Treatment Goals of Pulmonary Hypertension
Key result
Revised composite treatment goals better predict long-term outcomes in pulmonary arterial hypertension.
Why the study?
With advances in pulmonary arterial hypertension therapy, identifying clinically relevant treatment goals that correlate with long-term outcomes has become critical.
Structured PICO
P
Population
Patients with pulmonary arterial hypertension
I
Intervention
Achieving composite treatment goals including modified NYHA class I or II, 6-min walk distance ≥ 380 to 440 m, cardiopulmonary exercise testing, BNP normalization, normal/near-normal right ventricular size and function, and normalized hemodynamics
O
Outcome
Long-term outcome prediction and prognostication
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“[But] if we can't explain a reason, we will do a cardiopulmonary exercise test, which might give us a better idea than the six-minute walk test,”
“a simple, reproducible, and clinically important assessment tool and prognostic measure in PAH patients, both at the time of diagnosis and at follow-up during PAH treatment,”
Implication
More robust, composite treatment goals integrating exercise capacity and right ventricular function markers are required for accurate long-term prognostication in modern pulmonary arterial hypertension management.
Abstract
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).
Discussion
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Cite This Study
McLaughlin et al. (2013) conducted a review in Pulmonary arterial hypertension. Revised composite treatment goals, incorporating exercise capacity and noninvasive right heart function assessments, are proposed to better predict long-term outcomes in pulmonary arterial hypertension.