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Updated treatment algorithm of pulmonary arterial hypertension.

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The demands on a pulmonary arterial hypertension (PAH) treatment algorithm are multiple and in some ways conflicting. The treatment algorithm usually includes different types of recommendations with varying degrees of scientific evidence. In addition, the algorithm is required to be comprehensive but not too complex, informative yet simple and straightforward.

The type of information in the treatment algorithm are heterogeneous including clinical, hemodynamic, medical, interventional, pharmacological and regulatory recommendations. Stakeholders (or users) including physicians from various specialties and with variable expertise in PAH, nurses, patients and patients' associations, healthcare providers, regulatory agencies and industry are often interested in the PAH treatment algorithm for different reasons. These are the considerable challenges faced when proposing appropriate updates to the current evidence-based treatment algorithm.The current treatment algorithm may be divided into 3 main areas: 1) general measures, supportive therapy, referral strategy, acute vasoreactivity testing and chronic treatment with calcium channel blockers; 2) initial therapy with approved PAH drugs; and 3) clinical response to the initial therapy, combination therapy, balloon atrial septostomy, and lung transplantation. All three sections will be revisited highlighting information newly available in the past 5 years and proposing updates where appropriate.

The European Society of Cardiology grades of recommendation and levels of evidence will be adopted to rank the proposed treatments.

Treatment goals of pulmonary hypertension.

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With significant therapeutic advances in the field of pulmonary arterial hypertension, the need to identify clinically relevant treatment goals that correlate with long-term outcome has emerged as 1 of the most critical tasks.

Current goals include achieving modified New York Heart Association functional class I or II, 6-min walk distance >380 m, normalization of right ventricular size and function on echocardiograph, a decreasing or normalization of B-type natriuretic peptide (BNP), and hemodynamics with right atrial pressure <8 mm Hg and cardiac index >2.5 mg/kg/min(2). However, to more effectively prognosticate in the current era of complex treatments, it is becoming clear that the "bar" needs to be set higher, with more robust and clearer delineations aimed at parameters that correlate with long-term outcome; namely, exercise capacity and right heart function. Specifically, tests that accurately and noninvasively determine right ventricular function, such as cardiac magnetic resonance imaging and BNP/N-terminal pro-B-type natriuretic peptide, are emerging as promising indicators to serve as baseline predictors and treatment targets.

Furthermore, studies focusing on outcomes have shown that no single test can reliably serve as a long-term prognostic marker and that composite treatment goals are more predictive of long-term outcome.

It has been proposed that treatment goals be revised to include the following: modified New York Heart Association functional class I or II, 6-min walk distance ≥380 to 440 m, cardiopulmonary exercise test-measured peak oxygen consumption >15 ml/min/kg and ventilatory equivalent for carbon dioxide <45 l/min/l/min, BNP level toward "normal," echocardiograph and/or cardiac magnetic resonance imaging demonstrating normal/near-normal right ventricular size and function, and hemodynamics showing normalization of right ventricular function with right atrial pressure <8 mm Hg and cardiac index >2.5 to 3.0 l/min/m(2).

Clinical Significance of Downstaging in Patients With Limited-Disease Small-Cell Lung Cancer.

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We investigated the effect of downstaging on OS in LD-SCLC patients treated with first-line treatment.

PATIENTS AND METHODS: We retrospectively reviewed 210 LD-SCLC patients who were treated with first-line treatment at Seoul National University Hospital between April 1999 and November 2012. Compared with initial tumor, node, metastases (TNM) stage, cases that showed a lower TNM stage after treatment were defined as 'downstaging.' The relationship between downstaging and OS was analyzed, and a subgroup analysis on the responders was performed.

RESULTS: After first-line treatment, 78 (37.1%) patients achieved complete response, 97 (46.2%) achieved PR, and 35 (16.7%) experienced stable disease or progressive disease. A hundred and fifty one patients (71.9%) showed downstaging of their diseases, and the remaining 59 patients (28.1%) showed no change or upstaging. The median OS for patients achieving downstaging and no change/upstaging were 32.8 months and 13.1 months, respectively (P < .001). Of the 97 patients who achieved PR, the OS was significantly longer in patients who showed downstaging than those who did not (25.8 months vs. 13.8 months, respectively; P = .004). In multivariate analyses, female sex, downstaging, lower initial TNM stage, and prophylactic cranial irradiation were independent good prognostic factors for OS.

CONCLUSION: Downstaging might be an independent good prognostic factor in LD-SCLC. Specifically, downstaging is expected to be useful for stratification of patients achieving PR. Further prospective studies are warranted to verify whether patients who achieved PR without downstaging can be candidates for consolidation treatments after first-line treatment.

Assessment of health status in patients with newly diagnosed chronic obstructive pulmonary disease.

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Assessment of health status in patients with newly diagnosed chronic obstructive pulmonary disease.

PLoS One. 2013;8(12):e82782

Authors: Gao Y, Hou Q, Wang H

Abstract
SUBJECT: Chronic obstructive pulmonary disease (COPD) is a common disease worldwide. This study aimed to investigate the health status of patients with newly diagnosed COPD.
METHODS: A total of 45 healthy controls and 218 patients with newly diagnosed COPD were recruited. Pulmonary function test (PFT) values, COPD assessment test (CAT) scores, exacerbation history, and demographics were recorded.
RESULTS: Forced expiratory volume in 1 s percent (FEV1%) predicted was significantly decreased and the CAT score was significantly increased in patients with COPD compared with healthy controls (P <0.001). Among the COPD patients, the most commonly reported respiratory symptoms were cough (86.7%), sputum (80.3%), and dyspnea (45%). A total of 86.2% patients were in the moderate or severe stage (spirometric classification) of COPD, and 71.5% were in Group C or Group D (combined assessment). A total of 33.9% of the patients had 2 or more exacerbations in the previous year. Nearly half of the patients (45.4%) had a high CAT score of ≥10. Patients with a history of more exacerbations had a higher CAT score.
CONCLUSIONS: Most COPD patients were symptomatic and appeared to have moderate to severe airflow limitation or a high risk of exacerbation before definitely being diagnosed with COPD using the PFT.

PMID: 24349360 [PubMed - in process]

Prevalence of COPD and Tobacco Smoking in Tunisia - Results from the BOLD Study.

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Prevalence of COPD and Tobacco Smoking in Tunisia - Results from the BOLD Study.

Int J Environ Res Public Health. 2013;10(12):7257-71

Authors: Daldoul H, Denguezli M, Jithoo A, Gnatiuc L, Buist S, Burney P, Tabka Z, Harrabi I

Abstract
In Tunisia, there is a paucity of population-based data on Chronic Obstructive Pulmonary Disease (COPD) prevalence. To address this problem, we estimated the prevalence of COPD following the Burden of Lung Disease Initiative. We surveyed 807 adults aged 40+ years and have collected information on respiratory history and symptoms, risk factors for COPD and quality of life. Post-bronchodilator spirometry was performed and COPD and its stages were defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Six hundred and sixty one (661) subjects were included in the final analysis. The prevalence of GOLD Stage I and II or higher COPD were 7.8% and 4.2%, respectively (Lower Limit of Normal modified stage I and II or higher COPD prevalence were 5.3% and 3.8%, respectively). COPD was more common in subjects aged 70+ years and in those with a BMI < 20 kg/m2. Prevalence of stage I+ COPD was 2.3% in <10 pack years smoked and 16.1% in 20+ pack years smoked. Only 3.5% of participants reported doctor-diagnosed COPD. In this Tunisian population, the prevalence of COPD is higher than reported before and higher than self-reported doctor-diagnosed COPD. In subjects with COPD, age is a much more powerful predictor of lung function than smoking.

PMID: 24351745 [PubMed - in process]

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