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Prevalence and outcome in systemic sclerosis associated pulmonary arterial hypertension: application of a registry approach
  1. D Mukerjee1,
  2. D St George3,
  3. B Coleiro4,
  4. C Knight1,
  5. C P Denton1,
  6. J Davar2,
  7. C M Black1,
  8. J G Coghlan2
  1. 1Department of Rheumatology, Royal Free Hospital, Pond Street, London NW3 2QG, UK
  2. 2Department of Cardiology, Royal Free Hospital, Pond Street, London NW3 2QG, UK
  3. 3Southampton General Hospital, Tremona Road, Shirley, Southampton SO16 6YD, UK
  4. 4Department of Internal Medicine, St Lukes Hospital, Balkara, Malta
  1. Correspondence to:
    Professor C M Black, Centre for Rheumatology, Royal Free Hospital, Pond Street, London NW32QG. UK;
    c.blackrfc.ucl.ac.uk

Abstract

Objective: To determine the prevalence of systemic sclerosis associated pulmonary arterial hypertension (SScPAH), evaluate outcome, and identify predictors of mortality in a large patient cohort.

Methods: A prospective four year follow up study of 794 patients (722 from our own unit and 72 referrals). All patients screened for PAH using a combination of echocardiography, lung function testing, and clinical assessment. Patients with suspected raised pulmonary artery systolic pressures of >35 mm Hg, carbon monoxide transfer factor (Tlco) <50% predicted, or a precipitous fall in Tlco >20% over a one year period with no pulmonary fibrosis, and patients with SSc with breathlessness with no pulmonary fibrosis found were investigated with right heart catheterisation. All patients with SScPAH were treated in accordance with current best practice.

Results: The prevalence of PAH was 12% (89/722) by right heart catheter. The survival was 81%, 63%, and 56% at 1, 2, and 3 years from the diagnosis (in 89 patients from our own cohort and 59/72 referrals). Haemodynamic indices of right ventricular failure—raised mRAP (hazard ratio 21), raised mPAP (hazard ratio 20), and low CI (hazard ratio 11) predicted an adverse outcome There was no significant difference in survival between patients with SScPAH with (n=40) and without (n=108) pulmonary fibrosis (p=0.3).

Conclusions: The prevalence of SScPAH in this cohort was similar to that of other catheter based studies and lower than that of previous echo based studies. The 148 patients with SScPAH actively treated had comparable outcomes to those of the cohorts with primary pulmonary hypertension. A high mRAP was the strongest haemodynamic predictor of mortality. To improve prognosis, future treatments need to be implemented at an earlier disease stage to prevent right ventricular decompensation.

  • systemic sclerosis
  • pulmonary arterial hypertension
  • survival
  • iloprost
  • CCB, calcium channel blocker
  • HRCT, high resolution computed tomography
  • PAH, pulmonary arterial hypertension
  • PAP, pulmonary artery pressure
  • PASP, pulmonary artery systolic pressures, PFTs, pulmonary function tests
  • PPH, primary pulmonary hypertension
  • PVR, pulmonary artery vascular resistance
  • SSC, systemic sclerosis
  • Tlco-carbon monoxide transfer factor
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