Abstract
Health-related quality of life (HRQoL) scores assess symptom burden in pulmonary arterial hypertension (PAH) but data regarding their role in prognostication and risk stratification are limited. We assessed these relationships using the emPHasis-10 HRQoL measure.1745 patients with idiopathic PAH (IPAH), drug-induced PAH (DPAH), heritable PAH (HPAH) (collectively “(I/D/H)PAH”), or connective tissue disease-associated PAH (CTD-PAH), who had completed emPHasis-10 questionnaires at one of six UK referral centres between 2014 and 2017, were identified. Correlations with exercise capacity and World Health Organization (WHO) functional class were assessed, and exploratory risk stratification thresholds were tested.Moderate correlations were seen between emPHasis-10 scores and 6-min walk distance (r=−0.546), incremental shuttle walk distance (r=−0.504) and WHO functional class (r=0.497) (all p<0.0001). Distribution of emPHasis-10 score differed significantly between each WHO functional class (all p<0.0001). On multivariate analysis, emPHasis-10 score, but not WHO functional class, was an independent predictor of mortality. In a risk stratification approach, scores of 0–16, 17–33 and 34–50 identified incident patients with 1-year mortality of 5%, 10% and 23%, respectively. Survival of patients in WHO functional class III could be further stratified using an emPHasis-10 score ≥34 (p<0.01). At follow-up, patients with improved emPHasis-10 scores had improved exercise capacity (p<0.0001) and patients who transitioned between risk groups demonstrated similar survival to patients originally in those risk groups.The emPHasis-10 score is an independent prognostic marker in patients with (I/D/H)PAH or CTD-PAH. It has utility in risk stratification in addition to currently used parameters. Improvement in emPHasis-10 score is associated with improved exercise capacity.
Highlights
Pulmonary arterial hypertension (PAH) is a rare condition, characterised by increased pulmonary vascular resistance (PVR) and progressive right-ventricular failure leading to premature death [1]
Exercise limitation may be objectively assessed by exercise testing, but limitations of day-to-day physical activity are typically assessed by healthcare professionals using the World Health Organisation (WHO) functional class system
The emPHasis-10 score was higher in patients with connective tissue disease-associated PAH (CTD-PAH) (median 30 (19–38)) than in patients with (I/D/H)PAH (median 28 (17–37)) ( p=0.001)
Summary
Pulmonary arterial hypertension (PAH) is a rare condition, characterised by increased pulmonary vascular resistance (PVR) and progressive right-ventricular failure leading to premature death [1]. The importance of assessing patient-reported outcome measures (PROMs) in patients with pulmonary hypertension (PH) is recognised [4, 5] and three PH-specific tools for assessing health-related quality of life (HRQoL) have been developed [6,7,8]. One of these tools, emPHasis-10, is comprised of 10 fields and results in a score out of 50 where a higher score represents a higher symptom burden. Risk stratification has an established central role in the management of patients with PAH, PROMs are not incorporated in current risk assessment tools [12,13,14]
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