Short-term, low-dose riociguat or selexipag before BPA improved hemodynamics and BNP in CTEPH.
Background
Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe condition characterized by persistent blood clots in the pulmonary arteries, leading to increased pressure and right heart strain. Standard treatments include pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA), often supplemented by pulmonary vasodilators (PVs). While PVs can improve hemodynamics, dose adjustments can delay crucial BPA procedures. This creates a clinical need to evaluate the efficacy and safety of short-term, low-dose PV regimens to facilitate earlier BPA, addressing a gap in current pre-BPA strategies.
Study Design
This retrospective pilot study analyzed 20 patients with World Health Organization functional class III/IV CTEPH who received short-term, low-dose pulmonary vasodilators. Patients were administered either riociguat or selexipag and underwent right heart catheterization and their first balloon pulmonary angioplasty (BPA) within 60 days of starting PV therapy. The median duration of PV therapy was 18 days. Researchers compared hemodynamic parameters and brain natriuretic peptide (BNP) levels before and after PV treatment. First-session BPA complications were also assessed to evaluate safety.
Results
After a median of 18 days of low-dose pulmonary vasodilator therapy, significant improvements in key hemodynamic parameters were observed. > Mean pulmonary arterial pressure (mPAP) decreased from 42 to 40 mmHg, representing a mean reduction of -2.1 mmHg (95% confidence limits [CL], -4.2 to -0.02; p=0.0482). Pulmonary vascular resistance (PVR) showed a substantial decrease from 829 to 632 dyne·s·cm-5, a mean reduction of -197 dyne·s·cm-5 (95% CL, -227 to -117; p<0.0001). Furthermore, brain natriuretic peptide (BNP) levels, a marker of cardiac strain, significantly decreased from 284 to 146 pg/mL, a mean difference of -139 pg/mL (95% CL, -203 to -75; p=0.0002). Cardiac output and cardiac index also increased significantly. The study noted that higher baseline mPAP and PVR values were associated with greater reductions in these parameters. Regarding safety, BPA-related complications, specifically hemoptysis from peripheral lesions, occurred in four patients (20%).
Why It Matters
Short-term, low-dose pulmonary vasodilator therapy can be a viable strategy before balloon pulmonary angioplasty (BPA) in CTEPH patients, potentially improving outcomes by enabling earlier definitive treatment. By improving hemodynamics and reducing cardiac biomarkers like BNP within a median of 18 days, this approach may reduce the waiting period for crucial BPA procedures. The identification of higher baseline mPAP and PVR as predictors of greater response offers a valuable tool for patient selection and personalized treatment strategies, allowing clinicians to optimize the timing and benefit of PV initiation without unduly delaying the primary intervention.