ACTIVITY DESCRIPTION Target Audience Learning Objectives

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2 ACTIVITY DESCRIPTION Target Audience This continuing medical education activity is planned to meet the needs of primary care physicians who can contribute to early detection of disease and who are responsible for the long-term management of patients with PAH. Learning Objectives At the conclusion of the educational activity, the learner should be able to: Describe the pathophysiology of pulmonary arterial hypertension (PAH) and how early and aggressive treatment is essential for improved patient outcomes. Identify patients for PAH screening and utilize diagnostic approaches for early detection and referral of PAH patients. Discuss the role of primary care providers as part of the interprofessional healthcare team in the long-term management of patients with PAH.

3 FACULTY AND DISCLOSURE Trushil Shah, MD, MS Assistant Professor of Internal Medicine UT Southwestern Medical Center Dallas, TX Dr. Trushil Shah, MD has relevant financial relationships with the following commercial interests: Advisory Board: Gilead Sciences Research Support: Gilead Sciences and Actelion Pharmaceuticals Dr. Shah does not intend to discuss any off-label uses. No (other) speakers, authors, planners or content reviewers have any relevant financial relationships to disclose. Content review confirmed that the content was developed in a fair, balanced manner free from commercial bias. Disclosure of a relationship is not intended to suggest or condone commercial bias in any presentation, but it is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

4 Pulmonary Hypertension: Definitions Pulmonary Hypertension: Mean pulmonary arterial pressure (mpap) 25 mm Hg at rest on right heart catheterization (RHC) Pulmonary arterial hypertension (PAH): Mean pulmonary arterial pressure 25 mm Hg PCWP 15 mm Hg PVR >3 Woods units PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance Hoeper MM, et. al. J Am Coll Cardiol. 2013;62(25 Suppl):D42-50.

5 WHO Classification of Pulmonary Hypertension (Dana Point) Group 1: Pulmonary Arterial Hypertension Group 2: Pulmonary Hypertension Secondary to Left Heart Disease Group 3: Pulmonary Hypertension Secondary to Lung Disease and/or hypoxia Group 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH) Group 5: PH with Unclear Multifactorial Mechanisms Hemolytic disorders Metabolic disorders Sarcoidosis Simonneau G, et al. J Am Coll Cardiol. 2013;62(25 Suppl):D34-41.

6 ARS Question What is the most common cause of pulmonary hypertension? 1. Pulmonary arterial hypertension 2. Pulmonary hypertension secondary to left heart disease 3. Pulmonary hypertension secondary to lung disease 4. Chronic thromboembolic pulmonary hypertension

7 Left Heart Disease is Most Common Cause of PH Detected During Echocardiography PAH, 2.7% Unknown, 15.4% CTEPH, 2.0% Lung disease, Sleep-related hypoventilation, 9.3% Miscellaneous, 2.7% Left heart disease, 67.9% N=936 of 10,314 patients with echo pulmonary artery systolic pressure (PASP) >40 mm Hg. Strange G, et al. Heart. 2012;98:

8 World Health Organization (WHO) Group 1 PAH Classification of REVEAL (US Registry) Patients at Enrollment APAH, associated PAH; IPAH, idiopathic PAH; FPAH, familial PAH; PCH, pulmonary capillary hemangiomatosis; PPHN, persistent pulmonary hypertension; PVOD, pulmonary veno-occlusive disease; CVD/CTD, collagen vascular disease/connective tissue disease; CHD, congenital heart disease; HT, hypertension. Frumkin LR. Pharmacol Rev. 2012;64:

9 Patient Case: Nancy 40-year-old female with dyspnea on exertion and chest pressure for 2 months presents to clinic She reports occasional dizziness on exertion and one episode of syncope while walking her dog Admits to taking diet drugs for 2 years in 1990s and lost 40 pounds with this

10 History No past medical history No medications No drug allergies Family History: Father had coronary artery disease at age 70, no other medical history Social history: Drinks a glass of wine occasionally, never smoker, no illicit drug use

11 Physical Exam BP: 100/70, HR: 92, RR: 16, Temp: Normal, Wt.: 135 lb., Ht.: 5 4 JVD ~14 cm Clear lungs. No wheezes or rhonchi. Regular rate and rhythm, normal S1, loud P2, 3/6 holosystolic murmur best heard at left sternal border in 4 th intercostal space Trace pedal edema JVD, jugular vein distension

12 ARS Question What would you do next? 1. Refer to pulmonary hypertension specialist 2. Right heart catheterization 3. Transthoracic echocardiogram 4. CT pulmonary angiogram

13 High Index of Suspicion is Key Review of systems should include: Full connective tissue disease review of system Review of use of illicit drugs, smoking and alcohol Family history (familial PAH and connective tissue disease) Sexual history (HIV) DVT/PE/miscarriages (CTEPH) Congenital heart disease Anemia/hematological disorders/splenectomy Lung disease

14 Products Associated with PAH Galiè N, et al. Eur Respir J. 2016;37:

15 Presenting Symptoms in 2733 Patients in REVEAL Registry Dyspnea on exertion Fatigue Edema Chest pain/discomfort Presyncope/syncope Dizziness/lightheadedness Cough Palpitations Dyspnea at rest Raynaud's phenomenon Percentage Brown LM, et. al. Chest. 2011;140:19-26.

16 Clues to Diagnosis EKG, Chest x-ray, PFTs, CT pulmonary angiogram, etc. may be available and can give important clues to diagnosis Follow your usual work-up for dyspnea on exertion Always use available data PFTs, pulmonary function tests

17 EKG Findings in PH Right axis deviation Right ventricular hypertrophy Right atrial enlargement Repolarization abnormality

18 Radiographic Findings in PAH

19 CT Findings in PAH

20 CT Findings in PAH

21 Pulmonary Function Tests Mild restriction is common Mild decrease in DLCO If severe restriction or reduction in DLCO, then likely has concomitant ILD (especially with scleroderma patients) or PVOD DLCO, diffusing capacity of the lungs for carbon monoxide; ILD, interstitial lung disease; PVOD, pulmonary veno-occlusive disease

22 Nancy s Transthoracic Echocardiogram

23 Dilated Right Ventricle: RV is larger than LV Right Atrial enlargement

24 Septal Flattening

25 PASP is Estimated Using Tricuspid Regurgitant Jet Velocity PASP=RVSP in the absence of pulmonic outflow obstruction Modified Bernoulli Equation RVSP= 4(V TR ) 2 + RAP PASP, pulmonary artery systolic pressure; RVSP, right ventricle systolic pressure; RAP, right atrial pressure Barnett C, et al. JAMA. 2008;299:

26 Galiè N, et al. Eur Respir J. 2016;37: Echocardiography

27 Echocardiographic Signs Used to Assess the Probability of PH (in Addition to Tricuspid Regurgitation Velocity) Galiè N, et al. Eur Respir J. 2016;37:

28 ARS Question What should we do next? 1. Start sildenafil 2. Start ambrisentan 3. Obtain VQ scan 4. Obtain pulmonary function test VQ, ventilation-perfusion

29 VQ Scan Significant number of patients with CTEPH do not have a prior history of PE/DVT CTEPH is the only form of PH that is treatable with surgery (i.e., pulmonary endarterectomy) Mortality from pulmonary endarterectomy <5% at expert centers

30 Nancy s VQ scan

31 Abnormal VQ scan in a patient with CTEPH

32 ARS Question What next? 1. Pulmonary angiogram 2. Right heart catheterization 3. Start sildenafil 4. Start macitentan

33 Assessment of Pressures as the Catheter Passes Through the Heart Murray & Nadel s Textbook of Respiratory Medicine, 6 th ed, Elsevier 2016.

34 Pulmonary Hemodynamics in Different Groups of Pulmonary Hypertension Left heart disease: High PCWP and normal PVR VC RA RV PA PV LA LV PC Aorta Normal PCWP ( 15 mm Hg) and High PVR Pulmonary Arterial Hypertension PH secondary to lung disease CTEPH PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; VC, vena cava; RA, right atrium; RV, right ventricle; PA, pulmonary artery; PC, pulmonary capillaries; PV, pulmonary veins; LA, left atrium; LV, left ventricle

35 2015 ESC/ERS Diagnostic Algorithm Galiè N, et al. Eur Respir J. 2016;37:

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37 PAH Medication Targets

38 2015 ESC/ERS Recommendations for Monotherapy for PAH (Group 1) Galiè N, et al. Eur Respir J. 2016;37:

39 Why is it Important to Know About This Disease and Recognize it Early? Median time to diagnosis of PAH from symptom onset by RHC in 1980s was 1.3 years In 2000 s median time to diagnosis of PAH from symptom onset is still 1.1 years Rich S, et al. Ann Intern Med. 1987;107: Badesch DB, et al. Chest. 2010;137:

40 Modern PAH Therapy has Reduced Mortality from this Disease Significantly Benza RL, et al. Chest. 2012;142:

41 Factors That Play a Role in Delay in Diagnosis Obstructive airway disease (OR 1.93) Obstructive sleep apnea (OR 1.72) Age <36 years (OR 3.07) Six-minute walk distance <250 meters (OR 1.91) Brown LM, et al. Chest. 2011;140:19-26.

42 Role of Primary Care Physician Identify PAH early Refer to expert PAH center early for management Help co-manage co-existing conditions or underlying conditions Help co-manage drug side effects Be aware of drug interactions with pulmonary vasodilators Help with diuretic management Counsel patient regarding contraception and avoiding pregnancy

43 Management of Associated Conditions Connective tissue diseases (CTDs) like SLE, scleroderma, rheumatoid arthritis and myositis Anticoagulation management Though, to date, no immunosuppressive therapy has been proven to be effective for PAH in CTD-associated PAH, flares of these conditions need to be promptly identified and treated SLE, systemic lupus erythematosus

44 Common Side Effects PDE-5 inhibitors Nose bleeds Headache Dyspepsia Flushing Visual disturbances Diarrhea Endothelin Receptor Antagonists Peripheral edema Flushing Headache Dyspepsia Anemia Nasal congestion Elevated liver enzymes (esp. bosentan) Prostaglandins and Prostanoids Nausea, vomiting Flushing Jaw pain Headache Myalgia Hyperthyroidism (selexipag) Diarrhea Skin rash

45 ARS Question Which medication is contraindicated in patients on PDE-5 inhibitor therapy? 1. Azithromycin 2. Levofloxacin 3. Aspirin 4. Sublingual nitroglycerin

46 Drug Safety and Interactions PDE-5 inhibitors Avoid nitrates: can cause lifethreatening hypotension Avoid use with riociguat Protease inhibitors Endothelin receptor antagonists Teratogenic Prostaglandins Selexipag should not be used with gemfibrozil

47 Avoiding Pregnancy Patients with pulmonary hypertension do not tolerate physiological changes in pregnancy like increased plasma volume, increased cardiac output, and decreased systemic vascular resistance (SVR) well and often decompensate Pieper PG, et al. Best Pract Res Clin Obstet Gynaecol. 2014;28:

48 Preventing Pregnancy in PAH Advise patients to use at least 2 methods of contraception (generally IUD/progesterone implant/depot + condoms) Endothelin receptor antagonist and riociguat are teratogenic and pregnancy category X Selexipag is pregnancy category B1 and should be avoided

49 Communication with PAH Specialists Diuretic management Cardio-renal syndrome (oftentimes, BMPs will have elevated creatinine) Worsening of symptoms Worsening of associated conditions Any new PAH-related symptoms BMP, basic metabolic panel