Residual risk identified in routine noninvasive follow-up assessments in pulmonary arterial hypertension

Jonna Ostermann; Julian Pott; Jan K Hennigs; Kevin Roedl; Christoph Sinning; Lars Harbaum; Hans Klose

doi:10.1183/23120541.00072-2023

Residual risk identified in routine noninvasive follow-up assessments in pulmonary arterial hypertension

ERJ Open Res. 2023 May 30;9(3):00072-2023. doi: 10.1183/23120541.00072-2023. eCollection 2023 May.

Authors

Jonna Ostermann¹, Julian Pott¹, Jan K Hennigs¹, Kevin Roedl², Christoph Sinning³, Lars Harbaum^{1

4}, Hans Klose^{1

4}

Affiliations

¹ Division of Respiratory Medicine and Centre of Pulmonary Arterial Hypertension Hamburg, Department of Medicine II, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
² Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
³ Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg Germany.
⁴ These authors contributed equally.

Abstract

Background: 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.

Methods: 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.

Results: 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^-6) and 3-year (AUC 0.81, 95% CI 0.70-0.92, p=2.9×10^-8) 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.

Conclusion: 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.