Pulmonary hypertension Goal directed therapy Pulmonary Hypertension Programme University of Toronto FMD

Download Pulmonary hypertension Goal directed therapy Pulmonary Hypertension Programme University of Toronto FMD

Post on 29-Dec-2015

212 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

<ul><li><p>Pulmonary hypertensionGoal directed therapyPulmonary Hypertension ProgrammeUniversity of TorontoFMD</p></li><li><p>Disclaimer (1999)Support fromNo one in particular</p></li><li><p>Disclaimer (2011)Support fromActelionGlaxoPfizerUnited Therapeutics / Northern TherapeuticsGileadLillyBayer</p></li><li><p>GoalsIdentify modifiable and non-modifiableprognostic factors in patients with pulmonaryarterial hypertensionInterpret changes in hemodynamics andother indicators of disease severityRecognize how therapy is targeted inpatients with pulmonary hypertension</p></li><li><p>Dana Point Classification of PHGali N et al. Eur Heart J 2009; 30:2493-537Gali N et al. Eur Resp J 2009; 34:1219-63</p></li><li><p>Caregiver burdenEmergent themes were stresses on physical and mental well-being, Stress on social and personal lives, Threats to financial security and career paths. The interviewees reported a sense of isolation as related to dealing with a disease that is relatively unknown to the majority of friends and family. </p></li><li><p>The unwillingness to admit to their loved-ones, or indeed to themselves, that the caregiver role was taxing, augmented the sense of isolation</p></li><li><p>VasoconstrictorsVasodilatorsAn imbalance...</p></li><li><p>What is it?</p></li><li><p>Echo measures of RV functionTAPSETei Index = (a b) / bEccentricity index</p></li><li><p>Goals of treatmentImprove quality of lifeRestore exercise capacityImprove survival</p></li><li><p>Treatment paradigmAdd therapy for disease progression</p></li><li><p>2005; 25: 244249% of patients (n=169) 12 months 24 monthsDeadOff bosentanOn dual agents</p><p>On bosentan alone</p></li><li><p>Treatment paradigmAdd therapy for disease progression</p><p>Add therapy for failure to reach goals</p></li><li><p>Respiratory Medicine (2010) 104, 1588e1607</p></li><li><p>Respiratory Medicine (2010) 104, 1588e1607</p></li><li><p>McLaughlin VV, et al. Circulation. 2002;106:1477-1482. 020406080100Survival (%) 012243648607284No. at risk16233957048302010MonthsFC=3FC=4p=0.0001 by log-rank test847260483624120100 80 60 40 20 0FC=1No. at risk:FC=2FC=3FC=4Survival (%)MonthsImpact of Functional Class on SurvivalFunctional Class at BaselineFunctional Class at 1715 mos102030466386112115</p></li><li><p>JACC Vol. 40, No. 4, 2002</p></li><li><p>Circulation. 2006;114:1482-1489</p></li><li><p>Circulation. 122(2):164-72, 2010 Jul 13.2Multivariate predictors of 1 year outcome in REVEALPredicting survival in pulmonary arterial hypertension: insights from the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL).Benza RL; Miller DP; Gomberg-Maitland M; Frantz RP; Foreman AJ; Coffey CS; Frost A; Barst RJ; Badesch DB; Elliott CG; Liou TG; McGoon MD</p><p>Figure 2. Cox proportional-hazards estimates for multivariable model of survival, limited to terms included in the final stepwise model. Parameters significantly associated with 1-year survival only in univariable analyses included the Borg dyspnea scale, right ventricular dysfunction, pulmonary vascular resistance (PVR) index, pulmonary capillary wedge pressure, cardiac index, mean pulmonary artery pressure, and total serum bilirubin. Candidate predictor variables that were not significant at the univariable level included Tei index, vasoreactivity, race, newly diagnosed PAH, and income. Missing Borg scale and missing PVR index were both associated with lower-than-average observed survival and were therefore considered candidate predictor variables. APAH indicates associated I PAH; ECHO, echocardiogram; FPAH, familial PAH; mRAP, mean right atrial pressure; PoPH, portopulmonary hypertension; and RHC, right heart catheterization. *Reference category: NYHA/WHO functional class (Fn) II or missing. +If N-terminal proBNP is available and BNP is not, listed cut points are replaced with 1500 pg/mL. ++Restricted to tests performed within 1 year of enrollment; otherwise, the indicator is set to 0.</p></li><li><p>REVEAL observed 1-year survival from time of enrollment according to predicted risk strata.</p><p>Risk 1 yr survivalLow &gt; 95% Average 90-95%Mod high 85-90%High risk 70-85%Very high risk </p></li><li><p>REVEAL observed 1-year survival from time of enrollment according to predicted risk strata.</p><p>Risk 1 yr survivalProtective factors Risk factors (Median) (Median)Low &gt; 95% 11Average 90-95% 0 2Mod high 85-90% 03High risk 70-85% 0 4Very high risk </p></li><li><p>15 possible risk factors4 possible protective factors</p><p>0 - 22</p><p>Actual scores ranged from 1 15With a mean of 7.4</p></li><li><p>Prevalent cases</p><p>Incident cases</p></li><li><p>Combination therapy26 observational studies and 5 randomized trials were identified. </p><p>PDE-5 inhibitor and prostanoids, 6/7 studies reported improvement in 6MWD, 6/8 studies reported improvement in functional class, 6/6 studies reported improvement in hemodynamics and 1/2 trials demonstrated improvement in quality of life and time-to-clinical worsening. ERA and prostanoids, 4/6 studies and 1 trial reported improvement in 6MWD, 3/3 studies and 1/4 trials reported improvement in functional class, 4/5 studies and 1/4 trials reported improvement in PAP. ERA and PDE-5 inhibitor, 4/7 studies reported an improvement in 6MWD, and 2/6 studies report improvement in functional class.</p></li><li><p>Gali N et al. Eur Heart J 2009; 30:2493-537Gali N et al. Eur Resp J 2009; 34:1219-63</p></li><li><p>Gali N et al. Eur Heart J 2009; 30:2493-537Gali N et al. Eur Resp J 2009; 34:1219-63</p></li><li><p>PAH specific therapies are recommended in FC II patientsGali N et al. Eur Heart J 2009; 30:2493-537Gali N et al. Eur Resp J 2009; 34:1219-63</p></li><li><p>ESC/ERS recommendations for FC III patientsGali N et al. Eur Heart J 2009; 30:2493-537Gali N et al. Eur Resp J 2009; 34:1219-63</p></li><li><p>Prognostically important variablesand treatment goals</p></li><li><p>CHEST 2006; 130:214217</p></li><li><p>******</p></li></ul>

Recommended

View more >