Our @cardiomet_CE tweeps are hungry for education from the experts. Let’s expand our horizons a bit! Did you know that diabetic pts are at ⬆️risk for developing #pulmonaryhypertension (PH or #PAH), independent of #CAD, #heartfailure, #hypertension, or smoking?
— cardio-met (@cardiomet_CE) September 10, 2021
TOMORROW we start exploring a 🫁 problem that impacts #cardiometabolic care. Don’t miss our first #tweetorial on #pulmonaryhypertension from expert author @SudarRajagopal. Don’t miss it, @CardioNerds #cardiotwitter @MedTweetorials #pulmonarytwitter @PVRI @PHAssociation
— cardio-met (@cardiomet_CE) September 13, 2021
2) This program is supported by educational grants from Actelion, AstraZeneca, Bayer, Chiesi, and NovoNordisk, and is intended for healthcare professionals. Follow this thread for credit. And here is a case of a patient with #scleroderma . . .
— cardio-met (@cardiomet_CE) September 14, 2021
4) In general, how often should patients with scleroderma be screened for PAH?
— cardio-met (@cardiomet_CE) September 14, 2021
6) 2015 @ESCardio/@EuroRespSoc guidelines: Screening with resting echocardiography is recommended in asymptomatic patients, followed by annual screening with echo, diffusion capacity for carbon monoxide (DLco), and biomarkers. https://t.co/UrSbowkoXY
— cardio-met (@cardiomet_CE) September 14, 2021
8) 6th World Symposium: Annual screening with PFTs and echocardiography should be considered in patients with the SSc spectrum of diseases with uncorrected DLco <80%. https://t.co/dVEvIgDNbI
— cardio-met (@cardiomet_CE) September 14, 2021
10) Different thresholds for FVC%/DLCO% ratio ranging from ≥ 1.6 to ≥ 2.0. The sensitivity (91%) and NPV (93%) for detecting PAH are improved with the lower cut-off while specificity is improved with the higher cutoff.https://t.co/XeZGJRK4eK
— cardio-met (@cardiomet_CE) September 14, 2021
12) She underwent #TTE that demonstrated a moderately enlarged right ventricle with mild dysfunction. Minimal TR – TRjet 2.9 m/s with an estimated RVSP 44 mmHg. TAPSE 1.8 cm. IVC dilated with abnormal respiratory collapse.
— cardio-met (@cardiomet_CE) September 14, 2021
14) Mark your answer and return tomorrow for the answer and more discussion! You’re on your way to free CE/#CME. @kurt_prins @HelpMyBreathing @jeanlucvachiery @RyanTedfordMD @SashaPrisco @ImadAlGhouleh @zeenatsafdarmd @rjbernardoMD @RogerAlvarezDO @rama_elyafawi
— cardio-met (@cardiomet_CE) September 14, 2021
16) Yesterday’s poll? The answer is A: Scleroderma. PAH associated with scleroderma is associated with higher risk. Male sex, especially over the age of 60, is associated with worse outcomes in PAH.
— cardio-met (@cardiomet_CE) September 15, 2021
18) The answer is C: VQ scan. All patients undergoing an evaluation for PH should have a VQ scan to rule out chronic pulmonary embolism as a potential cause for their PH. Noncontrast CT chest is recommended to evaluate for parenchymal lung disease in certain populations.
— cardio-met (@cardiomet_CE) September 15, 2021
20) Here’s a “by the way” for you. Know about vasodilator testing in patients with possible PAH? Check out https://t.co/bQHKg2yrGb. Shout out to @PHAssociation
— cardio-met (@cardiomet_CE) September 15, 2021
22) Answer is B: Intermediate risk. French registry invasive risk assessment has 4 criteria for low-risk status: WHO functional class I or II, 6MWD > 440 m, RA pressure <8 and CI ≥ 2.5. She meets 2/4 criteria. pic.twitter.com/WhIWzDGVdU
— cardio-met (@cardiomet_CE) September 15, 2021
24) What therapy would you start? (and BTW this initial decision is best made by a #PAH specialist)
— cardio-met (@cardiomet_CE) September 15, 2021
A) Phosphodiesterase 5 inhibitor (PDE5i)
B) Endothelin Receptor Antagonist (ERA)
C) PDE5i + ERA
D) PDE5i + ERA + Prostacyclin
26) You see her in 3 months. She is FC 2 and her six minute walk distance has improved to 450 meters and NTproBNP is 350 ng/ml. Three noninvasive criteria: FC 1/2, 6MWD>440m, NTproBNP<300. What risk category does she fall into?
— cardio-met (@cardiomet_CE) September 15, 2021
28) What is the goal of therapy in PAH?
— cardio-met (@cardiomet_CE) September 15, 2021
A) Achieve a mean PA pressure < 20 mmHg.
B) Symptom control – functional class 1 or 2.
C) Achievement of low risk status.
D) Normalize PVR < 3 Wood units.
30) What options do we have for escalating therapy in this patient?
— cardio-met (@cardiomet_CE) September 15, 2021
A) Add oral IP agonist (selexipag or treprostinil)
B) Add inhaled or parenteral prostacyclin
C) Switch from PDE5i to sGC stimulator
D) All of the above
31) Mark your answer and return tomorrow for the answer, more education, and a link to secure your CE/#CME credit! Don’t stop now! @vaszochios @SheilaKrishnan2 @stevenhsu_md @mmamas1973 @DocHirsch @Geraint67 @AtulMalhotra13 @ME_Healer0812 @MarkDSiegel1 @maorsauler
— cardio-met (@cardiomet_CE) September 15, 2021
33) The answer is D: All of the above. All of these are reasonable strategies for treating patients who are not reaching their treatment goals on therapy with an PDE5i + ERA. If the patient were FC 4, a class I recommendation for IV epoprostenol would be recommended.
— cardio-met (@cardiomet_CE) September 16, 2021
35) The GRIPHON trial was a study of oral selexipag (a prostacyclin receptor agonist) compared to placebo in patients on stable PDE5i, ERA or both that showed an improvement in time to clinical worsening.https://t.co/WkzCSUt4V8 pic.twitter.com/4lkmmpqTsK
— cardio-met (@cardiomet_CE) September 16, 2021
37) Inhaled Prostacyclins options include inhaled iloprost (given 6 to 9 times daily) and inhaled treprostinil (given 4 times daily). Both of these drugs have been shown to improve six minute walk distance.https://t.co/tll364bcvahttps://t.co/C1ItY4iZo6
— cardio-met (@cardiomet_CE) September 16, 2021
39) The REPLACE trial considered the strategy of replacing a PDE5i with an sGC stimulator (riociguat). This study found that transitioning to riociguat was associated w/significant improvement in 6MWD, tho no benefit was seen in the tadalafil subgroup.https://t.co/00ps8yg6x7 pic.twitter.com/NpYDPZkbyn
— cardio-met (@cardiomet_CE) September 16, 2021
41) After discussion with the patient, an oral prostacyclin was added. Three months later, she returned for follow-up with an improvement in her 6MWD 460 m and NTproBNP 250 ng/ml. She has achieved low-risk status.
— cardio-met (@cardiomet_CE) September 16, 2021
43) To summarize, pulmonary arterial hypertension (#PAH) is a disease w/obstruction of small pulmonary blood vessels, resulting in right heart failure & death if untreated. Patients with high-risk features & those who need advanced therapies should be referred to expert centers.
— cardio-met (@cardiomet_CE) September 16, 2021
45) That’s it! You made it! FREE CE/#CME! #physicians #nurses #pharmacists make your way to https://t.co/xlyj6RjlEs for 0.5h credit, applicable 🇺🇸🇨🇦🇬🇧🇪🇺. And follow us so as not to miss next week’s accredited #tweetorial! #FOAMed #CardioTwitter pic.twitter.com/MUcRWpPtEK
— cardio-met (@cardiomet_CE) September 16, 2021