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COPD is frequently associated with mild to moderate pulmonary hypertension (PH). However, a small subset of patients develops severe PH, which is currently haemodynamically defined as mean pulmonary arterial pressure (mPAP) ⩾35 mmHg, or mPAP ⩾25 mmHg in combination with cardiac index <2.0 L•min −1 •m −2 [1, 2]. These cut-offs are, however, arbitrary and mainly based on expert opinion. In this study we aimed to determine prognostically relevant haemodynamic thresholds for severe PH in COPD by using an unbiased approach.We retrospectively analysed COPD patients with at least 1-year follow-up who underwent right heart catheterisation (RHC) and clinical evaluation at our clinic due to suspected PH between 2003 and 2018. RHC was performed in the supine position, with a mid-thoracic zero reference level, as previously described [3]. All data were included into a prospective local database (GRAPHIC (GRAz Pulmonary Hypertension In COPD) registry). Patients undergoing lung transplantation at any time (n=3) were excluded from this analysis. We performed Cox regression analysis, adjusting for age, sex and forced expiratory volume in 1 s (FEV 1 ) with the primary outcome all-cause mortality. For identification of the best prognostic cut-offs, we searched for the lowest p-values. Continuous baseline characteristics of the groups according to the best cut-off were compared using independent t-tests or Mann-Whitney U-test, as appropriate. Continuous variables are described as mean±SD or median (interquartile range), as appropriate. The study was approved by the institutional ethics board (EK: 32-180 ex 19/20) of the Medical University Graz.We included 139 COPD patients (age 68 (62-73) years; 55.4% male; mPAP 35 (27-43) mmHg; pulmonary vascular resistance (PVR) 4.3 (2.9-7.3) WU; FEV 1 56±20% predicted). 72 patients (52%) died during a follow-up of 8.0 (3.8-11.7) years, with a median time to death of 3.0 (1.3-5.2) years. 61 (44%) patients received any PAH drug at any time-point.Out of the examined haemodynamic parameters, after adjustment for age, sex and FEV 1 , PVR (HR 1.09, 95% CI 1.02-1.16; p=0.007) and mPAP (HR 1.03, 95% CI 1.01-1.05; p=0.001) were associated with survival, while pulmonary arterial wedge pressure (PAWP) and cardiac index were not ( p=0.696 and p=0.171). Among all haemodynamic parameters, PVR >5.0 WU was the best prognostic cut-off (HR 2.59, 95% CI 1.58-4.27; p<0.001) (figure 1a). Patients with PVR >5.0 WU were more frequently males ( p<0.001) and had a lower 6-min walk distance (254±112 versus 333±117 m; p<0.001), lower peak oxygen uptake (41±13 versus 61±23% predicted; p<0.001) and higher N-terminal pro brain natriuretic peptide (2288 (694-3634) versus 442 (160-1126) pg•mL −1 ; p<0.001) as compared to patients with PVR ⩽5.0 WU.For mPAP, the p-values for potential cut-off scores showed two equivalent minimal levels, the first at 33 mmHg (HR 2.26, 95% CI 1.37-3.71; p=0.001) (figure 1b) and the second at 45 mmHg (HR 2.44, 95% CI 1.43-4.16; p=0.001). Out of the patients with mPAP ⩾33 mmHg, n=28 (36%) and n=49 ...

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IntroductionSleep related breathing disorders (SRBD) are associated with both obesity and systemic inflammation. While the relationship between obesity and SRBD is established, the causality between inflammation and SRBD remains unclear. In this study we investigated the relation between SRBD and C-reactive protein (CRP) as a parameter of inflammation and the influence of SRBD treatment on CRP with additional regard to changes in metabolic and cardiovascular parameters.MethodsPolysomnography (PSG) and laboratory data of patients diagnosed with SRBD over a period of 5 years were prospectively collected in a database and retrospectively analysed regarding the association of SRBD (according to apnoea-hypopnoea- index (AHI), duration of events and extent of desaturation) to CRP, blood pressure, cholesterol, fasting plasma glucose, HbA1c, quality of life measured via a visual analogue scale (VAS 0–100%), and the effects of SRBD therapy on these parameters.Results716 patients were included in the study, 171 with mild SRBD (AHI ≥5 to <15/h), 209 with moderate SRBD (AHI 15 to <30/h), 336 with severe SRBD (AHI ≥30/h). Results according to severity of SRBD. Severe SRBD was significantly associated with elevated levels of CRP (3.7 [1.8–7.0] mg/l, vs. moderate (p = 0.001), and mild SRBD (p<0.001), and higher prevalence of hypertension as compared to moderate and mild SRBD (p<0.001, respectively). Results in highly successful treatment. If SRBD treatment was highly successful (AHI <5/h), CRP and quality of life improved significantly (p = 0.001 and p = 0.002), as did blood pressure (p<0.001 for systolic and diastolic values), although BMI increased (p<0.001). Results in partially successful treatment. If success was defined as reduction of AHI of ≥50%, CRP also decreased (p<0.001), as did blood pressure (p<0.001). Again, BMI increased (p<0.001).ConclusionThis is the first study to show an association of SRBD and CRP independently of BMI in a large cohort. The SRBD therapy-induced CRP decrease was not associated with BMI changes or metabolic changes but rather with the magnitude of AHI improvement.

IntroductionPositional therapy is a simple means of therapy in sleep apnoea syndrome, but due to controversial or lacking evidence, it is not widely accepted as appropriate treatment. In this study, we analysed data to positional therapy with regard to successful reduction of AHI and predictors of success.MethodsAll consecutive patients undergoing polysomnography between 2007 and 2011 were analysed. We used a strict definition of positional sleep apnoea syndrome (supine-exclusive sleep apnoea syndrome) and of therapy used. Patients underwent polysomnography initially and during follow-up.Results1275 patients were evaluated, 112 of which had supine-exclusive sleep apnoea syndrome (AHI 5-66/h, median 13/h), 105 received positional therapy. With this treatment alone 75% (70/105) reached an AHI <5/h, in the follow-up 1 year later 37% (37/105) of these still had AHI<5/h, 46% (43/105) yielded an AHI between 5 and 10/h. Nine patient switched to APAP due to deterioration, 3 wanted to try APAP due to comfort reasons. At the last follow-up, 32% patients (34/105) were still on positional therapy with AHI <5/h. BMI was a predictor for successful reduction of AHI, but success was independent of sex, the presence of obstructive versus central sleep apnoea, severity of sleep apnoea syndrome or co-morbidities.ConclusionPositional therapy may be a promising therapy option for patients with positional sleep apnoea. With appropriate adherence it yields a reasonable success rate in the clinical routine.