{"id":1467,"date":"2023-04-25T13:55:11","date_gmt":"2023-04-25T13:55:11","guid":{"rendered":"https:\/\/pulmonarymed-ce.com\/?p=1467"},"modified":"2023-04-26T12:06:00","modified_gmt":"2023-04-26T12:06:00","slug":"pah4","status":"publish","type":"post","link":"https:\/\/pulmonarymed-ce.com\/pah4\/","title":{"rendered":"Multidimensional, Serial Risk Assessment in PAH: How, Why, and Then What to Individualize Goal-Directed Therapy"},"content":{"rendered":"\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">1b) <a href=\"https:\/\/twitter.com\/AlbertaPHdoc?ref_src=twsrc%5Etfw\">@AlbertaPHdoc<\/a> from <a href=\"https:\/\/twitter.com\/hashtag\/Edmonton?src=hash&amp;ref_src=twsrc%5Etfw\">#Edmonton<\/a> will be discussing Serial, Multidimensional <a href=\"https:\/\/twitter.com\/hashtag\/RiskAssessment?src=hash&amp;ref_src=twsrc%5Etfw\">#RiskAssessment<\/a> in <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a>: How, Why, and Then What to Individualize Goal-Directed Therapy. It&#39;s all about \ud83e\udec1 !<br>\ud83d\udc4b<a href=\"https:\/\/twitter.com\/bmprii?ref_src=twsrc%5Etfw\">@bmprii<\/a> <a href=\"https:\/\/twitter.com\/SandeepSahayMD?ref_src=twsrc%5Etfw\">@SandeepSahayMD<\/a> <a href=\"https:\/\/twitter.com\/LucillaPiccari?ref_src=twsrc%5Etfw\">@LucillaPiccari<\/a> <a href=\"https:\/\/twitter.com\/PVRI?ref_src=twsrc%5Etfw\">@PVRI<\/a> <a href=\"https:\/\/twitter.com\/OSitbon?ref_src=twsrc%5Etfw\">@OSitbon<\/a> <a href=\"https:\/\/twitter.com\/jeanlucvachiery?ref_src=twsrc%5Etfw\">@jeanlucvachiery<\/a> <a href=\"https:\/\/twitter.com\/PGeorgeMD?ref_src=twsrc%5Etfw\">@PGeorgeMD<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807872740048898?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">3) Let\u2019s start with a case: 33\u2642\ufe0f presents to <a href=\"https:\/\/twitter.com\/hashtag\/emergencymedicine?src=hash&amp;ref_src=twsrc%5Etfw\">#emergencymedicine<\/a> w\/ dyspnea x 6m + two episodes exertional syncope.<br>Hx: regular methamphetamine use &gt;6 years ago, smoking; active <a href=\"https:\/\/twitter.com\/hashtag\/HIV?src=hash&amp;ref_src=twsrc%5Etfw\">#HIV<\/a> infection, intermittently taking anti-retroviral Rx, but not always adherent. No other meds.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807875164356610?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">5) Initial labs \u27a1\ufe0fNT-proBNP = 12,000 ng\/L, <a href=\"https:\/\/twitter.com\/hashtag\/lymphopenia?src=hash&amp;ref_src=twsrc%5Etfw\">#lymphopenia<\/a> with a <a href=\"https:\/\/twitter.com\/hashtag\/CD4?src=hash&amp;ref_src=twsrc%5Etfw\">#CD4<\/a>+ count of 130. Viral load is elevated &amp; liver enzymes are very high \u2013 ALT 1200, AST 1200, Bilirubin 27 IU\/L. He has acute <a href=\"https:\/\/twitter.com\/hashtag\/kidney?src=hash&amp;ref_src=twsrc%5Etfw\">#kidney<\/a> injury with Cr 300 and eGFR of 32. His chest X-ray is below: <a href=\"https:\/\/t.co\/7Weii5tuPq\">pic.twitter.com\/7Weii5tuPq<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807878419193857?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">7) Answer: A. He has 2 <a href=\"https:\/\/twitter.com\/hashtag\/riskfactors?src=hash&amp;ref_src=twsrc%5Etfw\">#riskfactors<\/a> for pulmonary arterial hypertension (Group 1 <a href=\"https:\/\/twitter.com\/hashtag\/PH?src=hash&amp;ref_src=twsrc%5Etfw\">#PH<\/a>): both methamphetamine &amp; HIV are assoc&#39;d w\/ <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a>. The clear lungs argue against <a href=\"https:\/\/twitter.com\/hashtag\/LV?src=hash&amp;ref_src=twsrc%5Etfw\">#LV<\/a> failure &amp; no signs of <a href=\"https:\/\/twitter.com\/hashtag\/PJP?src=hash&amp;ref_src=twsrc%5Etfw\">#PJP<\/a>. <a href=\"https:\/\/twitter.com\/hashtag\/DVT?src=hash&amp;ref_src=twsrc%5Etfw\">#DVT<\/a>+<a href=\"https:\/\/twitter.com\/hashtag\/PE?src=hash&amp;ref_src=twsrc%5Etfw\">#PE<\/a> could also explain presentation, but less likely to \u27a1\ufe0f bilateral edema.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807881023868928?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">9) You arrange an urgent right heart catheterization <a href=\"https:\/\/twitter.com\/hashtag\/RHC?src=hash&amp;ref_src=twsrc%5Etfw\">#RHC<\/a>: RA 12, RV 65\/7, EDP 19, PA 61\/21 with mean 39, PAWP 12, CO 2.43, CI 1.28, SVI 12, PVR 11 Wood units. MvO2 44%. There is no response to inhaled nitric oxide <a href=\"https:\/\/twitter.com\/hashtag\/iNO?src=hash&amp;ref_src=twsrc%5Etfw\">#iNO<\/a>.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807883422998528?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">11) How would you assess this patient\u2019s risk to determine his treatment?<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807885914316807?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">13) There are several approaches to risk assessment in <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a>. The REVEAL 2.0 score is an updated version of the original <a href=\"https:\/\/twitter.com\/hashtag\/REVEAL?src=hash&amp;ref_src=twsrc%5Etfw\">#REVEAL<\/a> score derived from a large \ud83c\uddfa\ud83c\uddf8 registry.<br>REVEAL original: \ud83d\udd13 <a href=\"https:\/\/t.co\/6V4fgj7ffb\">https:\/\/t.co\/6V4fgj7ffb<\/a><br>REVEAL 2.0 \ud83d\udd13 <a href=\"https:\/\/t.co\/KhrefYMdcl\">https:\/\/t.co\/KhrefYMdcl<\/a> <a href=\"https:\/\/t.co\/LlACTGMYIg\">pic.twitter.com\/LlACTGMYIg<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807888397451265?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">15) REVEAL Lite 2 is an abbreviated version of <a href=\"https:\/\/twitter.com\/hashtag\/REVEAL?src=hash&amp;ref_src=twsrc%5Etfw\">#REVEAL<\/a> 2.0, uses 6 variables (<a href=\"https:\/\/twitter.com\/hashtag\/BNP?src=hash&amp;ref_src=twsrc%5Etfw\">#BNP<\/a>\/NT-proBNP, <a href=\"https:\/\/twitter.com\/hashtag\/6MWD?src=hash&amp;ref_src=twsrc%5Etfw\">#6MWD<\/a>, <a href=\"https:\/\/twitter.com\/hashtag\/NYHA?src=hash&amp;ref_src=twsrc%5Etfw\">#NYHA<\/a> Functional Class, SBP &lt; 110 mm Hg, HR &gt;96 bpm, renal insuff) &amp; retains ability to discriminate pts into Low, Intermediate, &amp; High risk groups.<br>\ud83d\udd13 <a href=\"https:\/\/t.co\/EQIEaTWb7X\">https:\/\/t.co\/EQIEaTWb7X<\/a> <a href=\"https:\/\/t.co\/3oKXOrcNeU\">pic.twitter.com\/3oKXOrcNeU<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807891144613891?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">17) Using the 4-strata approach during follow-up nicely identifies groups with distinct survival trajectories.<br>\ud83d\udd13 <a href=\"https:\/\/t.co\/9Z5hsf1rQA\">https:\/\/t.co\/9Z5hsf1rQA<\/a> <a href=\"https:\/\/t.co\/qdHxkPYLmJ\">pic.twitter.com\/qdHxkPYLmJ<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807893711618048?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">19) This study showed that for patients in functional class II, expert clinicians frequently categorized patients as low risk when, in fact, many were at intermediate or high-risk using objective risk assessment tools. <a href=\"https:\/\/t.co\/Qk1rXSDKfq\">pic.twitter.com\/Qk1rXSDKfq<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807896559570944?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">21) Answer: D. No matter which way we slice it, this pt is high risk. Using the ESC\/ERS table, REVEAL 2.0 &amp; 2.0 Lite, he is hi risk. He is NYHA class III but has syncope, severe hemodynamics w\/\u2b06\ufe0f RAP, \u2b07\ufe0f CI &amp; SVI, very \u2b06\ufe0f NT-proBNP. Even w\/o other data like 6MWD, he is hi risk. <a href=\"https:\/\/t.co\/H4lHu3rebB\">pic.twitter.com\/H4lHu3rebB<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807899776589824?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">23) Answer: C, but it depends on the individual patient. Many factors to consider in addition to risk level, particularly when considering parenteral tx. Also, disease-specific considerations, preferences, &amp; patient-specific factors can influence tx selection. More on this later.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1650807902339317762?ref_src=twsrc%5Etfw\">April 25, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">25) Welcome back!! We are talking Multidimensional, Serial Risk Assessment in <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a> with expert author <a href=\"https:\/\/twitter.com\/AlbertaPHdoc?ref_src=twsrc%5Etfw\">@AlbertaPHdoc<\/a>. \ud83c\udd93CE\/<a href=\"https:\/\/twitter.com\/hashtag\/CME?src=hash&amp;ref_src=twsrc%5Etfw\">#CME<\/a> at the end of this \ud83e\uddf5!<br>\ud83d\udc4b<a href=\"https:\/\/twitter.com\/TamCardio?ref_src=twsrc%5Etfw\">@TamCardio<\/a> <a href=\"https:\/\/twitter.com\/docroham?ref_src=twsrc%5Etfw\">@docroham<\/a> <a href=\"https:\/\/twitter.com\/SudarRajagopal?ref_src=twsrc%5Etfw\">@SudarRajagopal<\/a> <a href=\"https:\/\/twitter.com\/heresi_gustavo?ref_src=twsrc%5Etfw\">@heresi_gustavo<\/a> <a href=\"https:\/\/twitter.com\/RyanTedfordMD?ref_src=twsrc%5Etfw\">@RyanTedfordMD<\/a> <a href=\"https:\/\/twitter.com\/rjbernardoMD?ref_src=twsrc%5Etfw\">@rjbernardoMD<\/a> <a href=\"https:\/\/twitter.com\/kurt_prins?ref_src=twsrc%5Etfw\">@kurt_prins<\/a> <a href=\"https:\/\/twitter.com\/SashaPrisco?ref_src=twsrc%5Etfw\">@SashaPrisco<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194081995890690?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">27) In this algorithm, the distinction is made for patients w\/ &amp; w\/o <a href=\"https:\/\/twitter.com\/hashtag\/cardiopulmonary?src=hash&amp;ref_src=twsrc%5Etfw\">#cardiopulmonary<\/a> <a href=\"https:\/\/twitter.com\/hashtag\/comorbidities?src=hash&amp;ref_src=twsrc%5Etfw\">#comorbidities<\/a>. Pts with significant CP issues were often excluded from <a href=\"https:\/\/twitter.com\/hashtag\/RCTs?src=hash&amp;ref_src=twsrc%5Etfw\">#RCTs<\/a>, &amp; several studies show that such pts do not respond to, or do not tolerate, more aggressive tx. <a href=\"https:\/\/t.co\/BvXEDddxSW\">pic.twitter.com\/BvXEDddxSW<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194084910833664?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">29) For high-risk <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a>, guidelines suggest upfront triple tx, tho strength of evidence for this rec is lower (Class IIa). Non-randomized studies suggested triple therapy may improve long-term survival vs 1 or 2 drugs, especially in high-risk patients.<br>\ud83d\udd13 <a href=\"https:\/\/t.co\/69y8zHGRQt\">https:\/\/t.co\/69y8zHGRQt<\/a> <a href=\"https:\/\/t.co\/CJMWMHxkKn\">pic.twitter.com\/CJMWMHxkKn<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194087574257665?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">31a) Answer: There is no right answer here, but there are several things to consider: 1) can this patient manage the complexity of parenteral drug long-term?<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194090430640132?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">31c) Answer Continued\u2026. <br>3) oral <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a> drugs might not be absorbed and metabolized normally with acute <a href=\"https:\/\/twitter.com\/hashtag\/RV?src=hash&amp;ref_src=twsrc%5Etfw\">#RV<\/a> failure, 4) <a href=\"https:\/\/twitter.com\/hashtag\/ERAs?src=hash&amp;ref_src=twsrc%5Etfw\">#ERAs<\/a>, especially <a href=\"https:\/\/twitter.com\/hashtag\/bosentan?src=hash&amp;ref_src=twsrc%5Etfw\">#bosentan<\/a>, have a risk of <a href=\"https:\/\/twitter.com\/hashtag\/hepatotoxicity?src=hash&amp;ref_src=twsrc%5Etfw\">#hepatotoxicity<\/a> (recall his liver enzymes were &gt;1000).<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194093127577602?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">31e) In patients with <a href=\"https:\/\/twitter.com\/hashtag\/methamphetamine?src=hash&amp;ref_src=twsrc%5Etfw\">#methamphetamine<\/a>-associated <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a>, parenteral <a href=\"https:\/\/twitter.com\/hashtag\/prostanoids?src=hash&amp;ref_src=twsrc%5Etfw\">#prostanoids<\/a> are used less frequently, despite patients having a worse overall prognosis than idiopathic PAH patients. See \ud83d\udd13 <a href=\"https:\/\/t.co\/V47Pg5Dxyn\">https:\/\/t.co\/V47Pg5Dxyn<\/a> <a href=\"https:\/\/t.co\/3alvQJHRll\">pic.twitter.com\/3alvQJHRll<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194095317000193?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">33) In this case, pt started on IV <a href=\"https:\/\/twitter.com\/hashtag\/epoprostenol?src=hash&amp;ref_src=twsrc%5Etfw\">#epoprostenol<\/a> in \ud83c\udfe5 but couldn&#39;t tolerate typical side effects (headache, flushing, diarrhea, myalgias) so it was d\/c&#39;d. He declined a trial of SQ <a href=\"https:\/\/twitter.com\/hashtag\/prostanoid?src=hash&amp;ref_src=twsrc%5Etfw\">#prostanoid<\/a>. He was tx&#39;d w\/ oral <a href=\"https:\/\/twitter.com\/hashtag\/tadalafil?src=hash&amp;ref_src=twsrc%5Etfw\">#tadalafil<\/a>. <a href=\"https:\/\/twitter.com\/hashtag\/Macitentan?src=hash&amp;ref_src=twsrc%5Etfw\">#Macitentan<\/a> started 1wk later after LFTs improved.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194097665703936?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">35) Answer: C. All of his variables line up in the intermediate-high risk column, with an average score of 3. Therefore, he is still intermediate-high risk.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194100345864193?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">37a) Adding <a href=\"https:\/\/twitter.com\/hashtag\/selexipag?src=hash&amp;ref_src=twsrc%5Etfw\">#selexipag<\/a> is based on the <a href=\"https:\/\/twitter.com\/hashtag\/GRIPHON?src=hash&amp;ref_src=twsrc%5Etfw\">#GRIPHON<\/a> trial, which remains the largest <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a> clinical trial to date. About 1\/3 of patients in GRIPHON were receiving background <a href=\"https:\/\/twitter.com\/hashtag\/PDE5i?src=hash&amp;ref_src=twsrc%5Etfw\">#PDE5i<\/a> &amp; an ERA.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194103030218760?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">38) The option to switch a <a href=\"https:\/\/twitter.com\/hashtag\/PDE5i?src=hash&amp;ref_src=twsrc%5Etfw\">#PDE5i<\/a> to <a href=\"https:\/\/twitter.com\/hashtag\/riociguat?src=hash&amp;ref_src=twsrc%5Etfw\">#riociguat<\/a> was studied in the <a href=\"https:\/\/twitter.com\/hashtag\/REPLACE?src=hash&amp;ref_src=twsrc%5Etfw\">#REPLACE<\/a> trial. In this open label RCT, patients switching to riociguat more often achieved the \u2018multi-component improvement\u2019 endpoint (improvement in 2\/3 of NYHA, 6MWD &amp; NT-pro-BNP)<br>See <a href=\"https:\/\/t.co\/bzkbeBnzNM\">https:\/\/t.co\/bzkbeBnzNM<\/a>. <a href=\"https:\/\/t.co\/rHH7N8Lal3\">pic.twitter.com\/rHH7N8Lal3<\/a><\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194105471414272?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">40) You decide to switch your patient to <a href=\"https:\/\/twitter.com\/hashtag\/riociguat?src=hash&amp;ref_src=twsrc%5Etfw\">#riociguat<\/a> for two reasons: 1. the patient reports experiencing episodes of priapism since starting tadalafil and 2. the patient refused a trial of <a href=\"https:\/\/twitter.com\/hashtag\/selexipag?src=hash&amp;ref_src=twsrc%5Etfw\">#selexipag<\/a> due to his experience with prostanoid side effects in hospital.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194108382179328?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">42) <a href=\"https:\/\/twitter.com\/hashtag\/PAH?src=hash&amp;ref_src=twsrc%5Etfw\">#PAH<\/a> therapies carry side effects and risk, and an individualized approach that considers comorbidities, concomitant medications, tolerability, social determinants of health and the availability of support also inform initial therapy and future changes.<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194110672248832?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<blockquote class=\"twitter-tweet\"><p lang=\"en\" dir=\"ltr\">43) Speaking of support, YOU just earned 0.75hr \ud83c\udd93CE\/<a href=\"https:\/\/twitter.com\/hashtag\/CME?src=hash&amp;ref_src=twsrc%5Etfw\">#CME<\/a>! \ud83d\uddb1\ufe0fto <a href=\"https:\/\/t.co\/DUSgYbMfeE\">https:\/\/t.co\/DUSgYbMfeE<\/a> and grab your certificate. I am <a href=\"https:\/\/twitter.com\/AlbertaPHdoc?ref_src=twsrc%5Etfw\">@AlbertaPHdoc<\/a> and I thank you for joining me. FOLLOW US here on <a href=\"https:\/\/twitter.com\/Pulmmed_CE?ref_src=twsrc%5Etfw\">@Pulmmed_CE<\/a> for more \ud83e\udec1 <a href=\"https:\/\/twitter.com\/hashtag\/pulmtwitter?src=hash&amp;ref_src=twsrc%5Etfw\">#pulmtwitter<\/a> <a href=\"https:\/\/twitter.com\/hashtag\/MedEd?src=hash&amp;ref_src=twsrc%5Etfw\">#MedEd<\/a> <a href=\"https:\/\/twitter.com\/hashtag\/FOAMed?src=hash&amp;ref_src=twsrc%5Etfw\">#FOAMed<\/a> <a href=\"https:\/\/twitter.com\/hashtag\/FOAMcc?src=hash&amp;ref_src=twsrc%5Etfw\">#FOAMcc<\/a> delivered wholly on Twitter!<\/p>&mdash; pulmmed_ce (@Pulmmed_CE) <a href=\"https:\/\/twitter.com\/Pulmmed_CE\/status\/1651194111808995331?ref_src=twsrc%5Etfw\">April 26, 2023<\/a><\/blockquote> <script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script>\n\n\n\n<iframe\n      id=\"JotFormIFrame-231143554541146\"\n      title=\"pah4 | Pulmmed CE 2023\"\n      onload=\"window.parent.scrollTo(0,0)\"\n      allowtransparency=\"true\"\n      allowfullscreen=\"true\"\n      allow=\"geolocation; microphone; camera\"\n      src=\"https:\/\/form.jotform.com\/231143554541146\"\n      frameborder=\"0\"\n      style=\"min-width:100%;max-width:100%;height:539px;border:none;\"\n      scrolling=\"no\"\n    >\n    <\/iframe>\n    <script type=\"text\/javascript\">\n    var ifr = document.getElementById(\"JotFormIFrame-231143554541146\");\n    if (ifr) {\n      var src = ifr.src;\n      var iframeParams = [];\n      if (window.location.href && window.location.href.indexOf(\"?\") > -1) {\n        iframeParams = iframeParams.concat(window.location.href.substr(window.location.href.indexOf(\"?\") + 1).split('&'));\n      }\n      if (src && src.indexOf(\"?\") > -1) {\n        iframeParams = iframeParams.concat(src.substr(src.indexOf(\"?\") + 1).split(\"&\"));\n        src = src.substr(0, src.indexOf(\"?\"))\n      }\n      iframeParams.push(\"isIframeEmbed=1\");\n      ifr.src = src + \"?\" + iframeParams.join('&');\n    }\n    window.handleIFrameMessage = function(e) {\n      if (typeof e.data === 'object') { return; }\n      var args = e.data.split(\":\");\n      if (args.length > 2) { iframe = document.getElementById(\"JotFormIFrame-\" + args[(args.length - 1)]); } else { iframe = document.getElementById(\"JotFormIFrame\"); }\n      if (!iframe) { return; }\n      switch (args[0]) {\n        case \"scrollIntoView\":\n          iframe.scrollIntoView();\n          break;\n        case \"setHeight\":\n          iframe.style.height = args[1] + \"px\";\n          if (!isNaN(args[1]) && parseInt(iframe.style.minHeight) > parseInt(args[1])) {\n            iframe.style.minHeight = args[1] + \"px\";\n          }\n          break;\n        case \"collapseErrorPage\":\n          if (iframe.clientHeight > window.innerHeight) {\n            iframe.style.height = window.innerHeight + \"px\";\n          }\n          break;\n        case \"reloadPage\":\n          window.location.reload();\n          break;\n        case \"loadScript\":\n          if( !window.isPermitted(e.origin, ['jotform.com', 'jotform.pro']) ) { break; }\n          var src = args[1];\n          if (args.length > 3) {\n              src = args[1] + ':' + args[2];\n          }\n          var script = document.createElement('script');\n          script.src = src;\n          script.type = 'text\/javascript';\n          document.body.appendChild(script);\n          break;\n        case \"exitFullscreen\":\n          if      (window.document.exitFullscreen)        window.document.exitFullscreen();\n          else if (window.document.mozCancelFullScreen)   window.document.mozCancelFullScreen();\n          else if (window.document.mozCancelFullscreen)   window.document.mozCancelFullScreen();\n          else if (window.document.webkitExitFullscreen)  window.document.webkitExitFullscreen();\n          else if (window.document.msExitFullscreen)      window.document.msExitFullscreen();\n          break;\n      }\n      var isJotForm = (e.origin.indexOf(\"jotform\") > -1) ? true : false;\n      if(isJotForm && \"contentWindow\" in iframe && \"postMessage\" in iframe.contentWindow) {\n        var urls = {\"docurl\":encodeURIComponent(document.URL),\"referrer\":encodeURIComponent(document.referrer)};\n        iframe.contentWindow.postMessage(JSON.stringify({\"type\":\"urls\",\"value\":urls}), \"*\");\n      }\n    };\n    window.isPermitted = function(originUrl, whitelisted_domains) {\n      var url = document.createElement('a');\n      url.href = originUrl;\n      var hostname = url.hostname;\n      var result = false;\n      if( typeof hostname !== 'undefined' ) {\n        whitelisted_domains.forEach(function(element) {\n            if( hostname.slice((-1 * element.length - 1)) === '.'.concat(element) ||  hostname === element ) {\n                result = true;\n            }\n        });\n        return result;\n      }\n    };\n    if (window.addEventListener) {\n      window.addEventListener(\"message\", handleIFrameMessage, false);\n    } else if (window.attachEvent) {\n      window.attachEvent(\"onmessage\", handleIFrameMessage);\n    }\n    <\/script>\n","protected":false},"excerpt":{"rendered":"<p>1b) @AlbertaPHdoc from #Edmonton will be discussing Serial, Multidimensional #RiskAssessment in #PAH: How, Why, and Then What to Individualize Goal-Directed Therapy. It&#39;s all about \ud83e\udec1 !\ud83d\udc4b@bmprii @SandeepSahayMD @LucillaPiccari @PVRI @OSitbon @jeanlucvachiery @PGeorgeMD &mdash; pulmmed_ce (@Pulmmed_CE) April 25, 2023 3) Let\u2019s start with a case: 33\u2642\ufe0f presents to #emergencymedicine w\/ dyspnea x 6m + two episodes [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"off","_et_pb_old_content":"","_et_gb_content_width":"","_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[25],"tags":[],"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/posts\/1467"}],"collection":[{"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/comments?post=1467"}],"version-history":[{"count":3,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/posts\/1467\/revisions"}],"predecessor-version":[{"id":1472,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/posts\/1467\/revisions\/1472"}],"wp:attachment":[{"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/media?parent=1467"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/categories?post=1467"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/pulmonarymed-ce.com\/wp-json\/wp\/v2\/tags?post=1467"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}