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PULMONARY VASCULAR RESPONSE TO NITRIC OXIDE AND SUBSEQUENT RESPONSE TO ADVANCED MEDICAL THERAPY IN INCIDENT PATIENTS WITH PULMONARY HYPERTENSION
1899 JACC March 21, 2017 Volume 69, Issue 11
Pulmonary Hypertension and Venous Thrombo-embolic Disease PULMONARY VASCULAR RESPONSE TO NITRIC OXIDE AND SUBSEQUENT RESPONSE TO ADVANCED MEDICAL THERAPY IN INCIDENT PATIENTS WITH PULMONARY HYPERTENSION Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 9:45 a.m.-10:30 a.m. Session Title: Understanding Pulmonary Vascular Disease: From Bench to Bedside Abstract Category: 35. Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease
Presentation Number: 1181-001
Authors: Richard A. Krasuski, Alexander J. Blood, Kishan Parikh, Rachel Elkin, Michael Zdradzinski, Thomas Bashore, Duke University Health System, Durham, NC, USA, The Cleveland Clinic, Cleveland, OH, USA Background: Pulmonary hypertension (PH) patients who are acutely vasoreactive (VR) have better survival than less reactive (LR) patients. How this predicts subsequent response to advanced medical therapy, however, remains less clear.
Methods: From a two-center prospective cohort of incident PH undergoing initial hemodynamic assessment, we identified 170 patients subsequently treated with endothelin antagonists (ETRA), phosphodiesterase-5 inhibitors (PDE-5) or prostaglandins (PG). Patients were stratified as being above (VR) or below (LR) the median percent drop in mean pulmonary artery pressure (mPAP) during inhalation of 40ppm nitric oxide. Follow-up was at 3 month intervals and an echo was repeated after 1 year of treatment.
Results: Median drop in mPAP with nitric oxide was 13% (interquartile range 5-22%). VR patients were similar to LR patients in terms of age (56±15 years), sex (66% women), race (79% white), WHO function class (58% class III and 17% class IV) and % with idiopathic PH (37%). VR patients had lower right atrial pressure (9.9±5.3 vs. 12.7±7.1 mmHg, p=0.005), better cardiac index (2.5±0.8 vs. 2.2±0.7 l/min/ m2, p=0.002) and greater 6 minute walk distance (347±114 vs. 276±134 m, p=0.014). Right ventricles of LR patients were larger (p=0.001), more hypocontractile (p=0.005) with greater tricuspid regurgitation (p=0.003) and higher right ventricular systolic pressure (RVSP; 83±24 vs. 70±22mmHg). Although utilization of ETRA and PDE-5 was similar, LR patients more frequently received PG (49% vs. 30%, p=0.009) and combination therapy (33% vs. 17%, p=0.022). Degree of change in 6 minute walk and most echo parameters including RVSP were similar, with the exception of right ventricular size, which decreased slightly more in VR patients (p=0.014). Mortality was 21% in VR patients vs. 49% in LR patients, (p<0.001) at a median follow-up of 34.1 months. Conclusions: Despite receiving more aggressive therapy, RV remodeling was similar and mortality considerably higher in less responsive patients. This suggests that LR patients have considerably more advanced and thereby less reversible disease and emphasizes the critical role for early disease identification and therapy in PH.
Pulmonary Hypertension and Venous Thrombo-embolic Disease PULMONARY VASCULAR RESPONSE TO NITRIC OXIDE AND SUBSEQUENT RESPONSE TO ADVANCED MEDICAL THERAPY IN INCIDENT PATIENTS WITH PULMONARY HYPERTENSION Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 9:45 a.m.-10:30 a.m. Session Title: Understanding Pulmonary Vascular Disease: From Bench to Bedside Abstract Category: 35. Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease
Presentation Number: 1181-001
Authors: Richard A. Krasuski, Alexander J. Blood, Kishan Parikh, Rachel Elkin, Michael Zdradzinski, Thomas Bashore, Duke University Health System, Durham, NC, USA, The Cleveland Clinic, Cleveland, OH, USA Background: Pulmonary hypertension (PH) patients who are acutely vasoreactive (VR) have better survival than less reactive (LR) patients. How this predicts subsequent response to advanced medical therapy, however, remains less clear.
Methods: From a two-center prospective cohort of incident PH undergoing initial hemodynamic assessment, we identified 170 patients subsequently treated with endothelin antagonists (ETRA), phosphodiesterase-5 inhibitors (PDE-5) or prostaglandins (PG). Patients were stratified as being above (VR) or below (LR) the median percent drop in mean pulmonary artery pressure (mPAP) during inhalation of 40ppm nitric oxide. Follow-up was at 3 month intervals and an echo was repeated after 1 year of treatment.
Results: Median drop in mPAP with nitric oxide was 13% (interquartile range 5-22%). VR patients were similar to LR patients in terms of age (56±15 years), sex (66% women), race (79% white), WHO function class (58% class III and 17% class IV) and % with idiopathic PH (37%). VR patients had lower right atrial pressure (9.9±5.3 vs. 12.7±7.1 mmHg, p=0.005), better cardiac index (2.5±0.8 vs. 2.2±0.7 l/min/ m2, p=0.002) and greater 6 minute walk distance (347±114 vs. 276±134 m, p=0.014). Right ventricles of LR patients were larger (p=0.001), more hypocontractile (p=0.005) with greater tricuspid regurgitation (p=0.003) and higher right ventricular systolic pressure (RVSP; 83±24 vs. 70±22mmHg). Although utilization of ETRA and PDE-5 was similar, LR patients more frequently received PG (49% vs. 30%, p=0.009) and combination therapy (33% vs. 17%, p=0.022). Degree of change in 6 minute walk and most echo parameters including RVSP were similar, with the exception of right ventricular size, which decreased slightly more in VR patients (p=0.014). Mortality was 21% in VR patients vs. 49% in LR patients, (p<0.001) at a median follow-up of 34.1 months. Conclusions: Despite receiving more aggressive therapy, RV remodeling was similar and mortality considerably higher in less responsive patients. This suggests that LR patients have considerably more advanced and thereby less reversible disease and emphasizes the critical role for early disease identification and therapy in PH.