Non-invasive risk prediction based on right ventricular function in patients with pulmonary arterial hypertension

Background

Individual risk assessment in patients with pulmonary arterial hypertension (PAH) is fundamental to improve their outcome. Although right ventricular (RV) dysfunction is a major determinant of outcome in PAH, echocardiographic measures of RV function are poorly represented by current risk models.

Objective

The objective of this study was to identify echocardiographic measures of RV function, which are associated with adverse outcome and to develop a non-invasive, echocardiography-based risk score for PAH patients.

Methods

In 254 patients with PAH we analyzed functional status, laboratory results, pulmonary function and echocardiographic measures. Echocardiographic measures comprised RV chamber diameters, right atrial area, fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), 2D RV strain and pericardial effusion. We used Cox regression models to assess the association with the composite endpoint of 5-year all-cause death or lung transplantation. The analyses included a conventional model using only guideline-recommended variables and a model adding significant echocardiographic measures. Based on the final multivariable model a point risk score was derived, indicating the association with the primary outcome.

Results

Median age was 65.5 years, 33.9% were females. During a median follow-up time of 4.18 years 74 patients died (n=63) or underwent lung transplantation (n=11). In univariable analyses low systolic blood pressure (Hazard ratio [HR] 0.99, 95% Confidence Interval [CI] 0.98,1.00), NYHA functional class IV (HR 3.23, 95% CI 1.48,7.07), 6-minute walk distance (HR 1.00, 95% CI 1.00,1.00), NT-proBNP concentrations (HR 1.00, 95% CI 1.00,1.00), renal impairment (HR 0.99, 95% CI 0.98,1.00), reduced diffusion capacity for carbon monoxide (HR 0.99, 95% CI 0.98,1.00), reduced TAPSE (HR 0.90, 95% CI 0.85,0.96) and reduced FAC (HR 0.97, 95% CI 0.94,1.00) were associated with the endpoint. A multivariable, conventional risk model, including NYHA functional class, 6-minute walk distance, NT-proBNP concentrations, pericardial effusion and right atrial area, resulted in a C-Index of 0.539. Adding TAPSE and FAC to this model improved the performance significantly (C-index 0.639, p-value 0.017). This model was translated to a 12-point score with the highest weighting assigned to TAPSE, FAC, pericardial effusion and 6-minute walk distance (Figure).

Conclusion

An easily applicable score integrating non-invasive, echocardiographic parameters of RV function improves prediction of adverse outcome in PAH patients.

Funding Acknowledgement

Type of funding sources: None. Risk prediction chart

[Puzzling B symptoms in a 61-year-old patient under treatment for rheumatoid arthritis]

Ein Patient mit rheumatoider Arthritis sowie B‑Symptomatik, Polyneuropathie und einschmelzenden Lungenveränderungen unter Immunsuppression entwickelte nach zunächst subakutem Verlauf rasch progrediente zentrale neurologische Symptome und ein letales Multiorganversagen. Als ursächlich erwies sich eine disseminierte Infektion mit Histoplasma capsulatum unter Beteiligung des zentralen Nervensystems. Die Erstinfektion hatte sich fünf Jahre zuvor bei einem Karibikurlaub ereignet. Die Kombination aus Reiseaktivität und Immunsuppression erfordert die Berücksichtigung sonst in Deutschland sehr seltener infektiologischer Diagnosen.

[Differential Diagnosis of Pulmonary Hypertension Using the Example of Collagenosis-associated PAH in the Context of Chronic Lung and Left Heart Disease]

Pulmonary hypertension (PH) can be diagnosed in the context of connective tissue diseases (CTD) as well as in elderly patients with multiple comorbidities. A correct clinical differential diagnosis and classification is essential before adequate therapeutic decisions can be made. Differential diagnosis of PH in CTD comprises associated pulmonary arterial hypertension (APAH), group 2 or 3 PH (PH arising from left heart or chronic lung disease), chronic thromboembolic PH (PH) and group 5 (e. g. in the context of terminal renal insufficiency). This is also true of elderly patients in whom the decision has to be made if the increasing number of coincident diseases lead to PH or have to be interpreted as comorbidities. In this manuscript, the differential diagnosis of PH is elucidated, focusing on CTD, in the context of left heart disease and chronic lung disease. Furthermore, criteria are presented facilitating an objective approach in this context.

[Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]

At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.

[Targeted therapy of pulmonary arterial hypertension: Recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the targeted therapy of PAH. This article summarizes the results and recommendations of the working group on targeted treatment of PAH.

[Dyspnoea in Patients with Pulmonary Hypertension (PH) - a Survey in Spezialized German PH Centres]

Dyspnoea is the predominant symptom in patients with pulmonary hypertension (PH) at diagnosis. However, since dyspnoea is nonspecific and often occurs in a number of common diseases, the presence of PH can easily be underdiagnosed.In addition, this symptom underlies a high variability in the subjective perception, therefore further diagnostic procedures are often delayed by the patients.A survey of the incidence and severity of dyspnoea in 372 patients with PAH was conducted by questionnaire in German centres. Age, sex distribution and the range of comorbidities corresponded to the findings of national and international registries.Approximately 99 % of patients reported the presence of dyspnoea on exertion, even at low loads.Remarkably, in 13 % of patients dyspnoea occurs as a paroxysmal symptom, which may lead to the differential diagnosis of bronchial asthma. In addition, the patients who were being followed in specialized PH centres reported an increase in dyspnoea during the last year.The results of the survey on the incidence of dyspnoea in patients with PAH are consistent with the findings of international studies.

[Riociguat: stimulator of soluble guanylate-cyclase. New mode of action for the treatment of pulmonary arterial and non operable chronic thromboembolic pulmonary hypertension]

Riociguat is the first clinically available soluble Guanylate-cyclase stimulator (sGC) and representative of a completely new class of drugs. Riociguat is approved for pulmonary arterial hypertension (PAH) and non-operable or recurrent/persistent chronic thromboembolic pulmonary hypertension (CTEPH). Moreover, Riociguat is currently under investigation for a wider spectrum of diseases. This article focusses on its mode of action and clinical trial data. Finally, based on these data, the status of approval, as well as the costs a proposal is given how Riociguat can be integrated in the current treatment of PAH and CTEPH.

Radiologic management of haemoptysis: diagnostic and interventional bronchial arterial embolisation

Hemoptysis can be a life-threatening pulmonary emergency with high mortality, is symptomatic of an underlying severe pulmonary disease and requires immediate diagnosis and treatment. Diagnostically, bronchoscopy, conventional chest x-ray and contrast-enhanced multislice computed tomography (MSCT) with CT angiography (CTA) provide information regarding the underlying pulmonary disease, bleeding site, the vascular anatomy of the bronchial arteries (BA) and extrabronchial branches, as well a basis for planning of endovascular intervention. Therapeutically, bronchial artery embolization (BAE) is a safe and effective technique in the hands of an experienced interventionist with profound knowledge of the BA anatomy and possible pitfalls as well as experience with first-line therapy of recurrent and massive hemoptysis or as an intervention prior to elective surgery. Recurrent episodes of hemoptysis are not uncommon and require a prompt repeat BAE after exclusion of extrabronchial systemic and pulmonary artery bleeding sources. This review article should give an overview of the history, anatomical and pathophysiological basics and the clinical context of hemoptysis and diagnosis, as well as a survey of management, treatment and results of BAE.

KEY POINTS

Hemoptyses are life threatening and require urgent diagnostic and therapy. Chest x-ray, bronchoscopy, and contrast-enhanced MSCT with CTA should be carried out before therapeutic bronchial artery embolization (BAE). BAE for the treatment of massive and recurrent hemoptysis is safe and effective. False embolization in spinal branches of BA are the most serious complication of a BAE. Repeatedly BAE refractory cases should undergo elective surgery.

[Utility of invasive diagnostics in acute lung injury]

Acute lung injury/acute respiratory distress syndrome (ARDS) may be induced by a variety of disease entities. Apart from supportive treatment including lung protective ventilation, identification of the underlying process is of crucial importance for optimal therapeutic results. Usually the cause of ARDS can be identified by history, laboratory and radiologicial tests. In some cases a diagnosis cannot be made in spite of an extensive, less invasive diagnostic work-up. In these situations the risks of empirical treatment have to be balanced against the procedural risk of invasive diagnostics, namely open lung biopsy. Today, reports on more than 500 lung biopsies performed in selected ARDS patients are available showing a relevant diagnostic yield at an acceptable procedure-associated risk. Intensive care physicians should be aware of this diagnostic instrument, which can represent the decisive diagnostic step in patients with ARDS of unknown origin.

[Heart rate measurement for determination of training intensity in outpatient pulmonary sport groups]

BACKGROUND

Exercise training is an integral component of the management of patients with asthma and COPD. A training intensity of 60-80% of maximum oxygen uptake (VO(2)max) has been recommended. Instead of ergospirometry measurement of heart rate can be used for training guidance. It is unknown whether the given target can be reached in outpatient training groups with substantial heterogeneity concerning diagnosis, disease severity, and age.

METHODS AND PATIENTS

61 adult patients (m = 15, w = 46; 63 +/- 9 years) with asthma (n = 50) or COPD (n = 11) exercised in groups of ambulant lung sports. An individualized target heart rate was calculated corresponding to an intensity of 60% to 80% of calculated VO(2)max which was equivalent to a heart rate from 97 to 137 beats per minute in the population studied. Heart rate, as a measure of the intensity of charge, was measured continuously with pulse frequency meters.

RESULTS

All but one asthma patient exercised in the targeted heart rate range. Patients reached 81 +/- 9% of the training goal of calculated 80% VO(2)max (asthma patients: 79 +/- 9% vs. COPD patients: 88 +/- 9%, p < 0.005) No significant differences regarding training intensities were observed in relation to severity of illness or age.

CONCLUSIONS

In outpatient lung sport groups of considerable heterogeneity regarding diagnosis, severity of illness and age, participants reach their individualized heart rate target range. COPD patients were training at a significantly higher relative training intensity. Heart rate is an easy to use parameter for training guidance.