Impact of race on survival in pulmonary arterial hypertension: Results from the REVEAL registry

Abstract

BACKGROUND: Prior research has suggested that the prevalence and outcomes of pulmonary arterial hypertension (PAH) may vary by race or ethnicity. However, these studies have been limited by small sample size or methodological techniques relying on epidemiologic data. The purpose of this study is to evaluate the relationship between race/ethnicity and survival in a large U.S.-based prospective multicenter registry. METHODS: Patients in the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL), a 5-year observational study of Group 1 PAH, were categorized by race/ethnicity. Baseline hemodynamic characteristics, clinical characteristics, and medication use was described. The relationship between race/ethnicity and outcome was evaluated by Kaplan−Meier and Cox proportional hazards modeling techniques. Left-truncation analysis, which adjusted for time from diagnosis to study enrollment, was used to minimize the effect of survivor bias. RESULTS: This analysis included 3,046 patients; 2,202 identified as white, 393 as black, 263 as Hispanic, 100 as Asian or Pacific Islander, and 88 as other. Unadjusted Kaplan−Meier survival analysis indicated that white patients had the lowest survival rates. After adjusting for variables of prognostic impact, race/ethnicity was no longer significantly associated with survival. Other results showed that black patients were more likely to have connective tissue disease−associated PAH, Hispanic patients were more likely to have portopulmonary hypertension, and Asian patients were more likely to have congenital heart disease−associated PAH. CONCLUSIONS: Analysis of the REVEAL registry did not find race/ethnicity to be a significant predictor of mortality. This is the largest analysis to date evaluating the role of race/ethnicity on outcomes in PAH.

In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A 6-Year Population Cohort Study of Over One Million Patients

“…Surprisingly, Asians/Pacific Islanders showed the greatest increase in mortality and total hospital charges of any race or ethnicity. Until the REVEAL registry, it was unclear whether different races or ethnicities had differing prognosis following the diagnosis of pulmonary hypertension; however, the authors of the REVEAL study concluded that race and ethnicity did not impact outcomes for patients with pulmonary hypertension [ 11 , 12 ]. In contrast, our study results show that Asians/Pacific Islanders are at a significantly higher risk than other races and ethnicities for mortality.…”

“…In contrast, our study results show that Asians/Pacific Islanders are at a significantly higher risk than other races and ethnicities for mortality. Also, Asian/Pacific Islander patients are more likely to have congenital heart disease-associated pulmonary hypertension, which would significantly increase their lifelong morbidity and mortality compared to patients first diagnosed with pulmonary hypertension in adulthood because those diagnosed in adulthood would likely have decreased lifetime survival and hospitalizations [ 11 ]. Genetic mutations in interaction with epigenetics and environmental factors, which may be present for Asians/Pacific Islanders, could also theoretically increase mortality in this patient group.…”

Health Disparities in Pulmonary Arterial Hypertension and the Impact of the COVID-19 Pandemic

“…Previous research in PAH has shown an association between worse outcomes and lower SES, so further investigation of geospatial determinants of health in PAH are worth consideration. 23,41 Socioeconomic Factors SDHs and SES have been identified as fundamental causes behind health disparities and racial differences in health. 32,58,63 These terms often incorporate factors that can alter health-related behaviors such as neighborhoods, income, education, wealth, occupation, health insurance coverage, and mar-ital status.…”

“…Based on the RE-VEAL Registry, Black patients were less likely to be prescribed phosphodiesterase-5 inhibitors, and Hispanic patients were less likely to be prescribed ERA therapy. 23 Hispanic patients have been found to be treated with less PAH-specific medications in general. 18 Racial and ethnic minorities are less likely to have health insurance, and for minorities with PAH, the lack of health insurance may have the greatest impact on their quality of care and could play a part in prescribing patterns.…”

“…16,18 However, analysis of the REVEAL Registry found no significant association between race or ethnicity and survival in PAH after correcting for variables of prognostic impact. 23 A review of vital statistics data from 1994-1998 revealed that African Americans with PAH exhibited substantially higher mortality rates compared to White populations, and African-American women had the highest mortality rates across all ages. 15 Underlying causes for these differences are unknown but could be related to social determinants of health (SDHs) and health inequities.…”