De-escalation/discontinuation of oxygen-therapy and medication is feasible and safe in chronic thromboembolic pulmonary hypertension patients treated with balloon pulmonary angioplasty

Introduction

There has been increasing evidence of the efficacy of balloon pulmonary angioplasty (BPA) in improving the hemodynamics, exercise capacity, and biomarkers of patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, there is no consensus on the adjustment of home oxygen therapy (HOT) and pulmonary hypertension (PH)-specific medications after BPA in patients with CTEPH.

Purpose

We aimed to examine the current status of the de-escalation/discontinuation of HOT and PH-specific medications post-BPA, and clarify its effect on subsequent hemodynamics, biomarkers, and long-term clinical outcomes.

Methods and results

From November 2012 to July 2019, 134 consecutive CTEPH patients who underwent BPA at a single university hospital were enrolled (age; 63.6±13.4 years, female; n=87 [64.9%], WHO functional class [WHO-FC] II/III/IV; 33/92/9). Hemodynamic data, functional capacity (6-minute walk distance and WHO-FC), biomarkers (brain natriuretic peptide [BNP] and high-sensitivity troponin T [hs-TropT]), and respiratory function were evaluated at baseline, immediately and 1 year post-BPA. Clinical outcomes (all-cause death and heart failure [HF] admission) were also assessed during the follow up period. The total number of sessions was 6.3±2.0, and the number of target vessels was 14.3±2.0. Mean pulmonary arterial pressure decreased from 37.8±11.2 to 20.4±5.1 mmHg 1-year after BPA (p<0.01). The proportion of patients who required HOT (at rest or on exertion) and combination medical therapy (≥2 PH-specific medications) decreased 1 year post-BPA (from 59.0% to 7.5%, and from 41.8% to 10.4%, respectively; Figure). Among 79 patients who required HOT during daytime, 64 patients (81.0%) discontinued HOT just after BPA completion. Among 56 patients who required combination medical therapy, 29 (51.8%) discontinued combination therapy. Baseline factors influencing the continuation of HOT and combination medical therapy post-BPA were almost identical (i.e. lower exercise capacity and pulmonary diffusion capacity, and worse hemodynamics). Results showed that discontinuation of HOT and combination medical therapy did not affect the maintenance of improved hemodynamics and levels of BNP and hs-TropT, and no adverse clinical outcomes (all-cause death and HF hospitalization) were observed during 1 year post-BPA.

Conclusions

Most CTEPH patients discontinued HOT and PH-specific combination medical therapy after BPA, which was not associated with the deterioration of hemodynamics, functional capacity, or biomarkers. No adverse long-term outcomes were observed. De-escalation/discontinuation of HOT and PH-specific combination medical therapy after BPA is feasible and safe for patients with CTEPH.

De-escalation of HOT and medical therapy

Funding Acknowledgement

Type of funding source: None

Microdetermination of prostaglandin E2 in joint fluid in rheumatoid arthritis patients using gas chromatography/selected ion monitoring

We devised an effective purification for the microdetermination of prostaglandin E2 (PGE2) in human joint fluid using gas chromatography/selected ion monitoring and determined PGE2 in the joint fluid in rheumatoid arthritis (RA) patients using this method. The methyl estermethoxime-tert-butyldimethylsilyl ether derivative was prepared, then gas chromatography/selected ion monitoring was carried out by monitoring the ion at m/z 566.4 for PGE2 and at m/z 570.4 for the internal standard (PGE2-d4). A good linear response over the range of 10 pg to 50 ng was demonstrated. We detected PGE2 to a level of about 46 pg/ml in the joint fluid of RA patients. The level of PGE2 in RA patients was significantly higher than that in osteoarthritis patients used as controls. Moreover, we measured inflammatory cytokine (IL-1beta, TNFalpha, IL-6 receptor) levels in joint fluid by using enzyme-linked immunosorbent assay. A relationships between the PGE2 level in joint fluid and these cytokines or biochemical data as the indicator of RA disease was not observed. We found that the PGE2 level in each patient was influenced by therapeutic drugs. The PGE2 level in RA patients with non-steroidal anti-inflammatory drugs was lower than with steroids.