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Is There Value in Repeating Inhaled Nitric Oxide Vasoreactivity Tests in Patients with Pulmonary Arterial Hypertension?

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Abstract

Background

In patients with pulmonary arterial hypertension (PAH), it remains unknown if the response to the acute pulmonary vasoreactivity test changes over time and determines prognosis.

Methods

We included PAH patients who underwent two right heart catheterizations (RHC) with acute vasoreactivity challenge using inhaled nitric oxide (NO). The hemodynamic response was assessed by absolute or percentage change in mean pulmonary artery pressure (mPAP) or pulmonary vascular resistance (PVR).

Results

We included 54 patients, age 51 ± 17 years, and 44 (82%) female. The median (IQR) time between the two RHC was 24.5 months (14.8–42 months). The percentage drop in mPAP was less pronounced in the second RHC (− 8.6 ± 8.1 versus − 12.3 ± 13.8 mmHg, p = 0.02). A total of 8 (14%) patients met criteria for a positive vasodilatory test during the first RHC but only 1 during the second. Patients with increased vasoreactivity at second RHC were more likely to receive (a) treatment with phosphodiesterase-5 inhibitors (PDE5-inh) at first RHC (56% versus 27%, p = 0.04) and (b) more PAH-specific medications by second RHC (2.3 ± 0.8 versus 1.8 ± 0.9, p = 0.03). Cox survival analysis showed that change in mPAP or PVR during vasodilatory challenge at or between the first and second RHC had no impact on survival.

Conclusions

Pulmonary vascular reactivity to inhaled NO might decrease over time; however, there is great variability among patients. The use of PDE5-inh at first RHC and number of PAH-specific treatments by the second RHC were associated with an improvement in pulmonary vasoreactivity over time.

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Abbreviations

NO:

Nitric oxide

NYHA:

New York Heart Association

PH:

Pulmonary hypertension

PAH:

Pulmonary arterial hypertension

RHC:

Right heart catheterization

CCB:

Calcium Channel blocker

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Funding

A.R.T is supported by NIH grant # R01HL130307.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA

    Rubabin Tooba

  2. Division of Immunity and Inflammation, Lerner Institute, Cleveland Clinic, Cleveland, OH, USA

    Allaa Almoushref

  3. Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

    Adriano R. Tonelli

  4. Pathobiology Division, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA

    Adriano R. Tonelli

Authors
  1. Rubabin Tooba
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  2. Allaa Almoushref
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  3. Adriano R. Tonelli
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Contributions

RT: Participated in the statistical analysis and interpretation of the results, writing the manuscript and participating in the subsequent revisions. Dr. Tooba coordinated the efforts of all authors for this study. AA: Participated in the data collection, interpretation of the results, and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted. ART: Participated in the design of the study, statistical analysis and interpretation of the results, writing and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted. Dr. Tonelli is the guarantor of the paper, taking responsibility for the integrity of the work, from inception to published article.

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Correspondence to Rubabin Tooba.

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The authors have no significant conflicts of interest with any companies or organizations whose products or services may be discussed in this article.

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Tooba, R., Almoushref, A. & Tonelli, A.R. Is There Value in Repeating Inhaled Nitric Oxide Vasoreactivity Tests in Patients with Pulmonary Arterial Hypertension?. Lung 198, 87–94 (2020). https://doi.org/10.1007/s00408-019-00318-0

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  • DOI: https://doi.org/10.1007/s00408-019-00318-0

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