Treating pulmonary hypertension in the elderly

ABSTRACT

Introduction

Despite an increasingly older pulmonary hypertension (PH) population, data on PH treatments in these patients are limited because there exist no clinical studies dedicated to geriatric groups. Furthermore, elderly patients with comorbidities have been systematically excluded from clinical trials, limiting the evidence base for drugs approved for pulmonary arterial hypertension (PAH).

Areas covered

This review is focused on the diagnosis and treatment of pulmonary hypertension (PH) in the elderly, which is a hot topic today. Areas covered by the authors include current changes in demographics, clinical characteristics, diagnoses, and risk assessment in the geriatric PAH population. A central part of this review is dedicated to the therapeutic challenges in elderly patients with PAH. The literature search is focused on sorting out post-capillary conditions in the elderly, and on current treatment strategies for PAH and for chronic thromboembolic pulmonary hypertension (CTEPH).

Expert opinion

 Current data indicate that despite more severe disease in elderly patients, the concept of hit hard and early is less used. For example, double upfront oral combination, a common strategy for younger patients, or early parenteral prostacyclins, are less used in the elderly, purporting worse outcomes for these patients.

KEYWORDS:

• Elderly
• pulmonary hypertension
• risk assessment
• treatment strategies
• survival

Article Highlights

• Pulmonary hypertension (PH) is a chronic pulmonary vascular disease that is characterized by remodeling of small pulmonary vessels, leading to increased pulmonary vascular resistance (PVR) and eventually right ventricular failure.

• Recent data from Pulmonary Hypertension registries have illustrated that the rate of PH diagnoses in elderly and very elderly patients is currently increasing; however, group 1 disease is relatively rare at old age

• Elderly PH patients are often diagnosed with more advanced disease, which results in new challenges for therapeutic management.

• Initial monotherapy with phosphodiesterase type 5 (PDE-5) inhibitors, followed by endothelin receptor antagonists (ERAs) have been preferred amongst the elderly.

• Upfront combinations, and any prostanoid therapies are rarely given, presumably contributing to the poorer outcome of these patients.

This box summarizes the key points contained in the article.

Declaration of Interest

IM Lang has relationships with drug companies including Actelion-Janssen, AstraZeneca, AOP Orphan Pharmaceuticals AG, Medtronic, Ferrer, and United Therapeutics. In addition to serving as an investigator on trials involving these companies, relationships include consultancy service, research grants and membership on scientific advisory boards. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.