Background The DETECT algorithm (DA)1 provides a sensitive tool for early identification of patients with Systemic Sclerosis (SSc) at risk of Pulmonary Arterial Hypertension (PAH) and advocates evaluation with Right Heart Catheterisation (RHC). Few published data look into its implementation in everyday clinical practice and compare it to annual echocardiographic (TTE) screening.
Objectives To compare DA and TTE screening of SSc patients for RHC referral rates and related patient characteristics.
Methods Data on 57 consecutive patients with a diagnosis of SSc that had at least one visit to Russells Hall Hospital Scleroderma clinic from February to November 2016 was prospectively collected on Excel (clinical history, physical examination, immunological status, treatment, PFTs, NT-proBNP, urate, ECG, TTE, CXR and HRCT results). DETECT scores were calculated ( www.detect-pah.com) and compared with the TTE probability for PAH as per the 2015 ESC/ERS Guidelines2.
Results 31 patients with a full set of data were included in the final analysis. 93.5% were female with a mean age of 64.4±12.9 years, 87% had limited cutaneous (lc) SSc, 58.1% positive anticentromere antibody and mean time since diagnosis was 6.2±3.2 years. The majority of patients (80%) were asymptomatic for PAH. Mean DLCO was 60.9±18.3% predicted (the DETECT study included on patients with DLCO<60%). We did not exclude patients with renal insufficiency; mean eGFR was 74±17.7ml/min.
The implementation of DA recommended RHC in 18/31 patients (DETECT step 2 score ≥35, 58%, see table 1) compared to just 4/31 (13%) based on TTE by 2015 ESC/ERS guidelines. The additional 14 patients identified by DA were found to have no statistically significant differences in SSc type, dyspnea symptomatology, immunosuppressive treatment, presence of interstitial lung disease (ILD), age, time from diagnosis or symptom onset, eGFR and CRP compared to patients where RHC was not recommended. From the 18 patients identified by DA, only 4 reported shortness of breath. 2/18 had existing cardiac conditions (aortic stenosis, left ventricular hypertrophy), while 9/18 had ILD (5 mild, 2 moderate, 2 severe as per HRCT).
Conclusions Implementation of DA in a largely asymptomatic non-selected SSc patient population is more sensitive for RHC referral than annual TTE screening. Recommendations for RHC per DETECT score are difficult to predict on symptom and other traditional clinical parameters. The use of DA will lead to increased RHC referrals. Cardiologists may need education on this new method for screening and although the ESC/ERS 2015 guidelines discuss DA, they conclude that its cost-effectiveness has not been clarified as compared with symptom-based detection.
Coghlan JG et al. Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study. Ann Rheum Dis 2014 Jul;73 (7):1340–9.
Galiè N et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J (2015) 37 (1): 67–119.
Disclosure of Interest None declared