THE ROLE OF PROVOCATIVE TESTING DURING HEMODYNAMIC ASSESSMENT TO IMPROVE PULMONARY HYPERTENSION DIAGNOSIS IN OLDER ADULTS

Abstract

BACKGROUND Pulmonary Hypertension (PH) complicates cardiac and respiratory diseases. Hemodynamic classification of PH broadly defines 2 subsets: pulmonary arterial hypertension (PAH) and PH of left heart disease (PH-LHD). In older patients, particularly with cardiovascular risk factors, clinical and hemodynamic characteristics of PAH and PH-LHD overlap. Thus clinicians face a therapeutic dilemma; PAH therapy may be underutilized in PAH patients to avoid inadvertent administration to PH-LHD patients. Our goal was to evaluate the utility of right heart catheterization(RHC) with exercise to support clinical decisions regarding use of PAH therapy in older adults suspected of having PH with risk factors for PH-LHD. METHODS AND RESULTS Retrospective cohort study of patients referred by a PH program for RHC with exercise to evaluate suspected or confirmed PH, between 2017-2020. Consecutive patients >50 years and at least 1 cardiovascular risk factor (BMI>30kg/m2, HTN, diabetes, hypercholesterolemia, ischemic heart disease, atrial fibrillation(AF)) were included. Primary outcome: use of PAH therapy at the time of RHC and in follow-up. Secondary outcomes: patient reported quality of life (QOL) at time of RHC and in follow-up, using SF36 assay. 61 patients were included in our study, mean age:69±10 years, 56% women. Over 90% patients has 2 or more risk factors for PH-LHD, 34% had a history of AF. At time of RHC, although more than 30% were known to have PH, PAH therapy was prescribed to 20% of patients; phosphodiesterase type 5 inhibitors (PDE5i) n=9, endothelin antagonists (ETA) n=1, and dual therapy (PDE5i+ETA) n=1. Baseline RHC demonstrated no PH in 22 patients (36%) and PH in 39 (64%): 27 with PAH, and 12 with PH-LHD. After exercise RHC, 14 (23%) had no PH, 44 were diagnosed with PH:16 with PAH and 28 with PH-LHD. In follow-up, the proportion of cohort treated with PAH therapy increased to 28%, mostly patients confirmed to have PAH at rest and exercise. PAH therapy included single PDE5i (8 patients), single ETA (5 patients), or combination therapy (with 2 or more PAH medications, 4 patients). Improvement in the physical functioning (median 10, IQR 23.8) and overall health (median 25, IQR 43.8) aspects of QOL were seen at 1 year follow-up. CONCLUSION Among patients with suspected or confirmed PH, and high burden of cardiovascular risk factors, use of PAH therapies is low. Exercise RHC increased the proportion of patients diagnosed with PH and shifted the classification in a proportion from PAH to PH-LHD. QOL improved as well. Pulmonary Hypertension (PH) complicates cardiac and respiratory diseases. Hemodynamic classification of PH broadly defines 2 subsets: pulmonary arterial hypertension (PAH) and PH of left heart disease (PH-LHD). In older patients, particularly with cardiovascular risk factors, clinical and hemodynamic characteristics of PAH and PH-LHD overlap. Thus clinicians face a therapeutic dilemma; PAH therapy may be underutilized in PAH patients to avoid inadvertent administration to PH-LHD patients. Our goal was to evaluate the utility of right heart catheterization(RHC) with exercise to support clinical decisions regarding use of PAH therapy in older adults suspected of having PH with risk factors for PH-LHD. Retrospective cohort study of patients referred by a PH program for RHC with exercise to evaluate suspected or confirmed PH, between 2017-2020. Consecutive patients >50 years and at least 1 cardiovascular risk factor (BMI>30kg/m2, HTN, diabetes, hypercholesterolemia, ischemic heart disease, atrial fibrillation(AF)) were included. Primary outcome: use of PAH therapy at the time of RHC and in follow-up. Secondary outcomes: patient reported quality of life (QOL) at time of RHC and in follow-up, using SF36 assay. 61 patients were included in our study, mean age:69±10 years, 56% women. Over 90% patients has 2 or more risk factors for PH-LHD, 34% had a history of AF. At time of RHC, although more than 30% were known to have PH, PAH therapy was prescribed to 20% of patients; phosphodiesterase type 5 inhibitors (PDE5i) n=9, endothelin antagonists (ETA) n=1, and dual therapy (PDE5i+ETA) n=1. Baseline RHC demonstrated no PH in 22 patients (36%) and PH in 39 (64%): 27 with PAH, and 12 with PH-LHD. After exercise RHC, 14 (23%) had no PH, 44 were diagnosed with PH:16 with PAH and 28 with PH-LHD. In follow-up, the proportion of cohort treated with PAH therapy increased to 28%, mostly patients confirmed to have PAH at rest and exercise. PAH therapy included single PDE5i (8 patients), single ETA (5 patients), or combination therapy (with 2 or more PAH medications, 4 patients). Improvement in the physical functioning (median 10, IQR 23.8) and overall health (median 25, IQR 43.8) aspects of QOL were seen at 1 year follow-up. Among patients with suspected or confirmed PH, and high burden of cardiovascular risk factors, use of PAH therapies is low. Exercise RHC increased the proportion of patients diagnosed with PH and shifted the classification in a proportion from PAH to PH-LHD. QOL improved as well.