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1 Pulmonary hypertension in scleroderma: different phenotypes UMR 995 Pr David LAUNAY, MD, PhD Service de Médecine Interne. Unité d'immunologie Clinique CNRMR Maladies Systémiques et Autoimmunes Rares Hôpital Claude-Huriez. CHRU Lille LIRIC
2 Disclosures of interest Grants from Actelion, Pfizer, GSK
3 Pulmonary hypertension in systemic sclerosis Frequent (10-15 %) Severe PH and ILD: first cause of morbimortality in SSc Overall survival of SSc-PAH: 50% at 3 years Overall survival of SSc-PH due to ILD : 35 % at 3 years Worse survival than idiopathic PAH ajusted for the severity PH in SSc : very heterogeneous disease with different phenotypes Various pathophysiological mechanisms, sometimes associated, leading to PH in SSc Heterogeneity of SSc with various subtypes and organ involvement Lefèvre G et al. Arthritis Rheumatol
4 Systemic sclerosis : an heterogneous disease different PH Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
5 Systemic sclerosis : an heterogneous disease different PH Precapillary PAH (group 1) Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
6 Systemic sclerosis : an heterogneous disease different PH Precapillary PAH (group 1) PVOD Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
7 Systemic sclerosis : an heterogneous disease different PH Precapillary PAH (group 1) Precapillary PH due to ILD (group 3) PVOD Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
8 Systemic sclerosis : an heterogneous disease different PH Precapillary PAH (group 1) Precapillary PH due to ILD (group 3) PVOD CTEPH (group 4) Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
9 Systemic sclerosis : an heterogneous disease different PH Postcapillary PH (cardiac involvement=group2) Precapillary PAH (group 1) Precapillary PH due to ILD (group 3) PVOD CTEPH (group 4) Galie N et al. Eur Respir J 2015; Galie N et al. Eur Heart J
10 Systemic sclerosis : an heterogneous disease cutaneous extension Limited cutaneous(lcssc) 70 % Rare visceral involvement except PH Anti-centromere Ab : 70 % Diffuse cutaneous(dcssc) 30 % - Frequent and early visceral involvement - Anti-topo isomérase I : 30 % Sobanski V et al. JAMA. (submitted) 10
11 Systemic sclerosis : an heterogneous disease organ involvement ILD (50%) Cardiac involvement Cutanous involvement Kidney GI Raynaud Courtesy to Abraham D Articulations&muscles 11
12 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe Mild to severe 12
13 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe Mild to severe absent ILD extensive 13
14 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe Mild to severe absent ILD extensive 14
15 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe DcSSc Mild to severe absent ILD extensive 15
16 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe DcSSc Mild to severe absent ILD extensive 16
17 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Mild to severe LcSSc DcSSc Mild to severe absent ILD extensive 17
18 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH 2/3 of patients PVOD Mild to severe LcSSc DcSSc Mild to severe Günther S et al. Arthritis Rheum 2012 Dorfmuller P et al. Human Pathol 2007 absent ILD extensive 18
19 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH 2/3 of patients PVOD Mild to severe LcSSc DcSSc Mild to severe Günther S et al. Arthritis Rheum 2012 Dorfmuller P et al. Human Pathol 2007 absent ILD extensive 19
20 PH in systemic sclerosis : major heterogeneity idiopathic PAH Precapillary PH Postcapillary PH Sometimes very difficult to classify patient in group 1, 1, 2 or 3 PVOD Mild to severe LcSSc DcSSc Mild to severe absent ILD extensive 20
21 How to define homogeneous phenotypes in PH in scleroderma? 21
22 How to define homogeneous phenotypes in PH in scleroderma? Cluster analysis : Principles To find homogeneous groups in a heterogeneous population 22
23 How to define homogeneous phenotypes in PH in scleroderma? Cluster analysis : Principles To find homogeneous groups in a heterogeneous population 1. Definition of clustering variables 2. The analysis finds homogeneous clusters according to these variables 3. Comparisons of the characteristics of the different clusters 23
24 How to define homogeneous phenotypes in PH in scleroderma? Cluster analysis : Principles To find homogeneous groups in a heterogeneous population 24
25 How to define homogeneous phenotypes in PH in scleroderma? Cluster analysis : Principles To find homogeneous groups in a heterogeneous population Personalized medicine and better understanding of the disease 25
26 Cluster analysis in scleroderma patients with precapillary PH Collaborative study between Registry of the French National Pulmonary Hypertension Network and Johns Hopkins Hospital (Paul Hassoun, Fred Wigley, Baltimore) Primary objective : cluster analysis to define homogeneous groups of patients Secondary objective: survival analysis of clusters 200 patients ACR-EULAR 2013 criteria for SSc Precapillary PH at RHC Baselien chest HRCT and LFT at baseline No CTEPH ILD classified as absent/limited/extensive (Goh s staging system) Statistical method Cluster analysis : K-means using 4 variables : FVC, DLCO, PVR et présence / extension ILD Survival analysis 26
27 Cluster analysis in scleroderma patients with precapillary PH Collaborative study between Registry of the French National Pulmonary Hypertension Network and Johns Hopkins Hospital (Paul Hassoun, Fred Wigley, Baltimore) Primary objective : cluster analysis to define homogeneous groups of patients Secondary objective: survival analysis of clusters 200 patients ACR-EULAR 2013 criteria for SSc Precapillary PH at RHC Baselien chest HRCT and LFT at baseline No CTEPH ILD classified as absent/limited/extensive (Goh s staging system) Statistical method Cluster analysis : K-means using 4 variables : FVC, DLCO, PVR et présence / extension ILD Survival analysis 27
28 Cluster analysis in scleroderma patients with precapillary PH Collaborative study between Registry of the French National Pulmonary Hypertension Network and Johns Hopkins Hospital (Paul Hassoun, Fred Wigley, Baltimore) Primary objective : cluster analysis to define homogeneous groups of patients Secondary objective: survival analysis of clusters 200 patients ACR-EULAR 2013 criteria for SSc Precapillary PH at RHC Baseline chest HRCT and LFT No CTEPH ILD classified as absent/limited/extensive (Goh s staging system) Statistical method Cluster analysis : K-means using 4 variables : FVC, DLCO, PVR et présence / extension ILD Survival analysis 28
29 Cluster analysis in scleroderma patients with precapillary PH Collaborative study between Registry of the French National Pulmonary Hypertension Network and Johns Hopkins Hospital (Paul Hassoun, Fred Wigley, Baltimore) Primary objective : cluster analysis to define homogeneous groups of patients Secondary objective: survival analysis of clusters 200 patients ACR-EULAR 2013 criteria for SSc Precapillary PH at RHC Baseline chest HRCT and LFT No CTEPH ILD classified as absent/limited/extensive (Goh s staging system) Statistical method Cluster analysis : K-means using 4 variables : FVC, DLCO, PVR et présence / extension ILD Survival analysis 29
30 Cluster analysis in scleroderma patients with precapillary PH Collaborative study between Registry of the French National Pulmonary Hypertension Network and Johns Hopkins Hospital (Paul Hassoun, Fred Wigley, Baltimore) Primary objective : cluster analysis to define homogeneous groups of patients Secondary objective: survival analysis of clusters 200 patients ACR-EULAR 2013 criteria for SSc Precapillary PH at RHC Baselien chest HRCT and LFT at baseline No CTEPH ILD classified as absent/limited/extensive (Goh s staging system) Statistical method Cluster analysis : K-means using 4 variables : FVC, DLCO, PVR et presence / extension ILD Survival analysis 30
31 Flowchart of the study 150 Patients retrieved from the French PH network 105 Patients retrieved from the US reference center for SSc-PH 55 were excluded : 54 had missing data on PAWP, PVR, TLC, DLCO, mpap and/or ILD 1 had a history of pneumectomy 200 Patients analyzed 31
32 Baseline characteristics n mean±sd or n (%) Age, years ±11.9 Males (23.5) Diffuse systemic sclerosis (26.3) Limited systemic sclerosis (73.7) Anti-centromere antibodies (35.9) Anti-topoisomerase antibodies (18.1) NYHA functional class III-IV (76.1) DLCO, % of predicted ±18.5 FVC, % of predicted ±22.9 Six-minute walk distance, meters ±108 No interstitial lung disease (47.0) Limited ILD according to Goh s staging system (21.0) Extensive ILD according to Goh s staging system (32.0) 32
33 Baseline characteristics n mean±sd or n (%) n mean±sd Age, years ±11.9 Males (23.5) Diffuse systemic sclerosis (26.3) Limited systemic sclerosis (73.7) mpap, mmhg ±10.6 PCWP, mmhg ±3.4 Cardiac index, L/min/m ±0.8 Pulmonary vascular resistance, WU ±4.6 Anti-centromere antibodies (35.9) Anti-topoisomerase antibodies (18.1) NYHA functional class III-IV (76.1) DLCO, % of predicted ±18.5 FVC, % of predicted ±22.9 Six-minute walk distance, meters ±108 No interstitial lung disease (47.0) Limited ILD according to Goh s staging system (21.0) Extensive ILD according to Goh s staging system (32.0) 33
34 Cluster analysis : 4 clusters C1/C2/C3/C4 C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 34
35 Cluster analysis : 4 clusters C1/C2/C3/C4 C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD 35
36 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD 36
37 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 moderate PAH with normal DLCO without extensive ILD C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD 37
38 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 moderate PAH with normal DLCO without extensive ILD C3 : 16 patients Severe PH (PVR : 19 ± 5 UW) 94 % no ILD or limited ILD Normal FVC but DLCO : 37±12 % 81 % LcSSc ; 50 % ACA ; 12 % anti-topo 1 C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD 38
39 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 moderate PAH with normal DLCO without extensive ILD C3 : 16 patients Severe PH (PVR : 19 ± 5 UW) 94 % no ILD or limited ILD Normal FVC but DLCO : 37±12 % 81 % LcSSc ; 50 % ACA ; 12 % anti-topo 1 severe PAH with low DLCO without extensive ILD C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD 39
40 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 moderate PAH with normal DLCO without extensive ILD C3 : 16 patients Severe PH (PVR : 19 ± 5 UW) 94 % no ILD or limited ILD Normal FVC but DLCO : 37±12 % 81 % LcSSc ; 50 % ACA ; 12 % anti-topo 1 severe PAH with low DLCO without extensive ILD C1 : 94 patients Moderate PH (PVR : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD C2 : 61 patients Moderate PH (PVR : 6 ± 3 UW) 100 % of extensive ILD FVC : 61 % and DLCO : 37±16 % 46 % DcSSc ; 12 % ACA ; 41 % anti-topo 1 40
41 Cluster analysis : 4 clusters C1/C2/C3/C4 C4 : 29 patients Moderate PH (PVR : 6 ± 2 UW) 100 % no ILD or limited ILD Normal FVC and DLCO : 76±16 % 75 % LcSSc ; 25 % ACA ; 20 % anti-topo 1 moderate PAH with normal DLCO without extensive ILD C3 : 16 patients Severe PH (PVR : 19 ± 5 UW) 94 % no ILD or limited ILD Normal FVC but DLCO : 37±12 % 81 % LcSSc ; 50 % ACA ; 12 % anti-topo 1 severe PAH with low DLCO without extensive ILD C1 : 94 patients Moderate PH (RVP : 8 ± 3 UW) 98 % no ILD or limited ILD Normal FVC but DLCO : 45±13 % 84 % LcSSc ; 50 % ACA ; 5 % anti-topo 1 moderate PAH with low DLCO without extensive ILD C2 : 61 patients Moderate PH (PVR : 6 ± 3 UW) 100 % of extensive ILD FVC : 61 % and DLCO : 37±16 % 46 % DcSSc ; 12 % ACA ; 41 % anti-topo 1 moderate PH due to extensive ILD with low DLCO 41
42 mpap C3 C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD C1 C4 C2 ILD 42
43 mpap C3 C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD C1 C4 C2 ILD 43
44 mpap C3 C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD C1 C4 DLCO C2 ILD 44
45 mpap C3 C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD C1 C4 DLCO C2 ILD 45
46 Survival in the 4 clusters Product-Limit Survival Estimates Avec nombre de sujets à risque Survival Estimated Probability C4 C1 C3 C2 C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD Months since PAH diagnosis cluster
47 Survival in the 4 clusters Product-Limit Survival Estimates Avec nombre de sujets à risque Survival Estimated Probability C4 C1 C3 C C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD 3-yr survival C1 : 81 % [95 % confidence interval 71-89] C4 : 87 % [64-98] C2 : 50 % [36-62] C3 : 62 % [34-81] Months since PAH diagnosis cluster
48 Survival in the 4 clusters Product-Limit Survival Estimates Avec nombre de sujets à risque Survival Estimated Probability C4 C1 C3 C C1 : moderate PAH with low DLCO without extensive ILD C2 : moderate PH due to extensive ILD with low DLCO C3 : severe PAH with low DLCO without extensive ILD C4 : moderate PAH with normal DLCO without extensive ILD 3-yr survival C1 : 81 % [95 % confidence interval 71-89] C4 : 87 % [64-98] C2 : 50 % [36-62] C3 : 62 % [34-81] Months since PAH diagnosis cluster Age and sex adjusted with C1 as a reference C2 : HR à 3,14 [95 % CI 1,66-5,94], p < 0,005 C3 : HR à 2,53 [95 % CI 0,99-6,49], p = 0,052 C4 : HR à 0,65 [95 % CI 0,19-2,27], p = 0,507 48
49 Discussion-Conclusion We found 4 clusters in patients with SSc and precapillary PH 2 clusters have a good prognosis : C1 et C4 C1 is the most frequent and corresponds to precapillary PAH, low DLCO and no extensive ILD group 1 & limited ILD or no ILD have the same behavior C4 resembles C1 but DLCO is preserved. Prognosis is even better (87 %) groupe 1 2 clusters have a bad prognosis : C2 et C3 49
50 Discussion-Conclusion 2 clusters have a bad prognosis : C2 et C3 C2 is characterized by 100 % of extensive ILD (& high percentage of DcSSc and anti-topo isomérase) and the worse 3-yr survival (50 %) the presence of an extensive ILD, whatever the hemodynamics, is a major grouping characteristic (group 3) C3 is characterized by a severe PAH with no extensive ILD and a 3- yr survival of 62% (groupe 1) Although completely different, C2 and C3 share a common bad prognosis 50
51 Discussion-Conclusion First study assessing the presence of homogeneous clusters in SSc patients with precapillary PH Helpful for the clinician Severe hemodynamics in SSc patient without an extensive ILD Extensive ILD whatever the hemodynamics are the 2 clusters with a bad prognosis In these patients, an early evaluation in a transplantation center should be performed The presence of a limited ILD or the absence of ILD seem to have the same signification and not to impact the prognosis Remaining questions (not exhaustive) : PVOD? Occult left ventricular dysfunction? 51
52 backup
53 Overall survival : 73.6% at 3 years Product-Limit Survival Estim 1.0 Survival Estimated Probability Months since PAH diagnosis 95% CI N at risk
54 Postcapillary PH Precapillary PH PH in sysemic sclerosis : major heterogeneity idiopathic PH PVOD Mild to severe LcSSc Occult postcapillary PH DcSSc Mild to severe Myocardial fibrosis : 20% Hachulla et al. Ann Rheum Dis 2009 absent ILD extensive 54
55 Postcapillary PH Precapillary PH PH in sysemic sclerosis : major heterogeneity idiopathic PH PVOD Mild to severe 20% of Occult postcapillary PH LcSSc DcSSc Mild to severe Fox B et al. Eur Respir J 2013 absent ILD extensive 55
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