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Multispecialty pulmonary hypertension clinic in the VA.

ABSTRACT: Pulmonary hypertension (PH) is often associated with cardiopulmonary co-morbidities, especially in older adults. A multispecialty approach to suspected PH is recommended, but there are few data on adherence to guidelines or outcomes in such patients. This was a single-center retrospective study of consecutively evaluated Veteran patients with suspected PH evaluated in a multispecialty PH clinic at a Veterans Affairs Medical Center, evaluating clinical characteristics, workup outcomes, and prognosis. The referral population (n = 125) was older (mean?±?SD age = 73.6?±?9.8 years) with frequent co-morbidities (e.g. COPD 60%) and obesity (mean?±?SD BMI = 32.8?±?8.1?kg/m2). Of 94 patients undergoing right heart catheterization (RHC), 73 (78%) had confirmed PH (mean pulmonary artery pressure???25?mmHg). PH was associated with higher BMIs (odds ratio [95% CI] for PH per 1 unit increase = 1.10 [1.02-1.19]) and brachial pulse pressures (odds ratio per 1?mmHg increase = 1.07 [1.02-1.13]). Seventy out of 73 were classifiable by WHO PH groupings. Most patients underwent guideline-recommended PH evaluation. Observed one-year mortality was high (17.8%); the one-year hospitalization rate was 34.2%. These results compare favorably to observations from the VA Clinical Assessment, Reporting, and Tracking cohort of Veterans with PH by RHC (19.1% and 60.9% one-year mortality and hospitalization rates, respectively). Multispecialty PH clinic evaluation revealed a high prevalence of co-morbidities in veterans with suspected PH; PH was prevalent in this referral population. PH patients had significant morbidity and mortality but supportive care measures improved following PH evaluation. Further prospective randomized study is needed to determine if a multispecialty clinic approach improves PH morbidity and mortality in veterans.

SUBMITTER: Jankowich M

PROVIDER: S-EPMC5703122 | biostudies-literature | 2017 Oct-Dec

REPOSITORIES: biostudies-literature

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Multispecialty pulmonary hypertension clinic in the VA.

Jankowich Matthew M Hebel Ryan R Jantz Jennifer J Abbasi Siddique S Choudhary Gaurav G

Pulmonary circulation 20170822 4

Pulmonary hypertension (PH) is often associated with cardiopulmonary co-morbidities, especially in older adults. A multispecialty approach to suspected PH is recommended, but there are few data on adherence to guidelines or outcomes in such patients. This was a single-center retrospective study of consecutively evaluated Veteran patients with suspected PH evaluated in a multispecialty PH clinic at a Veterans Affairs Medical Center, evaluating clinical characteristics, workup outcomes, and progno ...[more]

PMID: 28770656

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Project description:Pulmonary vascular arterial remodeling is an integral and well-understood component of pulmonary hypertension (PH). In contrast, morphological alterations of pulmonary veins in PH are scarcely described. Explanted lungs (n = 101) from transplant recipients with advanced chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary arterial hypertension (IPAH) were analyzed for venous vascular involvement according to a pre-specified, semi-quantitative grading scheme, which categorizes the intensity of venous remodeling in three groups of incremental severity: venous hypertensive (VH) grade 0 = characterized by an absence of venous vascular remodeling; VH grade 1 = defined by a dominance of either arterialization or intimal fibrosis; and VH grade 2 = a substantial composite of arterialization and intimal fibrosis. Patients were grouped according to clinical and hemodynamic characteristics in three groups: COPD non-PH, COPD-PH, and IPAH, respectively. Histological specimens were examined by a cardiovascular pathologist blinded to clinical and hemodynamic data. Pathological alterations of pulmonary veins were present in all hemodynamic groups, with the following incidences of VH grade 0/1/2: 34/66/0% in COPD non-PH; 19/71/10% in COPD-PH; and 11/61/28% in IPAH. In COPD, explorative correlation analysis of venous remodeling suggested a modest positive correlation with systolic and mean pulmonary artery pressure ( P = 0.032, respectively) and an inverse modest correlation with diffusion capacity for carbon monoxide ( P = 0.027). In addition, venous remodeling correlated positively with the degree of arterial remodeling ( P = 0.014). In COPD-PH and IPAH, advanced forms of pulmonary venous remodeling are present, emphasizing that the disease is not exclusively restricted to arterial lesions. In addition, venous remodeling may be related to the hemodynamic severity, but more rigorous analysis is required to clearly define potential relationships.

Project description:Background There has been a trend in recent years toward individualized medicine. Pharmacogenomics (PGx) is the use of patient-specific genetic variations to guide medication selection and treatment. Objective: The primary objective was to characterize the population of referring department patients and identify the number of high-evidence, actionable phenotype (HEAP) genes in this referred population to help guide marketing efforts to the most applicable patient populations and departments. Practice description: Located in a destination, tertiary care clinic. Providers refer patients to a Pharmacogenomics (PGx) specialist for a comprehensive medication review using their pharmacogenomic results. Practice Innovation: The practice is innovative because it has been using PGx in the pharmacy and medical practices since 2016 and has been routinely developing and incorporating PGx best practice alerts (BPAs) into the electronic medical record (EMR) since 2020. Evaluation Methods Genetic results were analyzed from a 27-gene PGx panel test which tests for both pharmacokinetic and pharmacodynamic genes. High-Evidence Actionable Phenotypes (HEAP) are defined as phenotypes with guideline support that may suggest an action by healthcare provider. Low-Evidence Nonactionable Phenotypes (LENP) are defined as phenotypes that do not recommend action. Results There were 1,236 atypical phenotypes identified in the 154 patients referred. Of the atypical genes, 39.97% were HEAP and 60.03% were LENP. Of the HEAP's identified, the majority came from CYP2D6, VKORC1, and UGT1A1. At least 1 HEAP was found in 98.7% of patients (n=152). Conclusion There are a variety of High Evidence Actionable Phenotypes (HEAPs) with a high likelihood of at least one HEAP gene in every patient. These phenotypes can result in serious safety concerns when combined with a medication impacted by one of these HEAP genes. Thus, referral to a pharmacogenomics consultation service may lead to an overall decrease in morbidity and mortality with potential cost avoidance.

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Multispecialty pulmonary hypertension clinic in the VA.

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Multispecialty pulmonary hypertension clinic in the VA.

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