Original Article

Prevalence of Acute Vasoresponsiveness in Patients With Pulmonary Hypertension: Treatment Implications

Authors: Vichaya Arunthari, MD, Michael G. Heckman, MS, Charles D. Burger, MD

Abstract

Objective: Pulmonary hypertension (PH) is a serious and often progressive disorder that results in right ventricular dysfunction. The general reported rate of patients who are responders is 10%–26%. More recently, using the current criteria, the rate of acute vasodilator response was as low as 6%. This study used the most current guidelines to assess the prevalence of acute vasoresponsiveness in patients with PH.


Methods: A retrospective chart review of 618 patients seen in the PH clinic at the Mayo Clinic Jacksonville from 1991 to June 2008 was conducted. We assessed the prevalence of acute vasoresponsiveness in patients with PH who had undergone vasodilator trial with epoprostenol or nitric oxide, using the current accepted criteria.


Results: One hundred and seventy-six patients who underwent a vasodilator trial that had complete hemodynamic data were identified. The average age was 61 ± 14 years and most were women (67%). The PH was severe with most patients in the World Health Organization (WHO) functional class III-IV (82%), and an average mean pulmonary artery pressure of 48 ± 11 mm Hg. Although the study group included all WHO diagnostic groups, 69% were diagnosed as Group I pulmonary arterial hypertension. We found an overall prevalence of response to acute vasodilator therapy to be 26%.


Conclusion: Using the most current criteria to identify acute responders to vasodilator therapy in PH patients, we found a slightly higher rate of “responders” than previously reported. Acute vasodilator testing identifies a clinically important group who may benefit from calcium channel blockers (CCBs), and this study confirms that a significant percentage of PH patients are acutely vasoresponsive.


Key Points


* The results of vasodilator testing in patients with pulmonary hypertension (PH) have prognostic and therapeutic implications.


* The rate of acute vasoresponsiveness in patients with PH varies from 6–26%.


* Significant proportions of PH patients are acutely vasoresponsive and may benefit from calcium channel blockers (CCBs).


* Inclusion of vasodilator testing should remain a standard of practice at the time of diagnostic right heart catheterization.

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References

1. Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest 2007;131:1917–1928.
 
2. Galiè N, Manes A, Branzi A. Evaluation of pulmonary arterial hypertension. Curr Opin Cardiol 2004;19:575–581.
 
3. Rich S, Dantzker DR, Ayres SM, et al. Primary pulmonary hypertension. A national prospective study. Ann Intern Med 1987;107:216–223.
 
4. D'Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med 1991;115:343–349.
 
5. Badesch DB, Abman SH, Ahearn GS, et al. Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004;126:35S–62S.
 
6. Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clin Chest Med 2007;28:91–115, viii.
 
7. Rich S, Kaufmann E, Levy PS. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med 1992;327:76–81.
 
8. Sitbon O, Humbert M, Jaïs X, et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension. Circulation 2005;111:3105–3111.
 
9. Humbert M, Sitbon O, Chaouat A, et al. Pulmonary arterial hypertension in France: results from a national registry. Am J Respir Crit Care Med 2006;173:1023–1030.
 
10. Trow TK, McArdle JR. Diagnosis of pulmonary arterial hypertension. Clin Chest Med 2007;28:59–73, viii.
 
11. McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004;126(1 suppl):14S–34S.
 
12. LaRaia AV, Waxman AB. Pulmonary arterial hypertension: evaluation and management. South Med J 2007;100:393–399.
 
13. McLaughlin VV, Presberg KW, Doyle RL, et al. Prognosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004;126(1 suppl):78S–92S.
 
14. Weir EK, Rubin LJ, Ayres SM, et al. The acute administration of vasodilators in primary pulmonary hypertension. Experience from the National Institutes of Health Registry on Primary Pulmonary Hypertension. Am Rev Respir Dis 1989;140:1623–1630.
 
15. Costa EL, Jardim C, Bogossian HB, et al. Acute vasodilator test in pulmonary arterial hypertension: evaluation of two response criteria. Vascul Pharmacol 2005;43:143–147.
 
16. Sandoval J, Bauerle O, Palomar A, et al. Survival in primary pulmonary hypertension. Validation of a prognostic equation. Circulation 1994;89:1733–1744.
 
17. Nootens M, Schrader B, Kaufmann E, et al. Comparative acute effects of adenosine and prostacyclin in primary pulmonary hypertension. Chest 1995;107:54–57.
 
18. Sitbon O, Humbert M, Jagot JL, et al. Inhaled nitric oxide as a screening agent for safely identifying responders to oral calcium-channel blockers in primary pulmonary hypertension. Eur Respir J1998;12:265–270.
 
19. Sitbon O, Brenot F, Denjean A, et al. Inhaled nitric oxide as a screening vasodilator agent in primary pulmonary hypertension. A dose-response study and comparison with prostacyclin. Am J Respir Crit Care Med 1995;151:384–389.