Aim: The prevalence of occult left heart disease (LHD) and the feasibility of vasodilator therapy in the progressively growing population of elderly subjects with pulmonary arterial hypertension (PAH) are under scrutiny. We evaluated the presence of a LHD phenotype and the patterns of vasodilator treatment in such patients. Methods: The PATRIARCA registry collected cross-sectional data from 180 subjects with PAH or chronic thromboembolic pulmonary hypertension and ≥70 years of age in 11 Italian centers between December 1st 2019 and September 15th 2020. After excluding patients with CTEPH or incomplete follow-up hemodynamic parameters, 69 individuals with PAH diagnosed at ≥65 years of age according to current guidelines were included in the analysis. A LHD phenotype was defined as follows, expanding the criteria adopted in the AMBITION trial: i) ≥3 among body mass index ≥30 kg/m2, systemic hypertension, diabetes, and significant coronary artery disease; ii) 2 of the risk factors for LHD above and ≥1 among permanent atrial fibrillation, left ventricular (LV) hypertrophy, LV ejection fraction <50%, at least moderate mitral or aortic valve disease, and left atrial dilation; iii) pulmonary vascular resistance (PVR) between 3 and 3,75 WU or PVR between 3.75 to 6.25 WU in the presence of a pulmonary artery wedge pressure (PAWP) of 13 to 15 mmHg. Results: Thirtyseven (54%) patients had a LHD phenotype according to the most recent clinical and hemodynamic evaluation, which was performed 16 (4-35) months after diagnosis. As per definition, they had higher rates of comorbidities and more often echocardiographic signs of LHD. The frequency of NYHA class I-II was comparable between the 2 groups, while the 6 minute-walking distance tended to be lower in subjects with a LHD phenotype than in those without. Furthermore, these latter had lower PVR and higher PAWP. No substancial differences in hemodynamic profile were seen, except for a higher right atrial pressure and a not significant lower PVR. No differences in PAH therapy were identified, while they were more frequently treated with RASi During the study period, 9 (16%) and 4 (8%) patients died in the LHD and no-LHD groups, respectively (P=0.40). Conclusions: In this real-world cohort of elderly patients, a LHD phenotype was common despite an initial hemodynamic diagnosis of PAH. However, it did not appear to cause simplification or discontinuation of pulmonary vasodilator therapy. Longitudinal studies are needed to determine whether and how a LHD phenotype affects the use and effects of PAH drugs in the elderly.

Left heart disease phenotype in elderly patients with pulmonary arterial hypertension: insights from the Italian PATRIARCA registry.

MICELI, ROBERTA
2022

Abstract

Aim: The prevalence of occult left heart disease (LHD) and the feasibility of vasodilator therapy in the progressively growing population of elderly subjects with pulmonary arterial hypertension (PAH) are under scrutiny. We evaluated the presence of a LHD phenotype and the patterns of vasodilator treatment in such patients. Methods: The PATRIARCA registry collected cross-sectional data from 180 subjects with PAH or chronic thromboembolic pulmonary hypertension and ≥70 years of age in 11 Italian centers between December 1st 2019 and September 15th 2020. After excluding patients with CTEPH or incomplete follow-up hemodynamic parameters, 69 individuals with PAH diagnosed at ≥65 years of age according to current guidelines were included in the analysis. A LHD phenotype was defined as follows, expanding the criteria adopted in the AMBITION trial: i) ≥3 among body mass index ≥30 kg/m2, systemic hypertension, diabetes, and significant coronary artery disease; ii) 2 of the risk factors for LHD above and ≥1 among permanent atrial fibrillation, left ventricular (LV) hypertrophy, LV ejection fraction <50%, at least moderate mitral or aortic valve disease, and left atrial dilation; iii) pulmonary vascular resistance (PVR) between 3 and 3,75 WU or PVR between 3.75 to 6.25 WU in the presence of a pulmonary artery wedge pressure (PAWP) of 13 to 15 mmHg. Results: Thirtyseven (54%) patients had a LHD phenotype according to the most recent clinical and hemodynamic evaluation, which was performed 16 (4-35) months after diagnosis. As per definition, they had higher rates of comorbidities and more often echocardiographic signs of LHD. The frequency of NYHA class I-II was comparable between the 2 groups, while the 6 minute-walking distance tended to be lower in subjects with a LHD phenotype than in those without. Furthermore, these latter had lower PVR and higher PAWP. No substancial differences in hemodynamic profile were seen, except for a higher right atrial pressure and a not significant lower PVR. No differences in PAH therapy were identified, while they were more frequently treated with RASi During the study period, 9 (16%) and 4 (8%) patients died in the LHD and no-LHD groups, respectively (P=0.40). Conclusions: In this real-world cohort of elderly patients, a LHD phenotype was common despite an initial hemodynamic diagnosis of PAH. However, it did not appear to cause simplification or discontinuation of pulmonary vasodilator therapy. Longitudinal studies are needed to determine whether and how a LHD phenotype affects the use and effects of PAH drugs in the elderly.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11567/1087230
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