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Combining bosentan and sildenafil in pulmonary arterial hypertension patients failing monotherapy: real-world insights

Fabio Dardi, Alessandra Manes, Massimiliano Palazzini, Cristina Bachetti, Gaia Mazzanti, Andrea Rinaldi, Alessandra Albini, Enrico Gotti, Enrico Monti, Maria Letizia Bacchi Reggiani, Nazzareno Galiè
European Respiratory Journal 2015 46: 414-421; DOI: 10.1183/09031936.00209914
Fabio Dardi
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Alessandra Manes
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Massimiliano Palazzini
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Cristina Bachetti
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Gaia Mazzanti
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Andrea Rinaldi
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Alessandra Albini
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Enrico Gotti
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Enrico Monti
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Maria Letizia Bacchi Reggiani
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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Nazzareno Galiè
Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Bologna University Hospital, Bologna, Italy
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  • For correspondence: nazzareno.galie@unibo.it
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  • FIGURE 1
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    FIGURE 1

    Overall survival. a) All-cause mortality and b) all-cause mortality by aetiology. PAH: pulmonary arterial hypertension; CHD: congenital heart disease; CTD: connective tissue disease; IPAH: idiopathic PAH; HPAH: heritable PAH. The percentages show the number of patients surviving.

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    FIGURE 2

    Non-elective hospitalisation- free survival for all-cause mortality. The percentages given are for patients alive and not requiring hospitalisation.

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    FIGURE 3

    All-cause mortality and triple combination therapy-free survival. Percentages shown are for patients alive and not requiring triple combination therapy.

  • FIGURE 4
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    FIGURE 4

    All-cause mortality for non-elective hospitalisation and triple combination therapy-free survival. Percentages shown are for patients alive and not requiring hospitalisation or triple combination therapy.

Tables

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  • TABLE 1

    Baseline characteristics at initiation of combination therapy

    All patientsIPAH/HPAHPAH-CHDPAH-CTD
    Patients n1811026129
    Male %40483817
    Age at initiation of combination therapy years50 (36–62)50 (36–62)45 (31–54)66 (58–72)
    Duration of monotherapy months16 (5–39)14 (4–35)26 (8–51)13 (6–27)
    New York Heart Association functional class III/IV %52543972
    6-min walking distance m425 (307–491)441 (271–516)428 (383–494)360 (219–425)
    Right atrial pressure mmHg9 (7–13)8 (7–12)9 (7–12)12 (7–16)
    Mean pulmonary arterial pressure mmHg62 (51–75)59 (49–69)78 (65–90)50 (44–56)
    Pulmonary wedge pressure mmHg10 (8–12)10 (8–12)11 (9–12)9 (6–12)
    Mean systemic arterial pressure mmHg85 (77–93)85 (77–91)82 (75–94)89 (82–97)
    Cardiac index L·min−1·m−22.2 (1.9–2.6)2.3 (1.9–2.7)2.1 (1.8–2.6)2.1 (1.9–2.4)
    Pulmonary vascular resistance WU13 (10–18)12 (9–16)17 (13–27)13 (8–14)
    Systemic vascular resistance WU20 (16–24)18 (16–23)21 (16–27)20 (18–25)
    Arterial oxygen saturation %93 (90–96)95 (92–97)90 (84–95)94 (92–97)
    Pulmonary arterial oxygen saturation %64 (57–69)62 (56–67)68 (61–73)60 (51–64)
    • Data are presented as median (interquartile range) unless otherwise stated. PAH: pulmonary arterial hypertension; IPAH: idiopathic PAH; HPAH: heritable PAH; CHD: congenital heart disease; CTD: connective tissue disease; WU: Wood units.

  • TABLE 2

    Symptomatic and haemodynamic parameters at baseline and after 3–4 months of combination therapy

    All patients n=192IPAH/HPAH n=93PAH-CHD n=60PAH-CTD n=28
    Baseline3–4 monthsp-valueBaseline3–4 monthsp-valueBaseline3–4 monthsp-valueBaseline3–4 monthsp-value
    NYHA FC III/IV4935<0.0015132<0.00138280.14671640.687
    6MWD m428 (339–496)465 (380–545)<0.001450 (302–531)498 (376–570)<0.001431 (394–498)456 (425–546)<0.001364 (214–426)397 (310–434)0.030
    RAP mmHg9 (7–12)8 (6–11)0.0038 (6–11)7 (6–10)0.0039 (7–12)9 (7–11)0.40512 (7–16)10 (6–15)0.321
    mPAP mmHg62 (51–76)57 (48–70)<0.00159 (49–69)54 (46–63)<0.00178 (65–90)73 (59–90)<0.00150 (43–56)49 (42–54)0.011
    CI L·min−1·m−22.3 (1.9–2.6)2.5 (2.2–2.9)<0.0012.3 (1.9–2.7)2.7 (2.4–3.0)<0.0012.1 (1.8–2.6)2.4 (2.1–2.9)0.0032.2 (1.9–2.5)2.5 (2.0–2.8)0.010
    PVR WU13 (10–18)11 (8–15)<0.00112 (9–16)10 (7–12)<0.00117 (13–27)14 (9–21)<0.00113 (8–14)9 (7–14)0.003
    • Data are presented as % or median (interquartile range), unless otherwise stated. PAH: pulmonary arterial hypertension; IPAH: idiopathic PAH; HPAH: heritable PAH; CHD: congenital heart disease; CTD: connective tissue disease; NYHA FC: New York Heart Association functional class; 6MWD: 6-min walking distance; RAP: right atrial pressure; mPAP: mean pulmonary arterial pressure; CI: cardiac index; PVR: pulmonary vascular resistance; WU: Wood units. The p-values were determined using a non-parametric Wilcoxon–Mann–Whitney test for all comparisons, except for NYHA that was evaluated by McNemar test.

  • TABLE 3

    Cause of death

    All patientsIPAH/HPAHPAH-CHDPAH-CTD
    Patients1921026129
    Death66341715
     Heart failure40171112
     Sudden death9441
     Haemoptysis4310
     Respiratory failure3300
     Infection3111
     Other30
     Neoplasia1
     Myocardial infarction1
     Renal failure1
     Unknown4400
    • Data are presented as n. PAH: pulmonary arterial hypertension; IPAH: idiopathic PAH; HPAH: heritable PAH; CHD: congenital heart disease; CTD: connective tissue disease.

Additional Files

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  • Supplementary material

    Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

    • Supplementary figures and table - Figures S1-S3 and table S1
  • Disclosures

    • A. Albini
    • A. Albini
    • M.L. Bacchi Reggiani. Albini
    • C. Bachetti
    • F. Dardi
    • N. Galie
    • E. Gotti
    • A. Manes
    • G. Mazzanti
    • E. Monti
    • M. Palazzini
    • A. Rinaldi
    • A. Albini
    • A. Albini
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Combining bosentan and sildenafil in pulmonary arterial hypertension patients failing monotherapy: real-world insights
Fabio Dardi, Alessandra Manes, Massimiliano Palazzini, Cristina Bachetti, Gaia Mazzanti, Andrea Rinaldi, Alessandra Albini, Enrico Gotti, Enrico Monti, Maria Letizia Bacchi Reggiani, Nazzareno Galiè
European Respiratory Journal Aug 2015, 46 (2) 414-421; DOI: 10.1183/09031936.00209914

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Combining bosentan and sildenafil in pulmonary arterial hypertension patients failing monotherapy: real-world insights
Fabio Dardi, Alessandra Manes, Massimiliano Palazzini, Cristina Bachetti, Gaia Mazzanti, Andrea Rinaldi, Alessandra Albini, Enrico Gotti, Enrico Monti, Maria Letizia Bacchi Reggiani, Nazzareno Galiè
European Respiratory Journal Aug 2015, 46 (2) 414-421; DOI: 10.1183/09031936.00209914
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