Papel prognóstico do teste de exercício cardiorrespiratório na avaliação de seguimento de pacientes com hipertensão arterial pulmonar
Arquivos
Data
2024-12-10
Autores
Daud, Meliane de Oliveira 
Orientadores
Arakaki, Jaquelina Sonoe Ota
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A hipertensão arterial pulmonar é uma condição hemodinâmica rara, grave e debilitante. Reconhece-se a sua elevada mortalidade, destacando a importância da avaliação multiparamêtrica periódica para estratificação de risco e orientação terapêutica. Os dados hemodinâmicos, obtidos por meio do cateterismo cardíaco ao repouso, desempenham um papel significativo na determinação da gravidade. Até o momento, poucos estudos abordaram os fatores prognósticos do teste de exercício cardiopulmonar na estratificação de risco multiparamétrica. Objetivo: Avaliar o papel do platô de pulso de O2 na avaliação multiparamétrica de seguimento de pacientes com HAP. Métodos: Estudo observacional de coorte retrospectivo acompanhada de forma sistemática no Setor de Circulação Pulmonar do Hospital São Paulo – Unifesp. Foram revisados prontuários dos pacientes portadores de HAP assistidos no ambulatório de Doenças da Circulação Pulmonar da Disciplina de Pneumologia, no período de janeiro de 2005 a dezembro de 2018 e seguidos até agosto de 2022. A estratificação de risco basal (ESC/ERS 2022 e REVEAL Lite 2.0) e de seguimento (ESC/ERS 2022 de 3 e 4 estratos e REVEAL Lite 2.0) foram realizadas. Fatores prognósticos potenciais foram identificados por análise univariada e regressão multivariada de Cox, com modelos incluindo a presença do platô de pulso de O2. O método de Kaplan-Meier foi usado para determinar a sobrevida global. Resultados: 144 pacientes foram selecionados para este estudo. A amostra é predominantemente jovem e do sexo feminino (82,6%) com idade média de 42 anos, média de DC6M de 423 ±93m e 53,5% dos pacientes apresentavam-se em classe funcional III ou IV da NYHA. Entre a coorte, durante o período de acompanhamento mediano de 7 anos, 59 (40,9%) pacientes faleceram e 7 (4,8%) realizaram transplante pulmonar, sendo a sobrevida estimada em 1 ano de 98,6%, em 3 anos de 89,3% e em 5 anos de 77,3%. A análise multivariada de regressão de Cox, em um modelo com TECR, a classe funcional, BNP ou NT-ProBNP e a presença de platô no pulso de oxigênio foram identificadas como preditores independentes para pior sobrevida na população avaliada em relação à DC6M e ao VSi, na reavaliação. Conclusão: A presença de platô no pulso de O2 na reavaliação dos pacientes com HAP apresenta associação com mortalidade ou transplante. Sua incorporação em modelo simplificado multiparamétrico de avaliação de risco de seguimento agrega maior discriminação de prognóstico, comparativamente à adição do VSi. Além disso, os escores de estratificação de risco da ERS/ESC, COMPERA 2.0 e REVEAL LITE 2.0 demonstram habilidade de discriminar desfechos nesta amostra de pacientes com HAP.
Introduction: Pulmonary arterial hypertension is a rare, serious and debilitating hemodynamic condition. Its high mortality rate is recognized, highlighting the importance of periodic multiparametric assessment for risk stratification and therapeutic guidance, with hemodynamic data obtained through cardiac catheterization for safety playing a significant role in determining severity. To date, few studies have addressed the prognostic factors of cardiopulmonary exercise testing in multiparametric risk stratification. Objective: To evaluate the role of the O2 pulse plateau in the multiparametric follow-up assessment of patients with PAH. Methods: Observational retrospective cohort study systematically monitored in the Pulmonary Circulation Sector of Hospital São Paulo – UNIFESP. The medical records of patients with PAH treated at the Pulmonary Circulation Diseases outpatient clinic of the Pulmonology Department were reviewed, from January 2005 to December 2018 and followed until August 2022. Baseline risk stratification (ESC/ERS 2022 and REVEAL Lite) and follow-up (ESC/ERS 2022 of 3 and 4 strata and REVEAL Lite) were carried out. Potential prognostic factors were identified by univariate analysis and multivariate Cox regression, with models including the presence of O2 pulse plateau. The Kaplan-Meier method was used to determine overall survival. Results: 144 patients were selected for this study. The sample was predominantly young and female (82.6%), with a mean age of 42 years, a mean 6MWD of 423 ± 93 m, and 53.5% of patients were in NYHA functional class III or IV. Among the cohort, during the median follow-up period of 7 years, 59 (40.9%) patients died and 7 (4.8%) underwent lung transplantation, with an estimated 1-year survival of 98.6%, 3-year survival of 89.3%, and 5-year survival of 77.3%. Multivariate Cox regression analysis, in a model with TECR, functional class, BNP or NT-ProBNP, and the presence of a plateau in the oxygen pulse were identified as independent predictors of worse survival in the population evaluated in relation to 6MWD and VSi, at the reassessment. Conclusion: The presence of a plateau in the O2 pulse during the reassessment of patients with PAH is associated with mortality or transplantation. Its incorporation into a simplified multiparametric model for follow-up risk assessment provides greater prognostic discrimination compared to the addition of VSi. In addition, the risk stratification scores of ERS/ESC, COMPERA 2.0, and REVEAL LITE 2.0 demonstrate the ability to discriminate outcomes in this sample of patients with PAH.
Introduction: Pulmonary arterial hypertension is a rare, serious and debilitating hemodynamic condition. Its high mortality rate is recognized, highlighting the importance of periodic multiparametric assessment for risk stratification and therapeutic guidance, with hemodynamic data obtained through cardiac catheterization for safety playing a significant role in determining severity. To date, few studies have addressed the prognostic factors of cardiopulmonary exercise testing in multiparametric risk stratification. Objective: To evaluate the role of the O2 pulse plateau in the multiparametric follow-up assessment of patients with PAH. Methods: Observational retrospective cohort study systematically monitored in the Pulmonary Circulation Sector of Hospital São Paulo – UNIFESP. The medical records of patients with PAH treated at the Pulmonary Circulation Diseases outpatient clinic of the Pulmonology Department were reviewed, from January 2005 to December 2018 and followed until August 2022. Baseline risk stratification (ESC/ERS 2022 and REVEAL Lite) and follow-up (ESC/ERS 2022 of 3 and 4 strata and REVEAL Lite) were carried out. Potential prognostic factors were identified by univariate analysis and multivariate Cox regression, with models including the presence of O2 pulse plateau. The Kaplan-Meier method was used to determine overall survival. Results: 144 patients were selected for this study. The sample was predominantly young and female (82.6%), with a mean age of 42 years, a mean 6MWD of 423 ± 93 m, and 53.5% of patients were in NYHA functional class III or IV. Among the cohort, during the median follow-up period of 7 years, 59 (40.9%) patients died and 7 (4.8%) underwent lung transplantation, with an estimated 1-year survival of 98.6%, 3-year survival of 89.3%, and 5-year survival of 77.3%. Multivariate Cox regression analysis, in a model with TECR, functional class, BNP or NT-ProBNP, and the presence of a plateau in the oxygen pulse were identified as independent predictors of worse survival in the population evaluated in relation to 6MWD and VSi, at the reassessment. Conclusion: The presence of a plateau in the O2 pulse during the reassessment of patients with PAH is associated with mortality or transplantation. Its incorporation into a simplified multiparametric model for follow-up risk assessment provides greater prognostic discrimination compared to the addition of VSi. In addition, the risk stratification scores of ERS/ESC, COMPERA 2.0, and REVEAL LITE 2.0 demonstrate the ability to discriminate outcomes in this sample of patients with PAH.
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Citação
DAUD, Meliane de Oliveira. Papel prognóstico do teste de exercício cardiorrespiratório na avaliação de seguimento dos pacientes com hipertensão arterial pulmonar. 2024. 73 f. Tese (Doutorado em Pneumologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo. (UNIFESP). São Paulo, 2024.