PG 2025: Pulmonary Literature Review and Interactive Complex Case Presentations (PG)-STEIGER PG Course FINAL Pul Lit Review CHEST 2025

STEIGER PG Course FINAL Pul Lit Review CHEST 2025 - BS

Pdf Summary

This pulmonary literature review presented by Dr. David J. Steiger at CHEST 2025 summarizes recent advances in pulmonary hypertension (PH) and thromboembolic disease, focusing on risk prediction, therapies, and management strategies.

<strong>Risk Prediction and Acute Pulmonary Embolism (PE):</strong>  
The Composite Pulmonary Embolism Shock Score (CPES) is highlighted as a practical tool to predict adverse outcomes in intermediate-risk acute PE without the need for right heart catheterization. CPES integrates factors such as troponin, BNP, saddle embolism, RV dysfunction, tachycardia, and DVT to identify patients requiring closer monitoring or advanced therapies. The score outperforms other models like BOVA and ESC in predicting complicated courses. Normotensive shock in intermediate-risk PE also identifies patients at elevated risk.

<strong>Advanced Therapies for Acute PE:</strong>  
The PEERLESS randomized trial compared large-bore mechanical thrombectomy (LBMT) with catheter-directed thrombolysis (CDT) for intermediate-risk PE. LBMT showed superiority in the composite primary endpoint—including clinical deterioration and ICU length of stay—without differences in mortality or bleeding. Early catheter-based therapy (within 12 hours of diagnosis) was associated with less hemodynamic decompensation and shorter ICU stays. However, explicit guidelines on timing of interventions remain lacking.

<strong>Pulmonary Arterial Hypertension (PAH) and Sotatercept:</strong>  
Sotatercept, a fusion protein targeting the activin signaling pathway, showed significant benefit in reducing pulmonary vascular resistance and clinical worsening in high-risk PAH patients on background therapy regardless of BMPR2 mutation status. Phase 3 trials demonstrated a 76% reduction in a composite outcome of death, lung transplant, or hospitalization with acceptable safety. This represents a promising add-on therapy influencing PAH treatment algorithms.

<strong>Cancer-Associated Venous Thromboembolism (VTE):</strong>  
Extended reduced-dose apixaban (2.5 mg twice daily) after 6 months of full-dose anticoagulation was non-inferior to full-dose apixaban in preventing recurrent VTE in cancer patients, with a lower risk of bleeding. DOACs demonstrated comparable efficacy and better compliance versus LMWH, reshaping VTE management in oncology.

<strong>Pulmonary Hypertension in Lung Disease:</strong>  
PH associated with COPD exhibits a vascular phenotype characterized by circulatory limitation, preserved spirometry, low diffusing capacity, and hypoxemia. PDE5 inhibitors improved transplant-free survival independent of lung function or comorbidities, supporting their potential benefit despite limited large RCT evidence. Inhaled treprostinil improved 6-minute walk distance and clinical outcomes but was linked to increased mortality signals in some studies, meriting further study.

<strong>Summary:</strong>  
This comprehensive update emphasizes refined risk stratification in PE using the CPES score, advantages of early and mechanical thrombectomy therapies, emergence of sotatercept as an effective PAH treatment, optimized anticoagulation strategies in cancer-associated VTE, and evolving understanding and management of PH in lung disease, especially COPD-associated PH. While significant advances have been made, further randomized trials are needed to optimize timing and selection of therapies across these challenging pulmonary vascular disorders.

Keywords

Pulmonary Hypertension

Pulmonary Embolism

Composite Pulmonary Embolism Shock Score

Mechanical Thrombectomy

Catheter-Directed Thrombolysis

Sotatercept

Pulmonary Arterial Hypertension

Cancer-Associated Venous Thromboembolism

Direct Oral Anticoagulants

COPD-associated Pulmonary Hypertension