUSION ILD patients with TLC/DLCO index > 1.67 have a high likelihood of PH and should undergo further evaluation. The composite model of PH prediction, including age, 6-min walk test and TLC/DLCO was highly specific for recognition of PH on echocardiography.
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Affiliation(s)
- Małgorzata Sobiecka
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland.
| | - Katarzyna Lewandowska
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jarosław Kober
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Monika Franczuk
- Department of Respiratory Physiopathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Agnieszka Skoczylas
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Witold Tomkowski
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jan Kuś
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
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King CS, Shlobin OA. The Trouble With Group 3 Pulmonary Hypertension in Interstitial Lung Disease: Dilemmas in Diagnosis and the Conundrum of Treatment. Chest 2020; 158:1651-1664. [PMID: 32387520 DOI: 10.1016/j.chest.2020.04.046] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022] Open
Abstract
Pulmonary hypertension (PH) due to interstitial lung disease (ILD; PH-ILD) can complicate a multitude of ILDs, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis, and nonspecific interstitial pneumonia. Development of PH-ILD is associated with increased need for supplemental oxygen, reduced mobility, and decreased survival. A high index of suspicion is required to make the diagnosis, given the substantial overlap in symptoms with those of ILD without PH. Severely reduced diffusing capacity or 6-min walk test distance, prominent exertional desaturation, and impaired heart rate recovery after exercise are all suggestive of the development of PH-ILD. Traditional transthoracic echocardiography is the most commonly used screening test for PH-ILD, but it lacks sensitivity and specificity. Newer echocardiographic tools involving 3-dimensional assessment of the right ventricle may have a role in both prognosis and the monitoring of patients with PH-ILD. Right-sided heart catheterization remains the gold standard for confirming a diagnosis of PH-ILD. Although there is little debate about the use of supplemental oxygen and diuretic therapy in the treatment of PH-ILD, treatment with pulmonary vasodilator therapy remains controversial. Although several studies have been terminated prematurely for harm, the recently completed INCREASE trial of inhaled treprostinil appears to validate the concept of treating PH-ILD with pulmonary vasodilators and, we hope, will serve as a foundation from which future studies can be developed.
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Affiliation(s)
- Christopher S King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Pulmonary Hypertension Program, Inova Fairfax Hospital, Falls Church, VA.
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McGettrick M, Peacock A. Group 3 pulmonary hypertension: Challenges and opportunities. Glob Cardiol Sci Pract 2020; 2020:e202006. [PMID: 33150151 PMCID: PMC7590933 DOI: 10.21542/gcsp.2020.6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Michael McGettrick
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Andrew Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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Shlobin OA, Kouranos V, Barnett SD, Alhamad EH, Culver DA, Barney J, Cordova FC, Carmona EM, Scholand MB, Wijsenbeek M, Ganesh S, Lower EE, Engel PJ, Wort J, Price L, Wells AU, Nathan SD, Baughman RP. Physiological predictors of survival in patients with sarcoidosis-associated pulmonary hypertension: results from an international registry. Eur Respir J 2020; 55:13993003.01747-2019. [DOI: 10.1183/13993003.01747-2019] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/11/2020] [Indexed: 11/05/2022]
Abstract
IntroductionSarcoidosis-associated pulmonary hypertension (SAPH) is associated with reduced survival in single-centre studies. The international Registry for SAPH (ReSAPH) with long-term follow-up was established to enrich our knowledge of this complication of sarcoidosis. This analysis aims to elucidate factors associated with reduced transplant-free survival in SAPH patients.MethodsReSAPH contains prospectively collected outcomes of SAPH patients since the time of registry enrolment. Information analysed includes right heart catheterisation data, pulmonary function testing, chest radiography, Scadding stage and 6-min walk distance (6MWD), among others. Cox regression models were used to identify independent predictors of transplant-free survival.ResultsData from 215 patients followed for a mean±sd 2.5±1.9 years were available for analysis. In the 159 precapillary patients, the Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival was 89.2%, 71.7% and 62.0%, respectively. Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival in the incident group was 83.5%, 70.3% and 58.3%, respectively, and in the prevalent group was 94.7%, 72.2% and 66.3%, respectively. Patients with reduced diffusing capacity of the lung for carbon monoxide (DLCO) (<35% predicted) and 6MWD <300 m in the precapillary cohort had significantly worse transplant-free survival. Reduced 6MWD and preserved forced expiratory volume (FEV1)/forced vital capacity (FVC) ratio were identified as independent risk factors for reduced transplant-free survival in the precapillary cohort.ConclusionReduced DLCO (<35% pred) and 6MWD (<300 m) at the time of registry enrolment were associated with reduced transplant-free survival in the overall precapillary cohort. Preserved FEV1/FVC ratio was identified as an independent risk factor for worsened outcomes.
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