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Ask PAs to Complete Survey on Joining 1st SVS ‘Section’
SVS President Dr. Clem Darling is asking all members to pass an email message – and survey – along to PAs and Nurse Practitioners with whom members work.
During the recent Vascular Annual Meeting, SVS leaders met with six physician assistants, all of whom work in vascular settings, and asked if they wish to work on establishing a home within the SVS. “Their response was a resounding and enthusiastic …YES!,” said Dr. Darling.
The group has now become the Steering Committee organizing the effort to create the historic first "Section" of the SVS.
SVS President Dr. Clem Darling is asking all members to pass an email message – and survey – along to PAs and Nurse Practitioners with whom members work.
During the recent Vascular Annual Meeting, SVS leaders met with six physician assistants, all of whom work in vascular settings, and asked if they wish to work on establishing a home within the SVS. “Their response was a resounding and enthusiastic …YES!,” said Dr. Darling.
The group has now become the Steering Committee organizing the effort to create the historic first "Section" of the SVS.
SVS President Dr. Clem Darling is asking all members to pass an email message – and survey – along to PAs and Nurse Practitioners with whom members work.
During the recent Vascular Annual Meeting, SVS leaders met with six physician assistants, all of whom work in vascular settings, and asked if they wish to work on establishing a home within the SVS. “Their response was a resounding and enthusiastic …YES!,” said Dr. Darling.
The group has now become the Steering Committee organizing the effort to create the historic first "Section" of the SVS.
Claim 2017 VAM Credits
Here’s how to claim Continuing Medical Education or MOC credits from the 2017 Vascular Annual Meeting.
1 Access the CME site, either through the Mobile App or through the website link: www.vsweb.org/ClaimCME
2 Log in, using either:
1 Last name and email address tied to your VAM registration OR
2 Registration ID number (no hyphens), located on registration confirmation or ID badges.
3 Follow the directions to list sessions, provide evaluations, take exams and generate credit certificates.
(Please note that the RPVI self-assessment process requires you to log in from a laptop or desktop computer.)
Credits must be claimed by Dec. 31. For more information, email [email protected].
Here’s how to claim Continuing Medical Education or MOC credits from the 2017 Vascular Annual Meeting.
1 Access the CME site, either through the Mobile App or through the website link: www.vsweb.org/ClaimCME
2 Log in, using either:
1 Last name and email address tied to your VAM registration OR
2 Registration ID number (no hyphens), located on registration confirmation or ID badges.
3 Follow the directions to list sessions, provide evaluations, take exams and generate credit certificates.
(Please note that the RPVI self-assessment process requires you to log in from a laptop or desktop computer.)
Credits must be claimed by Dec. 31. For more information, email [email protected].
Here’s how to claim Continuing Medical Education or MOC credits from the 2017 Vascular Annual Meeting.
1 Access the CME site, either through the Mobile App or through the website link: www.vsweb.org/ClaimCME
2 Log in, using either:
1 Last name and email address tied to your VAM registration OR
2 Registration ID number (no hyphens), located on registration confirmation or ID badges.
3 Follow the directions to list sessions, provide evaluations, take exams and generate credit certificates.
(Please note that the RPVI self-assessment process requires you to log in from a laptop or desktop computer.)
Credits must be claimed by Dec. 31. For more information, email [email protected].
Get involved with AGA
We’re soliciting members to serve in AGA leadership positions – as committee and center members, as well as on the AGA Institute Governing Board. This is an opportunity to network with other physicians and scientists, pursue a special interest, and make an impact in an area that is important to you.
Join a committee or center
AGA and AGA Institute are seeking members to serve on several committees and centers that recommend and oversee new and existing policies and programs. Terms will start in June 2018; nominations must be received by Nov. 1, 2017. Members can either nominate themselves or other members. For more information on the positions available, take a look at the AGA Committee page, http://www.gastro.org/about/people/committees.
Serve in a leadership position
The AGA Nominating Committee is in the midst of identifying candidates to join the governing board – in the offices of vice president, clinical research councillor, and practice councillor – as well as 10 nominees for the 2018-2019 AGA Nominating Committee. To learn more, or to nominate yourself or a colleague, email [email protected]. Nominations are due by Oct. 1, 2017; earlier submissions are encouraged.
We’re soliciting members to serve in AGA leadership positions – as committee and center members, as well as on the AGA Institute Governing Board. This is an opportunity to network with other physicians and scientists, pursue a special interest, and make an impact in an area that is important to you.
Join a committee or center
AGA and AGA Institute are seeking members to serve on several committees and centers that recommend and oversee new and existing policies and programs. Terms will start in June 2018; nominations must be received by Nov. 1, 2017. Members can either nominate themselves or other members. For more information on the positions available, take a look at the AGA Committee page, http://www.gastro.org/about/people/committees.
Serve in a leadership position
The AGA Nominating Committee is in the midst of identifying candidates to join the governing board – in the offices of vice president, clinical research councillor, and practice councillor – as well as 10 nominees for the 2018-2019 AGA Nominating Committee. To learn more, or to nominate yourself or a colleague, email [email protected]. Nominations are due by Oct. 1, 2017; earlier submissions are encouraged.
We’re soliciting members to serve in AGA leadership positions – as committee and center members, as well as on the AGA Institute Governing Board. This is an opportunity to network with other physicians and scientists, pursue a special interest, and make an impact in an area that is important to you.
Join a committee or center
AGA and AGA Institute are seeking members to serve on several committees and centers that recommend and oversee new and existing policies and programs. Terms will start in June 2018; nominations must be received by Nov. 1, 2017. Members can either nominate themselves or other members. For more information on the positions available, take a look at the AGA Committee page, http://www.gastro.org/about/people/committees.
Serve in a leadership position
The AGA Nominating Committee is in the midst of identifying candidates to join the governing board – in the offices of vice president, clinical research councillor, and practice councillor – as well as 10 nominees for the 2018-2019 AGA Nominating Committee. To learn more, or to nominate yourself or a colleague, email [email protected]. Nominations are due by Oct. 1, 2017; earlier submissions are encouraged.
Mark your calendar: 2018 AGA grants cycle announced
The AGA Research Foundation is excited to announce the start of its 2018 Research Grants cycle. This year the foundation will be awarding over $2 million in funding to support researchers within gastroenterology and hepatology. Now is your chance to view upcoming opportunities and plan your applications. Learn more below about the first application due in August, and visit the AGA Research Funding website (www.gastro.org/research-funding) for the full list. Contact [email protected] with any questions.
Applications due: Aug. 4, 2017
AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer
This award provides $50,000 per year for 2 years to an established investigator working on novel approaches in gastric cancer research. For the past 25 years, this $100,000 award has enhanced the fundamental understanding of gastric cancer pathobiology toward ultimately developing a cure for the disease.
The AGA Research Foundation is excited to announce the start of its 2018 Research Grants cycle. This year the foundation will be awarding over $2 million in funding to support researchers within gastroenterology and hepatology. Now is your chance to view upcoming opportunities and plan your applications. Learn more below about the first application due in August, and visit the AGA Research Funding website (www.gastro.org/research-funding) for the full list. Contact [email protected] with any questions.
Applications due: Aug. 4, 2017
AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer
This award provides $50,000 per year for 2 years to an established investigator working on novel approaches in gastric cancer research. For the past 25 years, this $100,000 award has enhanced the fundamental understanding of gastric cancer pathobiology toward ultimately developing a cure for the disease.
The AGA Research Foundation is excited to announce the start of its 2018 Research Grants cycle. This year the foundation will be awarding over $2 million in funding to support researchers within gastroenterology and hepatology. Now is your chance to view upcoming opportunities and plan your applications. Learn more below about the first application due in August, and visit the AGA Research Funding website (www.gastro.org/research-funding) for the full list. Contact [email protected] with any questions.
Applications due: Aug. 4, 2017
AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer
This award provides $50,000 per year for 2 years to an established investigator working on novel approaches in gastric cancer research. For the past 25 years, this $100,000 award has enhanced the fundamental understanding of gastric cancer pathobiology toward ultimately developing a cure for the disease.
Crohn’s & Colitis Congress registration open
Join the Crohn’s & Colitis Foundation and AGA for the inaugural Crohn’s & Colitis Congress™. Expand your knowledge, network with inflammatory bowel diseases (IBD) leaders across multiple disciplines and get inspired to improve patient care.
The Crohn’s & Colitis Congress, taking place Jan. 18-20, 2018 in Las Vegas, combines the strengths of the nation’s leading IBD patient organization, Crohn’s & Colitis Foundation, and the premier GI professional association, AGA. Together we are committed to convening the greatest minds in IBD to transform patient care and accelerate the pace of research.
The Crohn’s & Colitis Congress offers a bold multidisciplinary, clinically focused and forward-thinking program. The organizing committee and faculty represent key disciplines involved in the comprehensive care of IBD patients, as well as the foremost minds in research.
Sessions will emphasize case studies with multidisciplinary panel discussions covering:
- • Management of complicated IBD
- • Defining optimal treatment algorithms
- • Clinical and research challenges
Take a critical step toward finding cures and improving the lives of adults and children living with IBD. Learn more about the congress and register today by visiting www.crohnscolitiscongress.org.
Join the Crohn’s & Colitis Foundation and AGA for the inaugural Crohn’s & Colitis Congress™. Expand your knowledge, network with inflammatory bowel diseases (IBD) leaders across multiple disciplines and get inspired to improve patient care.
The Crohn’s & Colitis Congress, taking place Jan. 18-20, 2018 in Las Vegas, combines the strengths of the nation’s leading IBD patient organization, Crohn’s & Colitis Foundation, and the premier GI professional association, AGA. Together we are committed to convening the greatest minds in IBD to transform patient care and accelerate the pace of research.
The Crohn’s & Colitis Congress offers a bold multidisciplinary, clinically focused and forward-thinking program. The organizing committee and faculty represent key disciplines involved in the comprehensive care of IBD patients, as well as the foremost minds in research.
Sessions will emphasize case studies with multidisciplinary panel discussions covering:
- • Management of complicated IBD
- • Defining optimal treatment algorithms
- • Clinical and research challenges
Take a critical step toward finding cures and improving the lives of adults and children living with IBD. Learn more about the congress and register today by visiting www.crohnscolitiscongress.org.
Join the Crohn’s & Colitis Foundation and AGA for the inaugural Crohn’s & Colitis Congress™. Expand your knowledge, network with inflammatory bowel diseases (IBD) leaders across multiple disciplines and get inspired to improve patient care.
The Crohn’s & Colitis Congress, taking place Jan. 18-20, 2018 in Las Vegas, combines the strengths of the nation’s leading IBD patient organization, Crohn’s & Colitis Foundation, and the premier GI professional association, AGA. Together we are committed to convening the greatest minds in IBD to transform patient care and accelerate the pace of research.
The Crohn’s & Colitis Congress offers a bold multidisciplinary, clinically focused and forward-thinking program. The organizing committee and faculty represent key disciplines involved in the comprehensive care of IBD patients, as well as the foremost minds in research.
Sessions will emphasize case studies with multidisciplinary panel discussions covering:
- • Management of complicated IBD
- • Defining optimal treatment algorithms
- • Clinical and research challenges
Take a critical step toward finding cures and improving the lives of adults and children living with IBD. Learn more about the congress and register today by visiting www.crohnscolitiscongress.org.
This Month in CHEST: Editor’s Picks
Giants in Chest Medicine
John B. West, MD, PhD, DSc
By Dr. F. L. Powell
Original Research
Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.
By Dr. P. C. Hou, et al.
Maximal Inspiratory Pressure: Does the Choice of Reference Values Actually Matter?
By Dr. A. Rodrigues, et al.
Research Into Childhood Obstructive Sleep-Disordered Breathing:
A Systematic Review
By Dr. R. P. Venekamp, et al.
Topics in Practice Management
Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations
By Drs.Y. Shieh and M. Bohnenkamp
Giants in Chest Medicine
John B. West, MD, PhD, DSc
By Dr. F. L. Powell
Original Research
Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.
By Dr. P. C. Hou, et al.
Maximal Inspiratory Pressure: Does the Choice of Reference Values Actually Matter?
By Dr. A. Rodrigues, et al.
Research Into Childhood Obstructive Sleep-Disordered Breathing:
A Systematic Review
By Dr. R. P. Venekamp, et al.
Topics in Practice Management
Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations
By Drs.Y. Shieh and M. Bohnenkamp
Giants in Chest Medicine
John B. West, MD, PhD, DSc
By Dr. F. L. Powell
Original Research
Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.
By Dr. P. C. Hou, et al.
Maximal Inspiratory Pressure: Does the Choice of Reference Values Actually Matter?
By Dr. A. Rodrigues, et al.
Research Into Childhood Obstructive Sleep-Disordered Breathing:
A Systematic Review
By Dr. R. P. Venekamp, et al.
Topics in Practice Management
Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations
By Drs.Y. Shieh and M. Bohnenkamp
SLEEP STRATEGIES: Group 3 pulmonary hypertension linked to sleep-disordered breathing
Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).
The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).
The incidence of OSA is rising in parallel with the rising global incide
Patients with OSA who have PH are more likely to be obese, have decreased respiratory function (FEV1, vital capacity, and FEV1/VC ratio), and lower oxygen saturation/higher carbon dioxide content in blood (Chaouat et al. Chest. 1996;109[2]:380). These patients frequently present with shortness of breath and dyspnea on exertion. Echocardiogram remains the main screening tool for evaluation of PH. With that said, right-sided heart catheterization remains the gold standard for the diagnosis of all classes of PH; however, use of right-sided heart catheterization in group 3 pulmonary hypertension is reserved for select patients. This is likely because PH in patients with OSA is accepted as a more benign prognostic marker compared with other group 3 forms. Furthermore, patients with OHS are more prone to developing PH and cor pulmonale compared with patients with isolated OSA. OSA with PH has lower survival rates than OSA without PH. Studies showed that patients with OHS tend to do worse than patients with OSA alone (Aljohara et al. J Thorac Dis. 2017;9[3]:779).
AHI and PH
Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).
Treatment
The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that
Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.
Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).
The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).
The incidence of OSA is rising in parallel with the rising global incide
Patients with OSA who have PH are more likely to be obese, have decreased respiratory function (FEV1, vital capacity, and FEV1/VC ratio), and lower oxygen saturation/higher carbon dioxide content in blood (Chaouat et al. Chest. 1996;109[2]:380). These patients frequently present with shortness of breath and dyspnea on exertion. Echocardiogram remains the main screening tool for evaluation of PH. With that said, right-sided heart catheterization remains the gold standard for the diagnosis of all classes of PH; however, use of right-sided heart catheterization in group 3 pulmonary hypertension is reserved for select patients. This is likely because PH in patients with OSA is accepted as a more benign prognostic marker compared with other group 3 forms. Furthermore, patients with OHS are more prone to developing PH and cor pulmonale compared with patients with isolated OSA. OSA with PH has lower survival rates than OSA without PH. Studies showed that patients with OHS tend to do worse than patients with OSA alone (Aljohara et al. J Thorac Dis. 2017;9[3]:779).
AHI and PH
Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).
Treatment
The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that
Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.
Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).
The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).
The incidence of OSA is rising in parallel with the rising global incide
Patients with OSA who have PH are more likely to be obese, have decreased respiratory function (FEV1, vital capacity, and FEV1/VC ratio), and lower oxygen saturation/higher carbon dioxide content in blood (Chaouat et al. Chest. 1996;109[2]:380). These patients frequently present with shortness of breath and dyspnea on exertion. Echocardiogram remains the main screening tool for evaluation of PH. With that said, right-sided heart catheterization remains the gold standard for the diagnosis of all classes of PH; however, use of right-sided heart catheterization in group 3 pulmonary hypertension is reserved for select patients. This is likely because PH in patients with OSA is accepted as a more benign prognostic marker compared with other group 3 forms. Furthermore, patients with OHS are more prone to developing PH and cor pulmonale compared with patients with isolated OSA. OSA with PH has lower survival rates than OSA without PH. Studies showed that patients with OHS tend to do worse than patients with OSA alone (Aljohara et al. J Thorac Dis. 2017;9[3]:779).
AHI and PH
Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).
Treatment
The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that
Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.
Veterans' AAA Screening July 22-25; SFS Foundation a Sponsor as Part of Its Expanded Mission
The SVS Foundation is helping sponsor free abdominal aortic aneurysm screenings for veterans at the Veterans of Foreign Wars’ national convention in New Orleans July 22-25. The screenings are offered by New Orleans-based non-profit AAAneurysm Outreach in partnership with the VFW, the SVS Foundation and W.L. Gore Inc.
The SVS Foundation will distribute written materials for veterans, offering more information on AAAs and how to find a doctor who specializes in vascular diseases and abnormalities. The screening, in which as many as 2,000 veterans are expected to participate, is the SVS Foundation’s first event since expanding its mission in June to include providing patient education in vascular health.
SVS members are encouraged to spread the word about the screenings to patients who plan to attend the convention.
The SVS Foundation is helping sponsor free abdominal aortic aneurysm screenings for veterans at the Veterans of Foreign Wars’ national convention in New Orleans July 22-25. The screenings are offered by New Orleans-based non-profit AAAneurysm Outreach in partnership with the VFW, the SVS Foundation and W.L. Gore Inc.
The SVS Foundation will distribute written materials for veterans, offering more information on AAAs and how to find a doctor who specializes in vascular diseases and abnormalities. The screening, in which as many as 2,000 veterans are expected to participate, is the SVS Foundation’s first event since expanding its mission in June to include providing patient education in vascular health.
SVS members are encouraged to spread the word about the screenings to patients who plan to attend the convention.
The SVS Foundation is helping sponsor free abdominal aortic aneurysm screenings for veterans at the Veterans of Foreign Wars’ national convention in New Orleans July 22-25. The screenings are offered by New Orleans-based non-profit AAAneurysm Outreach in partnership with the VFW, the SVS Foundation and W.L. Gore Inc.
The SVS Foundation will distribute written materials for veterans, offering more information on AAAs and how to find a doctor who specializes in vascular diseases and abnormalities. The screening, in which as many as 2,000 veterans are expected to participate, is the SVS Foundation’s first event since expanding its mission in June to include providing patient education in vascular health.
SVS members are encouraged to spread the word about the screenings to patients who plan to attend the convention.
Webinars Set on Medicare Reimbursement
The SVS and Patient Safety Organization will host a Medicare reimbursement webinar on July 26 and 27, titled "The Quality Payment Program is Not Going Away: The Merit Based Incentive Payment Model (MIPS) and the Advanced Alternative Payment Models under Medicare for Vascular Surgeons."
Presentations will be at 6 p.m. Central Daylight Time Wednesday, July 26, and at noon (CDT) on Thursday, July 27.
Participants can learn how to avoid a 4 percent penalty in 2019 and possibly obtain bonus payments. The webinar will provide step-by-step guidance on:
• How to verify your participation status so you will know whether you need to submit data to MIPS or not
• Reporting quality measures via Medicare claims forms
• How to attest to performing a clinical improvement activity to CMS
• Participating in electronic health records
The SVS and Patient Safety Organization will host a Medicare reimbursement webinar on July 26 and 27, titled "The Quality Payment Program is Not Going Away: The Merit Based Incentive Payment Model (MIPS) and the Advanced Alternative Payment Models under Medicare for Vascular Surgeons."
Presentations will be at 6 p.m. Central Daylight Time Wednesday, July 26, and at noon (CDT) on Thursday, July 27.
Participants can learn how to avoid a 4 percent penalty in 2019 and possibly obtain bonus payments. The webinar will provide step-by-step guidance on:
• How to verify your participation status so you will know whether you need to submit data to MIPS or not
• Reporting quality measures via Medicare claims forms
• How to attest to performing a clinical improvement activity to CMS
• Participating in electronic health records
The SVS and Patient Safety Organization will host a Medicare reimbursement webinar on July 26 and 27, titled "The Quality Payment Program is Not Going Away: The Merit Based Incentive Payment Model (MIPS) and the Advanced Alternative Payment Models under Medicare for Vascular Surgeons."
Presentations will be at 6 p.m. Central Daylight Time Wednesday, July 26, and at noon (CDT) on Thursday, July 27.
Participants can learn how to avoid a 4 percent penalty in 2019 and possibly obtain bonus payments. The webinar will provide step-by-step guidance on:
• How to verify your participation status so you will know whether you need to submit data to MIPS or not
• Reporting quality measures via Medicare claims forms
• How to attest to performing a clinical improvement activity to CMS
• Participating in electronic health records
Family Fun in Toronto!
While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!
Family Escape Room - Loonie for Luck/The Moonshine Mile
Weekly Friday-Sunday
Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.
Royal Ontario Museum - Dinosaur Gallery
Ripley’s Aquarium of Canada
Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.
Toronto’s Ultimate Chocolate Tour
Weekly, Saturdays
1:00 PM - 4:00 PM
If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!
Ontario Science Centre
An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!
Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.
While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!
Family Escape Room - Loonie for Luck/The Moonshine Mile
Weekly Friday-Sunday
Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.
Royal Ontario Museum - Dinosaur Gallery
Ripley’s Aquarium of Canada
Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.
Toronto’s Ultimate Chocolate Tour
Weekly, Saturdays
1:00 PM - 4:00 PM
If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!
Ontario Science Centre
An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!
Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.
While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!
Family Escape Room - Loonie for Luck/The Moonshine Mile
Weekly Friday-Sunday
Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.
Royal Ontario Museum - Dinosaur Gallery
Ripley’s Aquarium of Canada
Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.
Toronto’s Ultimate Chocolate Tour
Weekly, Saturdays
1:00 PM - 4:00 PM
If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!
Ontario Science Centre
An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!
Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.