Critical care outcomes in patients with pre-existing pulmonary hypertension: insights from the ASPIRE registry

Abstract

Pulmonary Hypertension (PH) is a life-shortening condition characterised by episodes of decompensation precipitated by factors such as disease progression, arrhythmias and sepsis. Surgery and pregnancy also place additional strain on the right ventricle. Data on critical care management in patients with pre-existing PH are scarce.We conducted a retrospective observational study of a large cohort of patients admitted to the critical care unit of a national referral centre between 2000–17 to establish acute mortality, evaluate predictors of in-hospital mortality and establish longer-term outcomes in survivors to hospital discharge.242 critical care admissions involving 206 patients were identified. Hospital survival was 59.3%, 94% and 92% for patients admitted for medical, surgical or obstetric reasons. Medical patients had more severe physiological and laboratory perturbations than patients admitted following surgical or obstetric interventions. Higher APACHE II score, age and lactate, and lower SpO2/FiO2, platelet count and sodium level were identified as independent predictors of hospital mortality. An exploratory risk score, OPALS (Oxygen (SpO2:FiO2), ≤185; Platelets, ≤196×109·L−1; Age, ≥37.5 years; Lactate, ≥2.45 mmol·L−1; Sodium, ≤130.5 mmol·L−1), identified medical patients at increasing risk of hospital mortality. One of nine patients (11%) who were invasively ventilated for medical decompensation and 50% of patients receiving renal replacement therapy left hospital alive. There was no significant difference in exercise capacity or functional class between follow-up and pre-admission in patients who survived to discharge.These data have clinical utility in guiding critical care management of patients with known PH. The exploratory OPALS score requires validation.

Reply: External validation of the OPALS prediction model for in-hospital mortality in patients with acute decompensated pulmonary hypertension

“…They have assessed our previously proposed predictive score for outcomes in medically decompensated pulmonary hypertension (PH) patients: the OPALS score (oxygen (oxygen saturation measured by pulse oximetry/inspiratory oxygen fraction ratio ⩽185), platelets ⩽196×10 9 L −1 , age ⩾37.5 years, lactate ⩾2.45 mmol·L −1 and sodium ⩽130.5 mmol·L −1 ) in 74 PH patients. Discriminatory power was very similar to that observed in our derivation cohort (c-statistic of 0.77 versus 0.78) [ 2 ]. Furthermore, there was exceedingly high calibration between predicted and observed mortality in their validation cohort (R 2 =0.97).…”

“…Discriminatory power was very similar to that observed in our derivation cohort (c-statistic of 0.77 versus 0.78). 2 Furthermore, there was exceedingly high calibration between predicted and observed mortality in their validation cohort (R 2 =0.97). The OPALS score therefore appears to be a promising PH-specific tool for predicting outcomes in medically-decompensated patients.…”

“…Robin Condliffe 1,2 , Kris Bauchmuller 3 , Jennifer Southern 3 , David G Kiely 1,2 and Gary H Mills 3,4 Affiliations: 1…”

Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients – An Ongoing Approach

“…As a distinctive disease with multiple aetiologies, pulmonary arterial hypertension (PAH) is recognized as a cause of acute and chronic right-sided heart failure (RHF), but the clinical onset of the RHF is variable among different subgroups of PAH with similar degree of pulmonary pressure [ 3 , 4 ]. Data regarding admission, management, and outcomes of PAH patients in intensive care unit (ICU) are still limited, as a result of small number of diagnosed cases and lack of consisting data [ 5 , 6 , 7 ].…”

External validation of the OPALS prediction model for in-hospital mortality in patients with acute decompensated pulmonary hypertension

“…We were very pleased to read the article “Critical care outcomes in patients with pre-existing pulmonary hypertension: insights from the ASPIRE registry”, recently published in ERJ Open Research [ 1 ].…”