Anticoagulation in pulmonary arterial hypertension: a decision analysis

Abstract

Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43–0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66–1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.

Use of Oral Anticoagulant Drugs in Patients with Pulmonary Hypertension

“…Importantly, in the 12 studies included in the meta-analysis, in almost all of them VKAs were the only OAC used. Furthermore, modelling data seem to confirm the beneficial effect of OAC in idiopathic PAH patients, with a significant improvement in risk of outcomes and gain in terms of quality of life 34 . The use of OAC in CTEPH is pivotally indicated by its thromboembolic origin, even though this indication has not been supported by specific studies and the specific evidence is substantially scarce 2 .…”

Cyanotic Congenital Heart Disease in Pregnancy: A Review of Pathophysiology and Management

“…62 There is limited literature supporting prophylaxis in patients with PAH, and it is controversial whether this data can be applied to patients with ES. 62,65 Currently, there is no clinical data evaluating the risk and benefit of thromboembolic prophylaxis in pregnant patients with ES, and further studies are essential. 62…”

Pulmonary hypertension in the primary care setting

“…However, this is no longer routinely recommended. Jose et al 11 reports differing results regarding the use of anticoagulation in Group 1 pulmonary hypertension patients. Idiopathic pulmonary arterial hypertension patients were reported to have improved quality-adjusted life years, whereas patients with connective tissue disease-associated pulmonary arterial hypertension did not.…”

“…However, this is no longer routinely recommended. Jose et al 11 . reports differing results regarding the use of anticoagulation in Group 1 pulmonary hypertension patients.…”