Ostermann Jonna, Pott Julian, Hennigs Jan K, Roedl Kevin, Sinning Christoph, Harbaum Lars, Klose Hans
Division of Respiratory Medicine and Centre of Pulmonary Arterial Hypertension Hamburg, Department of Medicine II, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
ERJ Open Res. 2023 May 30;9(3). doi: 10.1183/23120541.00072-2023. eCollection 2023 May.
The 2022 ESC/ERS guidelines on pulmonary hypertension recommend noninvasive risk assessments based on three clinical variables during follow-up in patients with pulmonary arterial hypertension (PAH). We set out to test whether residual risk can be captured from routinely measured noninvasive clinical variables during follow-up in PAH.
We retrospectively studied 298 incident PAH patients from a German pulmonary hypertension centre who underwent routine noninvasive follow-up assessments including exercise testing, echocardiography, electrocardiography, pulmonary function testing and biochemistry. To select variables, we used least absolute shrinkage and selection operator (LASSO)-regularised Cox regression models. Outcome was defined as mortality or lung transplant after first follow-up assessment.
12 noninvasive variables that were associated with outcomes in a training sub-cohort (n=208) after correction for multiple testing entered LASSO modelling. A model combining seven variables discriminated 1-year (area under the curve (AUC) 0.83, 95% confidence interval (CI) 0.68-0.99, p=8.4×10) and 3-year (AUC 0.81, 95% CI 0.70-0.92, p=2.9×10) outcome status in a replication sub-cohort (n=90). The model's discriminatory ability was comparable to that of the guideline approach in the replication sub-cohort. From the individual model components, World Health Organization functional class, 6-min walking distance and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio were sensitive to treatment initiation. Addition of TAPSE/sPAP ratio to the guideline approach numerically increased its ability to discriminate outcome status.
Our real-world data suggest that residual risk can be captured by noninvasive clinical procedures during routine follow-up assessments in patients with PAH and highlights the potential use of echocardiographic imaging to refine risk assessment.
2022年欧洲心脏病学会/欧洲呼吸学会肺动脉高压指南推荐，在肺动脉高压（PAH）患者随访期间，基于三个临床变量进行无创风险评估。我们旨在测试在PAH患者随访期间，能否从常规测量的无创临床变量中捕捉残余风险。
我们对来自德国一家肺动脉高压中心的298例PAH初发患者进行了回顾性研究，这些患者接受了包括运动测试、超声心动图、心电图、肺功能测试和生化检查在内的常规无创随访评估。为了选择变量，我们使用了最小绝对收缩和选择算子（LASSO）正则化Cox回归模型。结局定义为首次随访评估后的死亡率或肺移植。
在校正多重检验后，训练亚组（n = 208）中与结局相关的12个无创变量进入了LASSO建模。一个包含七个变量的模型在复制亚组（n = 90）中区分了1年（曲线下面积（AUC）0.83，95%置信区间（CI）0.68 - 0.99，p = 8.4×10）和3年（AUC 0.81，95% CI 0.70 - 0.92，p = 2.9×10）的结局状态。该模型的鉴别能力与复制亚组中指南方法的鉴别能力相当。从个体模型组件来看，世界卫生组织功能分级、6分钟步行距离以及三尖瓣环平面收缩期位移与收缩期肺动脉压（TAPSE/sPAP）比值对治疗起始敏感。将TAPSE/sPAP比值添加到指南方法中在数值上增加了其区分结局状态的能力。
我们的真实世界数据表明，在PAH患者的常规随访评估期间，无创临床程序可以捕捉残余风险，并突出了超声心动图成像在完善风险评估方面的潜在用途。
