1b) @AlbertaPHdoc from #Edmonton will be discussing Multidimensional, Serial #RiskAssessment in #PAH: How, Why, and Then What to Individualize Goal-Directed Therapy. It's all about 🫁 !
— cardio-met (@cardiomet_CE) April 26, 2023
👋@bmprii @SandeepSahayMD @LucillaPiccari @PVRI @OSitbon @jeanlucvachiery @PGeorgeMD
3) Let’s start with a case: 33♂️ presents to #emergencymedicine w/ dyspnea x 6m + two episodes exertional syncope.
— cardio-met (@cardiomet_CE) April 26, 2023
Hx: regular methamphetamine use >6 years ago, smoking; active #HIV infection, intermittently taking anti-retroviral Rx, but not always adherent. No other meds.
5) Initial labs ➡️NT-proBNP = 12,000 ng/L, #lymphopenia with a #CD4+ count of 130. Viral load is elevated & liver enzymes are very high – ALT 1200, AST 1200, Bilirubin 27 IU/L. He has acute kidney injury #AKI with Cr 300 and eGFR of 32. His chest X-ray is below: pic.twitter.com/IQNkKLyYXK
— cardio-met (@cardiomet_CE) April 26, 2023
7) Answer: A. He has 2 #riskfactors for pulmonary arterial hypertension (Group 1 #PH): both methamphetamine & HIV are assoc'd w/ #PAH. The clear lungs argue against #LV failure & no signs of #PJP. #DVT+#PE could also explain presentation, but less likely to ➡️ bilateral edema.
— cardio-met (@cardiomet_CE) April 26, 2023
9) You arrange an urgent right heart catheterization #RHC: RA 12, RV 65/7, EDP 19, PA 61/21 with mean 39, PAWP 12, CO 2.43, CI 1.28, SVI 12, PVR 11 Wood units. MvO2 44%. There is no response to inhaled nitric oxide #iNO.
— cardio-met (@cardiomet_CE) April 26, 2023
11) How would you assess this patient’s risk to determine his treatment?
— cardio-met (@cardiomet_CE) April 26, 2023
13) There are several approaches to risk assessment in #PAH. The REVEAL 2.0 score is an updated version of the original #REVEAL score derived from a large 🇺🇸 registry.
— cardio-met (@cardiomet_CE) April 26, 2023
REVEAL original: 🔓 https://t.co/y1FHUuft3K
REVEAL 2.0 🔓 https://t.co/YbQXzCqufX pic.twitter.com/3DrwyVmciu
15) REVEAL Lite 2 is an abbreviated version of #REVEAL 2.0, uses 6 variables (#BNP/NT-proBNP, #6MWD, #NYHA Functional Class, SBP < 110 mm Hg, HR >96 bpm, renal insuff) & retains ability to discriminate pts into Low, Intermediate, & High risk groups.
— cardio-met (@cardiomet_CE) April 26, 2023
🔓 https://t.co/PRI8zL6Evp pic.twitter.com/xZNMs9cysc
17) Using the 4-strata approach during follow-up nicely identifies groups with distinct survival trajectories.
— cardio-met (@cardiomet_CE) April 26, 2023
🔓 https://t.co/D1XcC5vRMf pic.twitter.com/NVaNEdnYGI
19) This study showed that for patients in functional class II, expert clinicians frequently categorized patients as low risk when, in fact, many were at intermediate or high-risk using objective risk assessment tools. pic.twitter.com/sJK0PqbT0I
— cardio-met (@cardiomet_CE) April 26, 2023
21) Answer: D. No matter which way we slice it, this pt is high risk. Using the ESC/ERS table, REVEAL 2.0 & 2.0 Lite, he is hi risk. He is NYHA class III but has syncope, severe hemodynamics w/⬆️ RAP, ⬇️ CI & SVI, very ⬆️ NT-proBNP. Even w/o other data like 6MWD, he is hi risk. pic.twitter.com/wyU9hr7Ujy
— cardio-met (@cardiomet_CE) April 26, 2023
23) Answer: C, but it depends on the individual pt. There are many factors to consider in addition to risk level, particularly when considering parenteral therapies. Also, disease- and pt-specific considerations & preferences can influence treatment selection. More on this later.
— cardio-met (@cardiomet_CE) April 26, 2023
25) Welcome back!! We are talking Multidimensional, Serial Risk Assessment in #PAH with expert author @AlbertaPHdoc. 🆓CE/#CME at the end of this 🧵!
— cardio-met (@cardiomet_CE) April 27, 2023
👋@TamCardio @docroham @SudarRajagopal @heresi_gustavo @RyanTedfordMD @rjbernardoMD @kurt_prins @SashaPrisco
27) In this algorithm, the distinction is made for patients w/ & w/o #cardiopulmonary #comorbidities. Pts with significant CP issues were often excluded from #RCTs, & several studies show that such pts do not respond to, or do not tolerate, more aggressive tx. pic.twitter.com/sO8cNEBDXH
— cardio-met (@cardiomet_CE) April 27, 2023
29) For high-risk #PAH, guidelines suggest upfront triple tx, tho strength of evidence for this rec is lower (Class IIa). Non-randomized studies suggested triple therapy may improve long-term survival vs 1 or 2 drugs, especially in high-risk patients.
— cardio-met (@cardiomet_CE) April 27, 2023
🔓 https://t.co/tadcPH03mi pic.twitter.com/zZMdgzJmmU
31a) There is no right answer here, but please consider:
— cardio-met (@cardiomet_CE) April 27, 2023
1) can this patient manage the complexity of parenteral drug long-term?
2) pts w/ HIV & methamphetamine induced #PAH are generally not inc'd in clinical trials nor in the triple tx observational study discussed above.
31c) Answer Continued…
— cardio-met (@cardiomet_CE) April 27, 2023
5) Additionally, in patients with #HIV, interactions with HIV drugs need to be considered.
32) Social factors and patient safety also need to be considered carefully in patients with methamphetamine-associated #PAH. Parenteral therapies carry risks of central venous catheter infections (for i.v. route) and can cause site reactions that are painful (for s.c. route).
— cardio-met (@cardiomet_CE) April 27, 2023
34) Your patient makes it out of hospital on macitentan and tadalafil. At follow-up, he was still NYHA class III, NT-proBNP was still 1000ng/L and 6MWD was 305m. What’s his risk status using the ESC/ERS 4-strata approach?
— cardio-met (@cardiomet_CE) April 27, 2023
36) What are the treatment options for an intermediate-high risk patient? The 2022 guidelines suggest adding #selexipag, an oral prostacyclin receptor agonist, or switching a #PDE5i to #riociguat.
— cardio-met (@cardiomet_CE) April 27, 2023
37b) #Selexipag reduced morbidity/mortality primary endpoint by 40%, which was consistent across the number of background drugs.
— cardio-met (@cardiomet_CE) April 27, 2023
🔓 https://t.co/WkzCSUt4V8 pic.twitter.com/0NcCkT5fzF
39) Importantly, most patients in #REPLACE were on #sildenafil not #tadalafil. Although not powered to analyze differences by which #PDE5i was being taken at baseline, this effect appears to be driven by patients on sildenafil. pic.twitter.com/y59ip52q3S
— cardio-met (@cardiomet_CE) April 27, 2023
41) This real-world case highlights several nuances in selecting #PAH therapies. Risk scores help clinicians inform patients and guide therapeutic decisions but our overall goal should be to treat the patient, not the risk score. pic.twitter.com/ObyvQL4sNx
— cardio-met (@cardiomet_CE) April 27, 2023
43) Speaking of support, YOU just earned 0.75hr 🆓CE/#CME! 🖱️to https://t.co/M6xdMkKybL & grab your certificate. I am @AlbertaPHdoc & I thank you for joining me. FOLLOW US here on @cardiomet_CE for more programs #cardiotwitter #MedEd #FOAMed #FOAMcc delivered wholly on Twitter!
— cardio-met (@cardiomet_CE) April 27, 2023