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Chen YW, Lai CH, Liao YW, Liu MC, Wu YC, Hsu CY, Yu YH, Fu PK. A composite score based on cardiovascular parameters can predict the mortality risk of patients with newly diagnosed interstitial lung disease: A prospective observational study. J Cardiol 2024:S0914-5087(24)00058-3. [PMID: 38582493 DOI: 10.1016/j.jjcc.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND It is crucial to identify factors that can predict the risk of mortality in patients newly diagnosed with interstitial lung disease (ILD). This study sought to develop and assess a composite scoring system for mortality prediction among ILD patients based on cardiovascular parameters, which were previously reported as predictors of survival. METHODS We prospectively enrolled patients with newly diagnosed ILD and monitored their survival status for 24 months. Surviving and deceased patients were compared regarding their baseline characteristics including clinical, pulmonary, and cardiovascular parameters. A system of composite scores was established based on significant cardiovascular parameters and the Gender-Age-Physiology (GAP) score. Receiver operating characteristic curves were generated to identify their optimal cut-off values. Univariate as well as multiple multivariate regression models were built to investigate the mortality prediction of different individual and combined parameters. RESULTS Ninety-six patients newly diagnosed with ILD underwent cardiovascular evaluation. In univariate analysis, three cardiovascular parameters were identified as significant predictors of mortality risk in ILD patients, either individually or as a combination of composite scores: tricuspid regurgitation velocity > 3.1 m/s; N-terminal pro-B-type natriuretic peptide level > 300 pg/ml and computed tomography pulmonary artery/ascending aorta diameter ratio > 0.9. In multivariate analysis, a composite score of those parameters [hazard ratio (HR) = 2.37 (confidence interval [CI]:1.06-5.33); p = 0.037; Score 1] and GAP score [HR = 1.62 (CI: 1.11-2.36); p = 0.012] were the most significant predictors for mortality among ILD patients. Combination of Score 1 and GAP score (Score 2) can increase the accuracy of survival predictions (area under the curve 0.83; p < 0.001). CONCLUSIONS A composite score based on cardiovascular parameters and the GAP score can be used to predict the risk of mortality of patients with ILD. Such a score achieved better diagnostic accuracy than the GAP score alone. Nevertheless, further larger-scale randomized controlled trials are required for evaluation of the newly proposed score and confirmation of our results.
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Affiliation(s)
- Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Research Center, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Wan Liao
- Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Cheng Liu
- Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Cheng Wu
- Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hsuan Yu
- Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Pin-Kuei Fu
- Integrated Care Center of Interstitial Lung Disease, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Research, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.
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2
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Nathan SD, Tehrani B, Zhao Q, Arias R, Kim D, Pellegrini A, Collins AC, Diviney J, Chakravorty S, Khangoora V, Shlobin OA, Thomas C, Lavon BR, King CS, Chandel A. Pulmonary vascular dysfunction without pulmonary hypertension: A distinct phenotype in idiopathic pulmonary fibrosis. Pulm Circ 2024; 14:e12311. [PMID: 38174158 PMCID: PMC10762875 DOI: 10.1002/pul2.12311] [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: 07/13/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 01/05/2024] Open
Abstract
Pulmonary vascular dysfunction in the absence of pulmonary hypertension (PH) has been observed in patients with idiopathic pulmonary fibrosis (IPF). We describe the prevalence and etiology of elevated pulmonary vascular resistance (PVR) without PH among patients with IPF. Hemodynamic, echocardiographic, and functional respiratory imaging (FRI) data was compared between patients with IPF without PH with normal (<3 wood units) and elevated PVR (≥3 wood units). Mortality between these two groups were compared to patients with IPF and PH. Of 205 patients with IPF, there were 146 patients without PH, of whom 114 (78.1%) had a normal PVR and 32 (21.9%) who had a high PVR. Functional testing and hemodynamics were similar in the two groups, except for the cardiac index which was significantly lower in patients with a high PVR (2.3 vs. 2.6 L/min/m2; p = 0.004). Echocardiographic comparison demonstrated a higher tricuspid regurgitant velocity in those with a high PVR (3.4 vs 3.0 m/s; p = 0.046). FRI revealed proportionately fewer large vessels as a proportion of the vasculature in the patients without PH and elevated PVRs. Among patients without PH, PVR was associated with increased mortality. In conclusion, patients with IPF without PH but a high PVR appear to be a distinct phenotype with a prognosis between those with and without PH, likely reflecting the continuum of vascular dysfunction. The basis for this unique hemodynamic profile could not be definitively discerned although FRI suggested an aberrant anatomical vascular response.
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Affiliation(s)
- Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Benham Tehrani
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Qiong Zhao
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Rafael Arias
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Dennis Kim
- Department of MedicineInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Antonia Pellegrini
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Ashley Claire Collins
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Jack Diviney
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | | | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Christopher Thomas
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | | | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical CareWalter Reed National Military Medical CenterBethesdaMarylandUSA
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3
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Averjanovaitė V, Gumbienė L, Zeleckienė I, Šileikienė V. Unmasking a Silent Threat: Improving Pulmonary Hypertension Screening Methods for Interstitial Lung Disease Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:58. [PMID: 38256318 PMCID: PMC10820938 DOI: 10.3390/medicina60010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
This article provides a comprehensive overview of the latest literature on the diagnostics and treatment of pulmonary hypertension (PH) associated with interstitial lung disease (ILD). Heightened suspicion for PH arises when the advancement of dyspnoea in ILD patients diverges from the expected pattern of decline in pulmonary function parameters. The complexity of PH associated with ILD (PH-ILD) diagnostics is emphasized by the limitations of transthoracic echocardiography in the ILD population, necessitating the exploration of alternative diagnostic approaches. Cardiac magnetic resonance imaging (MRI) emerges as a promising tool, offering insights into hemodynamic parameters and providing valuable prognostic information. The potential of biomarkers, alongside pulmonary function and cardiopulmonary exercise tests, is explored for enhanced diagnostic and prognostic precision. While specific treatments for PH-ILD remain limited, recent studies on inhaled treprostinil provide new hope for improved patient outcomes.
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Affiliation(s)
| | - Lina Gumbienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania;
| | | | - Virginija Šileikienė
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania;
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4
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Saleem F, Ryerson CJ, Sarma N, Johannson K, Marcoux V, Fisher J, Assayag D, Manganas H, Khalil N, Morisset J, Glaspole IN, Goh N, Oldham JM, Cox G, Fell C, Gershon AS, Halayko A, Hambly N, Lok SD, Shapera S, To T, Wilcox PG, Wong AW, Kolb M, Khor YH. Predicting New-onset Exertional and Resting Hypoxemia in Fibrotic Interstitial Lung Disease. Ann Am Thorac Soc 2023; 20:1726-1734. [PMID: 37676933 DOI: 10.1513/annalsats.202303-208oc] [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: 03/08/2023] [Accepted: 09/07/2023] [Indexed: 09/09/2023] Open
Abstract
Rationale: Hypoxemia in fibrotic interstitial lung disease (ILD) indicates disease progression and is of prognostic significance. The onset of hypoxemia signifies disease progression and predicts mortality in fibrotic ILD. Accurately predicting new-onset exertional and resting hypoxemia prompts appropriate patient discussion and timely consideration of home oxygen. Objectives: We derived and externally validated a risk prediction tool for both new-onset exertional and new-onset resting hypoxemia. Methods: This study used ILD registries from Canada for the derivation cohort and from Australia and the United States for the validation cohort. New-onset exertional and resting hypoxemia were defined as nadir oxyhemoglobin saturation < 88% during 6-minute-walk tests, resting oxyhemoglobin saturation < 88%, or the initiation of ambulatory or continuous oxygen. Candidate predictors included patient demographics, ILD subtypes, and pulmonary function. Time-varying Cox regression was used to identify the top-performing prediction model according to Akaike information criterion and clinical usability. Model performance was assessed using Harrell's C-index and goodness-of-fit (GoF) likelihood ratio test. A categorized risk prediction tool was developed. Results: The best-performing prediction model for both new-onset exertional and new-onset resting hypoxemia included age, body mass index, a diagnosis of idiopathic pulmonary fibrosis, and percent predicted forced vital capacity and diffusing capacity of carbon monoxide. The risk prediction tool exhibited good performance for exertional hypoxemia (C-index, 0.70; GoF, P = 0.85) and resting hypoxemia (C-index, 0.77; GoF, P = 0.27) in the derivation cohort, with similar performance in the validation cohort except calibration for resting hypoxemia (GoF, P = 0.001). Conclusions: This clinically applicable risk prediction tool predicted new-onset exertional and resting hypoxemia at 6 months in the derivation cohort and a diverse validation cohort. Suboptimal GoF in the validation cohort likely reflected overestimation of hypoxemia risk and indicated that the model is not flawed because of underestimation of hypoxemia.
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Affiliation(s)
- Ferhan Saleem
- Department of Medicine and
- Department of Medicine, St. Martinus University, Willemstad, Curaçao, Netherlands Antilles
| | - Christopher J Ryerson
- Department of Medicine and
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nandini Sarma
- Department of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kerri Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Veronica Marcoux
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Deborah Assayag
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Helene Manganas
- Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | - Julie Morisset
- Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Ian N Glaspole
- Department of Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Nicole Goh
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Justin M Oldham
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gerard Cox
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Charlene Fell
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Halayko
- Departmentof Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nathan Hambly
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Stacey D Lok
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Alyson W Wong
- Department of Medicine and
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martin Kolb
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Yet H Khor
- Department of Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia; and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
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5
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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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6
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Scarpato BM, Locke BW, Bledsoe J, Knox DB, Conner K, Stoddard GJ, Cirulis MM, Elliott CG, Dodson MW. The association between pulmonary artery enlargement and mortality in an Emergency Department population undergoing computed tomography pulmonary angiography. Pulm Circ 2023; 13:e12225. [PMID: 37063745 PMCID: PMC10090800 DOI: 10.1002/pul2.12225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/16/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023] Open
Abstract
Findings of an enlarged pulmonary artery diameter (PAd) and increased pulmonary artery to ascending aorta ratio (PA:AA) on contrast-enhanced computed tomography pulmonary angiography (CTPA) are associated with increased mortality in particular groups of patients with cardiopulmonary disease. However, the frequency and prognostic significance of these incidental findings has not been studied in unselected patients evaluated in the Emergency Department (ED). This study aims to determine the prevalence and associated prognosis of enlarged pulmonary artery measurements in an ED cohort. We measured PA and AA diameters on 990 CTPA studies performed in the ED. An enlarged PA diameter was defined as >27 mm in females and >29 mm in males, while an increased PA:AA was defined as >0.9. Poisson regression was performed to calculate prevalence ratios for relevant comorbidities, and multivariable Cox regression was performed to calculate hazard ratios (HR) for mortality of patients with enlarged pulmonary artery measurements. An enlarged PAd was observed in 27.9% of 990 patients and was more commonly observed in older patients and in patients with obesity or heart failure. Conversely, PA:AA was increased in 34.2% of subjects, and was more common in younger patients and those with peripheral vascular disease or obesity. After controlling for age, sex, and comorbidities, both enlarged PAd (HR 1.29, 95% CI 1.00-1.68, p = 0.05) and PA:AA (HR 1.70, 95% CI 1.31-2.22 p < 0.01) were independently associated with mortality. In sum, enlarged PAd and increased PA:AA are common in patients undergoing CTPAs in the ED setting and both are independently associated with mortality.
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Affiliation(s)
- Brittany M. Scarpato
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Brian W. Locke
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Joseph Bledsoe
- Division of Emergency MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Emergency MedicineStanford MedicineStanfordCaliforniaUSA
| | - Daniel B. Knox
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Karen Conner
- Division of RadiologyIntermountain Medical CenterMurrayUtahUSA
| | | | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
| | - Charles Gregory Elliott
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
| | - Mark W. Dodson
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
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7
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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: 9] [Impact Index Per Article: 9.0] [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 MedicineHospital del MarBarcelonaSpain
| | - Brian Allwood
- Department of Medicine, Division of PulmonologyStellenbosch University & Tygerberg HospitalCape TownSouth Africa
| | - Katerina Antoniou
- Department of Thoracic MedicineUniversity of Crete School of MedicineHeraklionCreteGreece
| | - Jonathan H. Chung
- Department of RadiologyThe University of Chicago MedicineChicagoIllinoisUSA
| | - Paul M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Rajan Saggar
- Lung & Heart‐Lung Transplant and Pulmonary Hypertension ProgramsUniversity of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Patrizio Vitulo
- Department of Pulmonary MedicineIRCCS Mediterranean Institute for Transplantation and Advanced Specialized TherapiesPalermoSiciliaItaly
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Stephen John Wort
- National Pulmonary Hypertension Service at the Royal Brompton HospitalLondonUK
- National Heart and Lung Institute, Imperial CollegeLondonUK
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8
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Dawes TJW, McCabe C, Dimopoulos K, Stewart I, Bax S, Harries C, Samaranayake CB, Kempny A, Molyneaux PL, Seitler S, Semple T, Li W, George PM, Kouranos V, Chua F, Renzoni EA, Kokosi M, Jenkins G, Wells AU, Wort SJ, Price LC. Phosphodiesterase 5 inhibitor treatment and survival in interstitial lung disease pulmonary hypertension: A Bayesian retrospective observational cohort study. Respirology 2023; 28:262-272. [PMID: 36172951 DOI: 10.1111/resp.14378] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/08/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary hypertension is a life-limiting complication of interstitial lung disease (ILD-PH). We investigated whether treatment with phosphodiesterase 5 inhibitors (PDE5i) in patients with ILD-PH was associated with improved survival. METHODS Consecutive incident patients with ILD-PH and right heart catheterisation, echocardiography and spirometry data were followed from diagnosis to death, transplantation or censoring with all follow-up and survival data modelled by Bayesian methods. RESULTS The diagnoses in 128 patients were idiopathic pulmonary fibrosis (n = 74, 58%), hypersensitivity pneumonitis (n = 17, 13%), non-specific interstitial pneumonia (n = 12, 9%), undifferentiated ILD (n = 8, 6%) and other lung diseases (n = 17, 13%). Final outcomes were death (n = 106, 83%), transplantation (n = 9, 7%) and censoring (n = 13, 10%). Patients treated with PDE5i (n = 50, 39%) had higher mean pulmonary artery pressure (median 38 mm Hg [interquartile range, IQR: 34, 43] vs. 35 mm Hg [IQR: 31, 38], p = 0.07) and percentage predicted forced vital capacity (FVC; median 57% [IQR: 51, 73] vs. 52% [IQR: 45, 66], p=0.08) though differences did not reach significance. Patients treated with PDE5i survived longer than untreated patients (median 2.18 years [95% CI: 1.43, 3.04] vs. 0.94 years [0.69, 1.51], p = 0.003) independent of all other prognostic markers by Bayesian joint-modelling (HR 0.39, 95% CI: 0.23, 0.59, p < 0.001) and propensity-matched analyses (HR 0.38, 95% CI: 0.22, 0.58, p < 0.001). Survival difference with treatment was significantly larger if right ventricular function was normal, rather than abnormal, at presentation (+2.55 years, 95% CI: -0.03, +3.97 vs. +0.98 years, 95% CI: +0.47, +2.00, p = 0.04). CONCLUSION PDE5i treatment in ILD-PH should be investigated by a prospective randomized trial.
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Affiliation(s)
- Timothy J W Dawes
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Colm McCabe
- 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
| | - Konstantinos Dimopoulos
- 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.,Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, UK
| | - Iain Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Simon Bax
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Carl Harries
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Aleksander Kempny
- 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.,Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, UK
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Samuel Seitler
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Thomas Semple
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Radiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Wei Li
- National Heart and Lung Institute, Imperial College London, London, UK.,Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, UK.,Department of Echocardiography, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Peter M George
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vasileios Kouranos
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Felix Chua
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Elisabetta A Renzoni
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Maria Kokosi
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Athol U Wells
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephen J Wort
- 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
| | - 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
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9
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Nikkho SM, Richter MJ, Shen E, Abman SH, Antoniou K, Chung J, Fernandes P, Hassoun P, Lazarus HM, Olschewski H, Piccari L, Psotka M, Saggar R, Shlobin OA, Stockbridge N, Vitulo P, Vizza CD, John Wort S, Nathan SD. CLINICAL SIGNIFICANCE OF PULMONARY HYPERTENSION IN INTERSTITIAL LUNG DISEASE A Consensus Statement from The Pulmonary Vascular Research Institute's Innovative Drug Development Initiative ‐ Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12127. [PMID: 36016668 PMCID: PMC9395696 DOI: 10.1002/pul2.12127] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Pulmonary hypertension (PH) has been linked to worse outcomes in chronic lung diseases. The presence of PH in the setting of underlying Interstitial Lung Disease (ILD) is strongly associated with decreased exercise and functional capacity, an increased risk of hospitalizations and death. Examining the scope of this issue and its impact on patients is the first step in trying to define a roadmap to facilitate and encourage future research in this area. The aim of our working group is to strengthen the communities understanding of PH due to lung diseases and to improve the care and quality of life of affected patients. This introductory statement provides a broad overview and lays the foundation for further in‐depth papers on specific topics pertaining to PH‐ILD.
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Affiliation(s)
| | - Manuel J. Richter
- Department of Internal Medicine Pulmonary Hypertension Division Universities of Giessen and Marburg Lung Center (UGMLC) Germany
| | - Eric Shen
- United Therapeutics Corporation, Global Medical Affairs Silver Spring MD USA
| | - Steven H. Abman
- University of Colorado ‐ Anschutz Medical Campus School of Medicine and Children's Hospital Aurora CO USA
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic Medicine Heraklion Crete Greece
| | - Jonathan Chung
- Department of Radiology The University of Chicago Medicine Chicago IL USA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc, Regulatory Safety and Quality Department Warren NJ USA
| | - Paul Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Johns Hopkins University Baltimore MD
| | | | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine Medical University of Graz Graz Steiermark Austria
| | - Lucilla Piccari
- Department of Pulmonary Medicine Hospital del Mar, Pulmonary Hypertension Unit Barcelona Catalunya Spain
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; 2. Division of Cardiology and Nephrology Food and Drug Administration Silver Spring MD
| | - Rajan Saggar
- University of California Los Angeles David Geffen School of Medicine Lung & Heart‐Lung Transplant and Pulmonary Hypertension Programs Los Angeles CA USA
| | - Oksana A. Shlobin
- Inova Health System, Advanced Lung Disease and Transplant Program Falls Church VA USA
| | - Norman Stockbridge
- US Food and Drug Administration Division of Cardiology and Nephrology Silver Spring MD USA
| | - Patrizio Vitulo
- IRCCS Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Department of Pulmonary Medicine Palermo Sicilia Italy
| | | | - S. John Wort
- National Pulmonary Hypertension Service at Royal Brompton Hospital London. UK. National Heart and Lung Institute, Imperial College London UK
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program Inova Heart and Vascular Institute Falls Church Virginia
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10
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Gupta S, Padhan P, Subhankar S, Singh P. Cardiovascular complications in patients with interstitial lung disease and their correlation with 6-minute walk test and spirometry: A single-center study. J Family Med Prim Care 2021; 10:3330-3335. [PMID: 34760753 PMCID: PMC8565147 DOI: 10.4103/jfmpc.jfmpc_350_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Pulmonary hypertension and other cardiac complications occur frequently due to chronic hypoxia induced by interstitial lung diseases (ILD) or due to connective tissue disorder itself. Two-dimensional (2D) echocardiography is ideal for identifying abnormalities at a given time. In this study, we tried to detect cardiovascular complications in patients with ILD using 2D echocardiography and correlate them with a 6-minute walk test (6 MWT) and spirometry. Materials and Methods This study was carried out for 18 months including 100 consecutive cases of ILD. The diagnosis was made using the latest criteria as per the disease and high-resolution computed tomography (HRCT) thorax. All patients were evaluated with 2D echocardiography, 6 MWT, and spirometry along with routine investigations. Their results were analyzed using STATA 15.1 software. Result Cardiovascular involvement was detected in 68% of cases. Pulmonary hypertension predominated with a prevalence of 50%. In spirometry, mean Forced expiratory volume in first second (FEV1)and Forced vital capacity (FVC) were found to be 54.96 (L) and 53.49 (L), respectively, with a predominant restrictive pattern (89%). There was a significant correlation between baseline saturation of oxygen (SpO2) and pulmonary arterial systolic pressure (PASP) with a P value of <0.05. Baseline SpO2 and distance covered in 6 MWT had a significant correlation (P = 0.014). Conclusion A baseline or nighttime hypoxia is responsible for developing PAH. Pulmonary arterial hypertension should be suspected in patients unable to perform 6 MWT or having low baseline SpO2. A routine follow-up with a 6 MWT and baseline SpO2 should be performed in each visit to identify early deterioration of the disease.
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Affiliation(s)
- Saurabh Gupta
- Department of Pulmonary Medicine, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, Odisha, India
| | - Prasanta Padhan
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, Odisha, India
| | - Saswat Subhankar
- Department of Pulmonary Medicine, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, Odisha, India
| | - Pratima Singh
- Department of Pulmonary Medicine, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, Odisha, India
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11
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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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12
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Benn BS, Romero AO, Bawaadam H, Ivanick N, Lum M, Krishna G. Cone Beam CT Guidance Improves Transbronchial Lung Cryobiopsy Safety. Lung 2021; 199:485-492. [PMID: 34495390 DOI: 10.1007/s00408-021-00473-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/29/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Determining the cause of diffuse parenchymal lung disease (DPLD) is challenging. While surgical lung biopsy has been the standard approach, transbronchial lung cryobiopsy (TBLC) represents a minimally invasive alternative with an acceptable safety profile and reasonable accuracy. In this study, we prospectively assessed whether the use of cone beam CT (CBCT) coupled with a novel bronchoscope holder and prophylactic administration of vasoconstricting medications decreases potential complications and improves diagnostic accuracy when performing TBLC. METHODS 33 patients presenting for evaluation of newly diagnosed DPLD were enrolled. Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded. RESULTS Mean patient age was 67, with the majority Caucasian (n = 26, 79%) and male (n = 20, 61%). Mean pulmonary function values revealed restrictive lung disease (76 ± 14% predicted) and diffusing capacity impairment (52 ± 16%). A non-usual interstitial pneumonia imaging pattern was commonly seen (n = 20, 61%). CBCT guided TBLC was performed in one lobe (n = 29, 88%) or two lobes (n = 4, 12%) with mean probe-to-pleura distance of 4.2 ± 1.3 mm. No peri or post procedural complications occurred. 32 patients (97%) received a histological diagnosis with a final multidisciplinary conference diagnosis possible for 32 (97%). CONCLUSION CBCT guided TBLC coupled with a novel articulating scope holder and prophylactic phenylephrine administration has the potential to increase safety and diagnostic yield for patients with newly identified DPLD. Future studies comparing different aspects of this approach in isolation and with other modalities have the potential to refine this procedure to improve patient care.
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Affiliation(s)
- Bryan S Benn
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank, Milwaukee, WI, 53226, USA.
| | - Arthur Oliver Romero
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, CA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hasnain Bawaadam
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Nathaniel Ivanick
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, CA, USA.,Department of Pulmonary Medicine, Roswell Park Cancer Center, Buffalo, NY, USA
| | - Mendy Lum
- Respiratory Care Services, El Camino Health, Mountain View, CA, USA
| | - Ganesh Krishna
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, CA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Palo Alto Medical Foundation, Palo Alto, CA, USA
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13
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Alhamad EH, Cal JG, Alrajhi NN, AlBoukai AA. Acute exacerbation in interstitial lung disease. Ann Thorac Med 2021; 16:178-187. [PMID: 34012485 PMCID: PMC8109689 DOI: 10.4103/atm.atm_14_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/21/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND: Information regarding acute exacerbation (AE) in patients with interstitial lung disease (ILD) is limited. OBJECTIVES: The objective of the study was to elucidate the clinical features and outcome of AE among ILD patients. METHODS: We retrospectively analyzed the data of 667 consecutive ILD (nonidiopathic pulmonary fibrosis [IPF] ILD, n = 463; IPF, n = 204) patients. ILD patients meeting the 2016 definition of AE-IPF were identified. Information analyzed included pulmonary function tests, 6-min walk tests, and right heart catheterization data, among others. Cox regression models were used to identify independent predictors of survival. RESULTS: AE was identified in non-IPF ILD (n = 113) and IPF (n = 74). Compared with AE-IPF patients, non-IPF ILD patients with AE were of younger age, predominantly women, and primarily nonsmokers (all, P < 0.0001). The estimated survival probabilities at 1, 3, and 5 years were 88%, 75%, and 70%, respectively, in the ILD without AE group; 80%, 57%, and 50%, respectively, in the non-IPF ILD with AE group; and 53%, 38%, and 28%, respectively, in the AE-IPF group (P < 0.0001 by log-rank analysis). Age, body mass index, IPF diagnosis, AE, diffusion capacity of the lung for carbon monoxide <35% predicted, 6-min walk distance <300 meters, and cardiac index were independent predictors of survival in the ILD cohort. CONCLUSIONS: Non-IPF ILD patients with AE have distinct clinical features compared to AE-IPF patients. Importantly, AE is one of many independent risk factors associated with worsened outcomes regardless of the underlying ILD type.
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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
| | - Nuha N Alrajhi
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad A AlBoukai
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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