Recogni(on & Evalua(on of the Pa(ent with PAH: The need for early diagnosis

Transcription

1 Recogni(on & Evalua(on of the Pa(ent with PAH: The need for early diagnosis James R. Klinger, MD Division of Pulmonary Medicine Rhode Island Hospital Professor of Medicine Alpert Medical School of Brown University Providence, RI

2 Disclosures James Klinger, MD serves as a consultant for or receives research support from : Actelion Bayer Gilead Sciences Ikaria Lung Rx NIH- NHLBI. Pfizer United TherapeuNcs

3 ObjecNve IdenNfy the necessary steps to appropriately diagnose panents with PAH earlier in the course of the disease

4 Pre- test QuesNon 1 The average Nme between symptom onset and diagnosis in panents with pulmonary arterial hypertension is approximately: A) 3 months B) 6 months C) 1 year D) 2 years

5 Pre- test QuesNon 1 Compared to panents in NYHA funcnonal class III or IV, treatment of PAH in NYHA class I or II results in: A) Improved survival B) Fewer hospitalizanons C) The need for fewer medicanons D) Greater improvement from baseline in 6 min walking distance

6 The Challenge to Early Diagnosis of PAH PresenNng symptoms are: Insideous Slowly progressive Similar to other more common diseases PAH is a rare disease Extensive workup necessary to determine a cause of elevated pulmonary artery pressure

7 Difficulty in DisNnguishing PAH Symptoms from Other Diseases Symptoms Dyspnea with exernon Chest discomfort FaNgue Lightheadedness Pedal edema Differen(al Diagnosis COPD Asthma CHF CAD Depression DecondiNoning

8 Prevalence of Group 1 PAH CONDITIONS PREVALENCE * PAH 15 per million IPAH 5.9 per million HPAH Scleroderma Portopulmonary hypertension Congenital heart disease HIV Sickle cell disease Schistosomiasis Chronic hemolytic anemia U.S. families % 1 6% per million 0.5% estimate 32% % Highly variable; currently being studied * Prevalence varies substantially depending on the type, etiology, and underlying condition Reported estimates are based on personal communications Note: Numbers may also reflect differences in diagnostic criteria (e.g., ECHO vs right heart catheterization) and study design (e.g., retrospective vs prospective) Simonneau, et al. J Am Coll Cardiol. 2009;54(1):S43-54.

9 Pulmonary Arterial Hypertension is an Uncommon Cause of PH: Armadale Echocardiography Study Lung CETPH, 0.6% disease/sleep related hypventilation, 9.7% PAH, 2.3% Unknown, 6.8% Congenital heart disease, 1.9% Left heart disease, 78.7% N = 483 of 4579 patients with spap > 40 mm Hg on echocardiography. PSAP = Pulmonary artery systolic pressure Gabbay E, et al. Am J Respir Crit Care Med. 2007;175:A713.

10 The Need for Early Diagnosis

11 PAH is a Progressive CondiNon Mild Disease May include: Inflammation Gaine S. JAMA. 2000; 284: Moderate Disease May include: Inflammation Vasoconstriction Fibrosis Hypertrophy Severe Disease May include: Cell proliferation Plexiform lesions 11

12 Hemodynamic Progression of PAH Presymptomatic/ Compensated Symptomatic/ Decompensating Declining/ Decompensated CO Symptom Threshold PAP PVR RAP Right Heart Dysfunction Time CO, cardiac output; PAP, pulmonary arterial pressure; PVR, pulmonary vascular resistance; RAP, right aterial pressure.

13 Impact of FuncNonal Class on Survival in IPAH 80 FC I 60 FC II FC III FC IV NYHA I or II 0.6 P < NYHA III or IV Months No. at risk 115 Cumulative survival Survival (%) Months No. at risk McLaughlin VV, et al. Circula(on. 2002;106: Sitbon O, et al. J Am Coll Cardiol. 2002;40: NYHA I or II: 91 NYHA III or IV:

14 Delay in Time to Diagnosis PAH Registries Registry Year N Age (yrs) (%) Time to Diagnosis (months) mpap (mmhg) CI l/m2 PCWP (mmhg) NIH ± ± ± ± 4 French Study2* ± ± ± ± ± ± ± ± 3.5 REVEAL3* ± *prevalent and incident cases 1D Alonzo GE et al. Ann Intern Med. 1991;115: Humbert M et al. Circula(on. 2010;122: Badesch DB et al Chest Feb;137(2):

15 Three Quarters of Newly Diagnosed PAH PaNents Present with Advanced Disease Study French Registry1 NYHA I NYHA NYHA III NYHA IV 1% 24% 63% 12% 61.3% 12.3% REVEAL Registry2 1Humbert M et al. Circula(on. 2010;122: Badesch DB et al Chest Feb;137(2):

16 DiagnosNc Goals

17 RecogniNon

18 Clinical Presenta-on History Exam (PH) Dyspnea (86%) Loud P2 (listen at apex) RV lift (left parasternal fingertips) RV S3, S4 Systolic murmur (TR; inspiratory augmentation) Fatigue (27%) Chest pain (22%) Edema (22%) Syncope (17%) Dizziness (15%) Early systolic click Cough (14%) Midsystolic ejection Palpitations (13%) murmur Diastolic murmur (PR) Exam (RV Failure) JVD; increased A wave, V wave; hepatojugular reflex Pulsatile liver Hepatomegaly Edema Ascites Low BP, low PP, cool extremities Adapted from McLaughlin VV et al. J Am Coll Cardiol. 2009;53: REVEAL. Brown LM et al. Chest. 2011;140:19-26.

19 Electrocardiogram Associated With Right Ventricular Hypertrophy (RVH) Image courtesy of Vallerie McLaughlin, MD

20 Chest X- ray

21 Manifesta(on of PAH on Echocardiogram RV enlargement RA enlargement Septal straightening Loss of IVC inspiratory collapse Tricuspid regurgitation Pericardial effusion Decreased RV systolic dysfunction TAPSE (tricuspid annular plane systolic excursion) TAPSE 2.3 cm TAPSE 1.5 cm Relatively preserved RV function RV dysfunction McLaughlin VV et al. J Am Coll Cardiol. 2009;53:

22 EvaluaNon

23 Pivotal Tests Contingent Tests ACCF/AHA Diagnostic Algorithm History Exam CXR ECG Echocardiogram Index of Suspicion of PH TEE Exercise Echo VQ Scan Pulmonary Angiography Chest CT Angiogram Coagulopathy Profile PFT s ABG s Overnight Oximetry Polysomnography Other CTD Serologies Chronic PE Ventilatory Function Gas Exchange Sleep Disorder Scleroderma, SLE, RA Portopulmonary HTN LFT s Establish Baseline Prognosis Functional Test (6MWT, CPET) RH Cath RVE, RAE, RVSP, RV Function Left Heart Disease VHD, CHD HIV Infection HIV ANA Contribute to Assessment of: Vasodilator Test Exercise RH Cath Volume Loading Left Heart Cath McLaughlin VV, et al. J Am Coll Cardiol. 2009;53: Confirmation of PH Hemodynamic Profile Vasodilator Response

24 Palerns on Echo: PAH vs PVH PAH Pulmonary Venous HTN 2-D echo Normal LA, LV size; small LV (< 3.5 cm) Dilated LA and/or LV No LVH ± LVH NL to high EF Variable EF RV:LV > 1.0 RV:LV < 1.0 RV apex sharing RV stops short of apex Septal flattening (systole and/or diastole) LV remains round in short axis (LV pushback) Pericardial effusion No effusion Doppler Variable PASP Variable PASP No MR 2 plus MR or greater E<A E > A (pseudonormal or restrictive)

25 Right Heart CatheterizaNon for PAH Measures: Pulmonary arterial pressure (PAP) Cardiac output (CO) Right atrial pressure (RAP) Pulmonary arterial wedge pressure (PAWP) Pulmonary and systemic vascular resistance RaNonale for use Confirm the diagnosis Assess severity of hemodynamic impairment Test pulmonary vasoreacnvity Determine prognosis Galie, et al. Eur Heart J. 2009;30:

26 Is There a Reason to Suspect PAH? Evalua(on for CTEPH Not a PAH subgroup, but: Cannot be missed Is potennally curable with thromboendarterectomy (PEA) 3% to 4% of acute PE do not ennrely resolve One half of those with CTEPH do not have an apparent history of acute PE Normal VQ scan excludes chronic PE CT angiogram can detect chronic clot (but the radiologist should be experienced when interprenng the imaging distal disease can be subtle) McLaughlin VV et al. J Am Coll Cardiol. 2009;53:

27 Is There a Reason to Suspect PAH? VQ Scan Idiopathic Pulmonary Arterial Hypertension Chronic Pulmonary Embolism

28 Does Screening Help?

29 PAH Symptoms + RHC No PAH Symptoms + TRV > 3 + RHC Humbert M, et al. Arthritis Rheum Nov;63(11):

30 Efficacy of Treatment in PAH Pa(ents Func(onal Class II The EARLY Study Time to Clinical Worsening Change in PVR (primary endpoint) Change in 6 min Walk Distance Galie N et al. Lancet 21;371(9630):

31 Piqalls of Screening by Echocardiography 570 panents screened 33 referred for RHC 14 diagnosed with PAH Prevalence 2.5% False posinve rate 19/33 = 57.6% False neganve rate?/537 =???

32 Does the use of MulNple DiagnosNc Tests Aid in the Screening of PAH? BNP 6 min walk distance PFTs Exercise stress test

33 Sickle Cell Patients Screened for PH (exploratory analysis) Parent F et al. N Engl J Med Jul 7;365(1):44-53.

34 Algorithm for DETECTing PAH in Systemic Sclerosis Steen VD et al. Arthritis Rheum Jul;35(7): Coghlan JG, Ann Rheum Dis Jul;73(7):

35 Screening Guidelines: PaNents With Known Risk for PAH Substrate Further Assessment Rationale Known BMPR2 mutation Echo yearly; RHC if echo shows evidence of PAH Early PAH detection; 20% chance of developing PAH Systemic sclerosis* Echo yearly; RHC if echo shows evidence of PAH 8% prevalence of PAH HIV Echo if symptomatic; RHC if echo shows evidence of PAH 0.5% prevalence of PAH Portal hypertension Echo if OLT considered; RHC if echo shows evidence of PAH 4% prevalence of PAH; predictive of poor outcome Congenital heart disease Echo and RHC at diagnosis; consider repair of L-R shunt defect High PAH probability if unrepaired (Eisenmenger) % FVC *Systemic sclerosis: consider echocardiogram if % DLCO >1.6 or unexplained declining DLCO. McLaughlin VV et al. J Am Coll Cardiol. 2009;53:

36 Screening RecommendaNons for High Risk PaNents - 5th WHO Conference on PH Hoeper MM et al. J Am Coll Cardiol Dec 24;62(25 Suppl):D42-50.

37 Post- test QuesNon 1 The average Nme between symptom onset and diagnosis in panents with pulmonary arterial hypertension is approximately: A) 3 months B) 6 months C) 1 year D) 2 years

38 Post- test QuesNon 2 Compared to panents in NYHA funcnonal class III or IV, treatment of PAH in NYHA class I or II results in: A) Improved survival B) Fewer hospitalizanons C) The need for fewer medicanons D) Greater improvement from baseline in 6 min walking distance

39 Summary PAH is usually diagnosed late in the course of the disease long ater the onset of symptoms PAH should be considered in all panents with unexplained symptoms of dsypnea, fangue, exernonal chest pain or syncope PaNents at high risk of developing PAH should be considered for regular screening with echocardiography, PFTs, BNP