A conversation with Jim White, MD, PhD, a Pulmonologist from the University of Rochester Medical Center
As the medical director of the Pulmonary Hypertension Program at the University of Rochester Medical Center (URMC) – a nationally accredited pulmonary arterial hypertension (PAH) comprehensive care center – Jim White, MD, PhD treats patients and conducts a wide variety of clinical trials, with a particular focus on PAH. White recently published a study in the Journal of Heart and Lung Transplantation that provides definitive proof that utilizing risk scores directly associates with predicting clinical outcomes in patients with PAH.
White describes the impact this study can have on physicians’ practice, and how it can improve patient outcomes.
Why is this study so important for pulmonologists?
There are two main reasons that I'm excited to share this paper with peers in my field.
Number one: this is by far the best evidence to date that using a formalized risk score directly associates with patient outcomes in PAH. This study is proof of that association. Our study is the first time there has been a large, long-term, randomized and controlled study that showed convincingly that a change in risk scores can predict outcomes, whether for better or for worse. This is the best evidence in our field that using risk scores ensures our patients are improving in formal, measurable ways. There is evidence to suggest that not a lot of physicians are using risk scores in their practice, and this study could potentially change how people practice.
Number two: this is a step toward risk scores becoming a part of how we test new drug therapies, which can increase both the pace and efficiency of drug development. Our study is moving the field toward a time when we don't have to put patients on placebos for years to determine if a drug works or not. This would be such a relief for our patients. It can also make trials less expensive because we have more opportunity to develop drugs through shorter trials. This could potentially mean new therapies that otherwise wouldn’t come to market.
How do risk scores work? How often do you assess them?
There are several different types of risk scores that can be used: COMPERA, REVEAL 2.0, and REVEAL Lite 2. Each one is described in our paper, and all are perfectly acceptable to use even if they have some differences. There are three key components to a risk score: 1) NT-proBNP level, a hormone produced by the heart that can be assessed through a blood test, 2) some measure of exercise tolerance, and 3) functional class and measurement of symptoms. The different types of risk scores may have other different components, but you add them all together to get the overall risk score.
What I’m encouraging physicians to do is to pick a risk score type and calculate it with your patient on a regular basis, every 3 to 6 months. Epic has tools to do this, you can easily incorporate risk scores in your electronic medical records. If you show that treatment you prescribed has improved that risk score, you can be confident that patients will do better in the long-term, namely less hospitalization, less death. Regular usage of risk scores should become a formal part of practice.
Which risk score do you use at URMC? Why?
We use REVEAL Lite 2. It’s one of the more difficult ones to use because there are a lot of components, but it results in the most precise predictions, whether things are going well or not well. The simpler tools still work too though! All are effective at predicting clinical outcomes, but I prefer the robustness of REVEAL Lite 2.
How have you seen this play out with your patients? Has it changed your interactions?
Many doctors already review components of risk scores with their patients, but aren’t routinely testing for exercise tolerance or testing for the NT-proBNP needed to calculate a risk score. You really need to be assessing these variables on a regular basis until your patient is low risk so you can stay ahead of the assessment.
In some cases, a patient may say “I’m feeling better,” and that’s the end of the story. A physician might not calculate risk score after that point. This is where a change in practice is needed, by consistently getting that risk score until the patient is at a point where you believe they are at the lowest risk they can achieve.
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Read the full study here: “Contemporary risk scores predict clinical worsening in pulmonary arterial hypertension - An analysis of FREEDOM-EV”
The Journal of Heart and Lung Transplantation invited White to speak about his work on JHLT: The Podcast (November 2022).
This study drew heavily from a 2019 study, also authored by White, published in the American Journal of Respiratory and Critical Care Medicine, “Combination Therapy with Oral Treprostinil for Pulmonary Arterial Hypertension. A Double-Blind Placebo-controlled Clinical Trial”