Precision medicine in Pulmonary Hypertension

Take home messages in “Update of Pulmonary Hypertension Guideline” 1. Definition: • No diastolic PA gradient for PAH, use “PVR” 2. Classification: add 1.3 Drug- and toxin-induced PAH 1.5 PAH long-term responders to calcium channel blockers 1.6 PAH with overt features of venous/capillaries (PVOD/PCH) involvement 2.4 Congenital/acquired cardiovascular conditions leading to post-capillary PH 5.4 Developmental lung disorders 5.4 Complex cogngenital heart disease 3. Algorithm for diagnosis: • CTEPH and Lt heart disease must to be ruled out first due to treatable and better prognosis 4. Risk assessment: • Systematic assessment for improvement using measurable parameters is important • Patient with low risk PAH having best prognosis (mortality < 5%/year) 5. Medication regimen: • Start medication early is benefit even functional class I or II • Using initial triple drugs therapy as fast as we can is preferred 6. Algorithm for treatment: • Find out PAH patient who response to calcium channel blockers and use the medication, cheaper and more effective • Target is achieving “low risk PAH” (mortality < 5%/year) • Lung (and heart) transplantation is the final hope of survival Take home messages in “Pitfall in PAH-Specific Medical Treatment” 1. Correct(Precise) diagnosis is ESSENTIAL 2. Impact on management options and prognosis 3. PAH target ed medical therapy – not suitable for all PH patients(especially group II and III) 4. Treatment of PAH a. Before start Rx : discuss with the patient(and family) in detail about Dx, prognosis, plan of treatment b. Course of disease : not curable, usually will progress c. Cost of Rx and potential side effects d. Mention : Lung transplantation Take home messages in “Common Mistake in Pulmonary Hypertension Diagnosis and Management” 1. Mistakes in PHT management is not uncommon. 2. Disease-awareness is the first key for early diagnosis. 3. Right heart catheterization is mandatory in PHT management for both diagnosis and risk stratification. 4. Carefully interpret every investigation. 5. Keep your knowledge update.

Precision medicine in Non-coronary vessel disease

Take home messages in “Peripheral Artery Disease” 1. Peripheral artery disease is a marker for systemic atherosclerosis disease and increase the risk of coronary and cerebrovascular disease morbidity and death 2. Patients with pheripheral artery disease have 4 times increase of myocardial infarction and 2-3 times of stroke. 3. Issue to be concerned before carotid stenosis revascularization : - Symptomatic vs Asymptomatic - Patient’s condition - High risk carotid including aortis arch anatomy 4. Revascularization of asymptomatic vertebral artery stenosis is not indicated, irrespective of the degree of severity. 5. Routine revascularization is not recommended in RAS secondary to atherosclerosis. 6. Lower extremity artery disease - Intermittent claudication : Goal to provide relief of symptoms - Critical limb ischemia : Goal to promote limb survival Take home messages in “Coarctation of Aorta” 7. Don’t forget to feel the pulse and measure the blood pressure in lower extremities in adolescents or young adults with hypertension. 8. Pulse wave Doppler at descending aorta is necessary tool to detect coarctation of aorta. 9. Non- surgical modality is a useful alternative. 10. Unrepaired or repaired coarctation of aorta require lifetime follow up. Take home messages in “Takayasu’s Arteritis” 11. Takayasu’s arteritis : diagnosis depends on physician and carefully physical exam 12. ESR(low sensitivity) and non-invasive imaging(CTA/MRA +/- PET) of whole aorta is helpful to evaluate activity of disease 13. Early diagnosis and long term treat with immunosuppressive : Reduced complication and progression of disease. 14. Severe cardiovascular manifestation : Increased heart failure, morbidity and mortality. 15. Multidisciplinary tyeam is needed : Rheumatologist/vascular radiologist/interventionist/vascular surgeon.

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Precision medicine in Pulmonary Hypertension

Take home messages in “Update of Pulmonary Hypertension Guideline” 1. Definition: • No diastolic PA gradient for PAH, use “PVR” 2. Classification: add 1.3 Drug- and toxin-induced PAH 1.5 PAH long-term responders to calcium channel blockers 1.6 PAH with overt features of venous/capillaries (PVOD/PCH) involvement 2.4 Congenital/acquired cardiovascular conditions leading to post-capillary PH 5.4 Developmental lung disorders 5.4 Complex cogngenital heart disease 3. Algorithm for diagnosis: • CTEPH and Lt heart disease must to be ruled out first due to treatable and better prognosis 4. Risk assessment: • Systematic assessment for improvement using measurable parameters is important • Patient with low risk PAH having best prognosis (mortality < 5%/year) 5. Medication regimen: • Start medication early is benefit even functional class I or II • Using initial triple drugs therapy as fast as we can is preferred 6. Algorithm for treatment: • Find out PAH patient who response to calcium channel blockers and use the medication, cheaper and more effective • Target is achieving “low risk PAH” (mortality < 5%/year) • Lung (and heart) transplantation is the final hope of survival Take home messages in “Pitfall in PAH-Specific Medical Treatment” 1. Correct(Precise) diagnosis is ESSENTIAL 2. Impact on management options and prognosis 3. PAH target ed medical therapy – not suitable for all PH patients(especially group II and III) 4. Treatment of PAH a. Before start Rx : discuss with the patient(and family) in detail about Dx, prognosis, plan of treatment b. Course of disease : not curable, usually will progress c. Cost of Rx and potential side effects d. Mention : Lung transplantation Take home messages in “Common Mistake in Pulmonary Hypertension Diagnosis and Management” 1. Mistakes in PHT management is not uncommon. 2. Disease-awareness is the first key for early diagnosis. 3. Right heart catheterization is mandatory in PHT management for both diagnosis and risk stratification. 4. Carefully interpret every investigation. 5. Keep your knowledge update.

Precision medicine in Non-coronary vessel disease

Take home messages in “Peripheral Artery Disease” 1. Peripheral artery disease is a marker for systemic atherosclerosis disease and increase the risk of coronary and cerebrovascular disease morbidity and death 2. Patients with pheripheral artery disease have 4 times increase of myocardial infarction and 2-3 times of stroke. 3. Issue to be concerned before carotid stenosis revascularization : - Symptomatic vs Asymptomatic - Patient’s condition - High risk carotid including aortis arch anatomy 4. Revascularization of asymptomatic vertebral artery stenosis is not indicated, irrespective of the degree of severity. 5. Routine revascularization is not recommended in RAS secondary to atherosclerosis. 6. Lower extremity artery disease - Intermittent claudication : Goal to provide relief of symptoms - Critical limb ischemia : Goal to promote limb survival Take home messages in “Coarctation of Aorta” 7. Don’t forget to feel the pulse and measure the blood pressure in lower extremities in adolescents or young adults with hypertension. 8. Pulse wave Doppler at descending aorta is necessary tool to detect coarctation of aorta. 9. Non- surgical modality is a useful alternative. 10. Unrepaired or repaired coarctation of aorta require lifetime follow up. Take home messages in “Takayasu’s Arteritis” 11. Takayasu’s arteritis : diagnosis depends on physician and carefully physical exam 12. ESR(low sensitivity) and non-invasive imaging(CTA/MRA +/- PET) of whole aorta is helpful to evaluate activity of disease 13. Early diagnosis and long term treat with immunosuppressive : Reduced complication and progression of disease. 14. Severe cardiovascular manifestation : Increased heart failure, morbidity and mortality. 15. Multidisciplinary tyeam is needed : Rheumatologist/vascular radiologist/interventionist/vascular surgeon.

จดหมายเชิญเข้าร่วมประชุมงาน CMCC ตารางงานประชุม Precision Cardiology