Prognostic Value of Follow-Up Hemodynamic Variables After Initial Management in Pulmonary Arterial Hypertension

Weatherald, Jason; Boucly, Athénaïs; Chemla, Denis; Savale, Laurent; Peng, Mingkai; Jevnikar, Mitja; Jaïs, Xavier; Taniguchi, Yu; O’Connell, Caroline; Parent, Florence; Sattler, Caroline; Hervé, Philippe; Simonneau, Gérald; Montani, David; Humbert, Marc; Adir, Yochai; Sitbon, Olivier

doi:10.1161/circulationaha.117.029254

Cited by 179 publications

(196 citation statements)

References 35 publications

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“…However, in a new study rom the French PAH registry, only a 6MWD ≤440 m independently predicted death or transplantation, whereas baseline WHO/NYHA functional class III-IV, RAP ≥8 mm Hg and cardiac index < 2.5 L × min −1 × m −2 were associated with a higher risk of death or transplantation in the univariate analysis [5]. These and further studies [4][5][6][7] confirmed that haemodynamic variables obtained by right heart catheterization are essential for risk stratification as proposed by the guidelines. On the other hand, in many studies, single haemodynamic variables were not independent prognostic predictors and varied largely in their prognostic relevance within different studies [2,[4][5][6]8].…”

Section: Introductionmentioning

confidence: 88%

“…In both cohorts, patients with an RV index > 91 had a significantly increased mortality compared to patients with an RV index ≤91 (p = 0.00092). The fully adjusted Cox regression analysis (model 3) showed a more than 2.5-fold higher mortality risk in patients with an RV index above the cutoff (HR 2.56 [95% CI 1.29, 5.08], p = 0.0071; Fig. 4).…”

Section: Development Of the Rv Index And Application In The Developmementioning

confidence: 99%

“…However, there is still a debate about which parameters are the best to be used for this approach as studies report different results regarding single haemodynamic parameters [2,[4][5][6]8]. The current guidelines recommend RAP, cardiac index and SvO 2 as variables for risk prediction [1].…”

Section: Haemodynamic Variables and Risk Stratification In Pahmentioning

confidence: 99%

“…The current guidelines recommend RAP, cardiac index and SvO 2 as variables for risk prediction [1]. However, while RAP was most commonly reported to be associated with the outcome [2,[4][5][6], this was not true for the cardiac index in 2 large recent studies [5,8]. One of these studies [5] suggested that stroke volume index as a predictor was superior to other haemodynamic variables reflecting cardiac function; however, in the same study, SvO 2 as a reportedly strong predictor of outcome [4,15] was lacking because of missing data.…”

Section: Haemodynamic Variables and Risk Stratification In Pahmentioning

confidence: 99%

“…These data confirmed findings of a study which used a similar subset of variables in 530 Swedish patients with newly diagnosed PAH [4]. However, in a new study rom the French PAH registry, only a 6MWD ≤440 m independently predicted death or transplantation, whereas baseline WHO/NYHA functional class III-IV, RAP ≥8 mm Hg and cardiac index < 2.5 L × min −1 × m −2 were associated with a higher risk of death or transplantation in the univariate analysis [5]. These and further studies [4][5][6][7] confirmed that haemodynamic variables obtained by right heart catheterization are essential for risk stratification as proposed by the guidelines.…”

Section: Introductionmentioning

confidence: 99%

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Right Ventricular Index for Risk Stratification of Patients with Pulmonary Arterial Hypertension

Sinning¹,

Harbaum

Schrage³

et al. 2018

Respiration

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Background: Right ventricular (RV) dysfunction is a major prognostic predictor in pulmonary arterial hypertension (PAH). Objectives: The objective of this study was to assess the prognostic impact of a newly developed index merging haemodynamic parameters into 1 variable. Methods: We retrospectively assessed 2 cohorts of 248 patients (164 from Hamburg and 84 from Heidelberg) with invasively diagnosed PAH. During a median follow-up time of 3.6 years (3.1 and 4.0 years for Hamburg and Heidelberg, respectively), the composite endpoint of all-cause mortality and lung transplantation occurred in 57 patients (53 and 4 patients for Hamburg and Heidelberg, respectively). The RV index was developed in the Hamburg cohort and validated in the Heidelberg cohort: (right atrial pressure × pulmonary vascular resistance)/mixed venous oxygen saturation. Results: Patients with a high RV index had a higher incidence of the combined endpoint in Kaplan-Meier analyses in the Hamburg and Heidelberg cohort (p = 0.017 and p = 0.034, respectively). The calculated RV index cut-off value was 91 and identified patients with a worse outcome in the Hamburg cohort and showed a trend in the Heidelberg cohort (p < 0.001 and p = 0.089, respectively). The RV index in Cox regression hazard models was an independent predictor of outcomes after adjustment for sex and age in both cohorts (Hamburg: hazard ratio [HR] 1.26 [95% CI 1.08, 1.47], p = 0.0027; Heidelberg: HR 2.27 [95% CI 1.46, 3.51], p < 0.001). A nomogram based on these results allowed risk stratification. Conclusion: Merging 3 haemodynamic variables into 1 variable, the RV index increased the prognostic power up to an independent risk factor. The RV index is easy to calculate and allows the construction of a nomogram for an individualized risk assessment.

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Section: Introductionmentioning

confidence: 88%

Section: Development Of the Rv Index And Application In The Developmementioning

confidence: 99%

Section: Haemodynamic Variables and Risk Stratification In Pahmentioning

confidence: 99%

Section: Haemodynamic Variables and Risk Stratification In Pahmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Right Ventricular Index for Risk Stratification of Patients with Pulmonary Arterial Hypertension

Sinning¹,

Harbaum

Schrage³

et al. 2018

Respiration

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Long‐term predictive value of stroke volume index obtained from right heart catheterization: Insights from the veterans affairs clinical assessment, reporting, and tracking program

Bavry

Hess

Waldo

et al. 2020

Clinical Cardiology

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Background: Right heart catheterization-derived hemodynamic parameters have been associated with short-term prognosis. Hypothesis: Hemodynamic parameters will be associated with long-term prognosis. Methods: Retrospective cohort study from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program included patients who underwent an index right heart catheterization between 2008 and 2016. Cox proportional hazard models were used to examine the association between stroke volume index and all-cause mortality. Results: For the final cohort of 37 209 patients, mean follow-up was 3.7 ± 2.5 years. All-cause mortality was 42.0% in the low (<35 cc/beat/m 2) compared with 33.2% in the normal stroke volume index group (≥35 cc/beat/m 2). In adjusted analysis, low stroke volume was significantly associated with higher mortality risk (HR (95% CI) 1.14 (1.10-1.18); P < .001) independent of clinical parameters. The area under the curve (AUC) for continuous measures of stroke volume index at predicting mortality in a Cox proportional hazard model was 0.56 at 3 years. When stroke volume index was combined with 14 clinical covariates, the AUC was 0.70 at 3 years. The addition of stroke volume index to these clinical covariates did not increase the discriminatory ability of the model at 1 year in a clinically meaningful way (integrated discrimination improvement index = 0.0021, 95% CI: 0.0010-0.0034). Conclusions: The long-term prognostic value of right heart catheterization-derived stroke volume index appears to be marginal. While there was a weak association of low stroke volume index and excess mortality, inclusion of this parameter to a set of clinical covariates did not improve prognostic discrimination.

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Profiles and treatment patterns of patients with pulmonary arterial hypertension on monotherapy at experienced centres

et al. 2022

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Aims Guideline recommendations highlight the critical role of combination therapy for the treatment of pulmonary arterial hypertension (PAH). Conversely, registry data demonstrate that a considerable number of PAH patients remain on monotherapy. The reasons for this discrepancy remain elusive. The aim of this study was to assess the patient profiles, treatment patterns, and disease characteristics of patients diagnosed with PAH who were kept on monotherapy at experienced pulmonary hypertension (PH) centres and to capture potential reasons for monotherapy. Methods and results We analysed the patient profiles of 182 patients on monotherapy with PAH‐targeted drugs, managed at experienced PH expert centres (Cologne, Giessen, Heidelberg, and Dresden). Patients were identified based on their latest follow‐up visit and analysed retrospectively from the time of PAH diagnosis to last follow‐up. Patients were dichotomized by age, and patient characteristics, treatment patterns, response to therapy, change in risk status, and drug tolerability were recorded during the course of their disease. Patients' mean age was 69.1 ± 13.1 years at the most recent follow‐up (Key Time Point 1) and 64.5 ± 14.9 years at the time of diagnosis (Key Time Point 2). The mean time on monotherapy was 60.7 ± 53.8 months; 35.7/64.3% of patients were male/female. The majority (66.5%) had idiopathic PAH, followed by PAH associated with connective tissue disease (17.0%) and portopulmonary PH (8.2%). Among patients on monotherapy, there were five main clusters: (i) patients with failed escalation attempts mostly because of intolerability (26.9%); (ii) low risk on monotherapy, favourable response, and no reason for escalation (24.2%); (iii) patients with mild PAH (36.3%); (iv) elderly patients with PAH and multiple co‐morbidities (38.5%); and (v) patients with associated forms of PAH where the level of evidence for combination therapies is considered low (16.5%). There were substantial differences between patients above or below the median age (68 years). The most frequently used monotherapy for PAH was phosphodiesterase type 5 inhibitors (75.3%). Conclusions A considerable number of PAH patients are on monotherapy at large PH expert centres, characterized by specific reasons that justify this kind of treatment. Nevertheless, as comprehensive treatment strategies have shown improved long‐term outcomes even in mildly symptomatic patients, each case of monotherapy should be justified.

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Prognostic Value of Follow-Up Hemodynamic Variables After Initial Management in Pulmonary Arterial Hypertension

Abstract: SVI and right atrial pressure were the hemodynamic variables that were independently associated with death or lung transplantation at first follow-up RHC after initial PAH treatment. These findings suggest that the SVI could be a more appropriate treatment target than cardiac index in PAH.

Cited by 179 publications

References 35 publications

Right Ventricular Index for Risk Stratification of Patients with Pulmonary Arterial Hypertension

Right Ventricular Index for Risk Stratification of Patients with Pulmonary Arterial Hypertension

Long‐term predictive value of stroke volume index obtained from right heart catheterization: Insights from the veterans affairs clinical assessment, reporting, and tracking program

Profiles and treatment patterns of patients with pulmonary arterial hypertension on monotherapy at experienced centres

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