Prognostic factors for pulmonary artery hypertension: An interview with Jignesh Patel, MD

By Scott Cunningham, MD, PhD, MDLinx
Published April 24, 2017

Key Takeaways

Background: Pulmonary artery hypertension (PAH) is a debilitating, fatal disease; however, recent advances in treatment have resulted in an encouraging average survival from 2.8 years to 7+ years over the last 30 years. With improvements in treatment, there is a clear need to develop non-invasive methods, such as Doppler echocardiography, to assess pulmonary vasoreactivity, pharmacologic responsiveness, and hemodynamics in addition to the invasive gold standard, right heart catheterization (RHC), according to a study published in the March 2017 issue of the journal Heart, Lung and Circulation.

Jignesh Patel, MD, from the Division of Pulmonary and Critical Care Medicine, Department of Medicine, at the State University of New York at Stony Brook in Stony Brook, NY, and colleagues reported that the pulmonary capillary wedge pressure (PCWP) does not predict all-cause mortality in patients with PAH undergoing treatment with trepostinil and PCWPs < 8 mmHg, 8-11 mmHg, and > 11 mmHg during a 4-year follow-up. As reported by others, however, the study confirmed older age, non-Caucasian race, and pulmonary vascular resistance to be independent predictors of mortality.

MDLinx: Is there a role for PCWP other than prognosticating mortality in managing patients with PAH?

Dr. Patel: PCWP serves an important role in diagnosis and management of patients with pulmonary hypertension. To date, PCWP has not demonstrated any role in prognostication in PAH patients.

MDLinx: Is it possible that measurement of the peak tricuspid regurgitant velocity-to-right ventricular outflow tract-time-velocity integral as an alternative to right heart catheterization could serve as a prognosticator in patients with PAH? Are you aware of any other non-invasive measures of pulmonary vascular resistance (PVR) that may be useful for serial testing?

Dr. Patel: Measurement of tricuspid regurgitation peak velocity (TR Vmax) and TR Vmax: right ventricular outflow tract (RVOT) velocity time interval (VTI) at peak velocity have also been noted to be serve as prognosticators in PAH patients. Other prognostic non-invasive variables have included higher New York Heart Association (NYHA) Functional Class, lower 6-minute walk distance (6MWD), higher brain natriuretic peptide (BNP) or N-terminal (NT) pro BNP, pericardial effusion on echo, lower carbon monoxide diffusing capacity (DLCO), and lower cardiac output. Serial testing of these parameters to measure prognosis has not been well studied.

MDLinx: Were there any statistical differences regarding the PCWP as a prognostic measure in one classification group of PAH patients vs another (eg, WHO Group 1 vs Group 2)?

Dr. Patel: This sub-analysis was not tested as part of our current study.

MDLinx: Is it possible that there are other parameters more amenable to non-invasive testing than PVR to assess pharmacologic responsiveness and disease progression?

Dr. Patel: Noninvasive testing parameters that were utilized to assess pharmacologic responsiveness and disease progression primarily include 6MWD and NYHA Class. Echocardiographic parameters including TR Vmax have also been utilized in clinical follow up.

MDLinx: Would you comment on future directions in the interval assessment of patients with PAH?

Dr. Patel: Interval assessment of PAH patients will continue to include current testing, including RHC measurements (ie, PVR, pulmonary artery systolic pressure, cardiac output), BNP testing, and 6MWD in the future. The role of novel biomarkers in PAH continues to be studied at this time.

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