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March 2014

March 2014

American Thoracic Society Welcomes the EPA's New Standards on Automobile Emissions

March 3, 2014 – The American Thoracic Society applauds today’s release by the Environmental Protection Agency of new standards reducing the amount of sulfur allowed in gasoline and reducing emissions from new cars and SUVs. These changes will have an enormous positive impact on public health.

“The adverse health consequences of traffic-related air pollution are well documented, and as pulmonary physicians, we see the effects of polluted air on patients’ ability to breathe every day,” says Patricia Finn, MD, president of the American Thoracic Society. “The effects of smog on respiratory health are particularly pronounced for patients living with asthma, COPD, or other lung diseases.”

“The impact of air pollution on respiratory health also disproportionately affects people with lower incomes, who are more likely to live near highways or other heavily used roadways,” said Dr. Finn. “Children are also at increased risk from the effects of air pollution because their lungs are still developing and they tend to be more active outdoors than adults.”

The EPA’s new standards, known as the Tier 3 standards, could save up to 2,000 lives, prevent 19,000 asthma attacks and prevent nearly 300,000 missed days of work and school each year by the year 2030, according to EPA estimates.  These reductions will more than offset the costs of implementing the new standards.

The Tier 3 Vehicle Emission and Fuel Standards Program will set new vehicle emissions standards and lower the sulfur content of gasoline beginning in 2017. The vehicle standards will reduce both tailpipe and evaporative emissions from passenger cars, light-duty trucks, medium-duty passenger vehicles, and some heavy-duty vehicles, and the gasoline sulfur standard will enable more stringent vehicle emissions standards and make emissions control systems more effective.

Traffic-Related Air Pollution Associated with Changes in Right Ventricular Structure and Function

Exposure to high levels of traffic-related air pollution is associated with changes in the right ventricle of the heart that may contribute to the known connection between air pollution exposure and heart disease, according to a new study.

“Although the link between traffic-related air pollution and left ventricular hypertrophy, heart failure, and cardiovascular death is established, the effects of traffic-related air pollution on the right ventricle have not been well studied,” said lead author Peter Leary, MD, MS, of the University of Washington Medical Center in Seattle. “Using exposure to nitrogen dioxide as a surrogate for exposure to traffic-related air pollution, we were able to demonstrate for the first time that higher levels of exposure were associated with greater right ventricular mass and larger right ventricular end-diastolic volume. Greater right ventricular mass is also associated with increased risk for heart failure and cardiovascular death.”

The findings were published online ahead of print publication in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.

The study involved 3,896 participants who were free of clinical cardiovascular disease in the Multi-Ethnic Study of Atherosclerosis and who underwent cardiac magnetic resonance imaging (MRI). Using estimated exposure to outdoor oxides of nitrogen at the homes of participants over the year preceding MRI, the authors found that increased exposure to nitrogen dioxide was associated with an approximately 1.0 g (5 percent) increase in right ventricular mass and a 4.1 mL (3%) increase in right ventricular end-diastolic volume.

These relationships remained after accounting for differences among participants in cardiovascular risk factors, left ventricular mass and volume, markers of inflammation, lung disease and socioeconomic status.

The authors note that this type of study can be limited in several ways. Specifically, estimates of air pollution exposure are not perfect and it remains possible that something related to air pollution, but not air pollution itself (known as confounding), was responsible for the association. For these reasons and others, this study cannot prove that traffic-related air pollution causes changes in the right heart, but does strongly suggest the relationship.

“The morphologic changes in the right ventricle of the heart that we found with increased exposure to nitrogen dioxide add to the body of evidence supporting a connection between traffic-related air pollution and cardiovascular disease,” said Dr, Leary. “The many adverse effects of air pollution on human health support continued efforts to reduce this burden.”

American Thoracic Society Releases Guidelines for the Diagnosis and Management of Pulmonary Hypertension of Sickle Cell Disease

The  American Thoracic Society has developed clinical practice guidelines to help  clinicians identify and manage patients with sickle cell disease who are at increased  risk for mortality from pulmonary hypertension.

“With the development of new treatments, many  patients with sickle cell disease are now surviving long enough to develop  pulmonary hypertension, with an estimated prevalence of 6 to 11 percent,” said Elizabeth  S. Klings, MD, associate professor of medicine  at the Boston University School of Medicine and chair of the committee  that produced the guidelines. “Although pulmonary hypertension and elevated  tricuspid jet velocity (TRV, an indicator of pulmonary hypertension measured by  echocardiography) are both associated with an increased mortality risk, there  is currently no standardized approach for identifying and managing these  patients.”

The  guidelines appear in the March 15th issue of the American Thoracic  Society’s American Journal of  Respiratory and Critical Care Medicine.
Guideline  recommendations include:

  • Mortality  risk can be accurately determined noninvasively by measurement of the TRV with  Doppler echocardiography or by measurement of serum N-terminal pro–brain  natriuretic peptide (NT-pro-BNP) levels and can be determined invasively by  direct hemodynamic measurements via right heart catheterization (RHC).
  • An  increased risk for mortality is defined as a TRV ≥ 2.5 m/second, an NT-pro-BNP level  ≥ 160 pg/ml, or RHC-confirmed pulmonary hypertension.
  • Patients  found to have an increased mortality risk should be treated with hydroxyurea.  Patients who do not respond to or are not candidates for hydroxyurea treatment  can be considered for  chronic  transfusion therapy.
  • In  patients with RHC-confirmed pulmonary hypertension, venous thromboembolism, and  no additional risk factors for hemorrhage, indefinite anticoagulant therapy  rather than a limited duration of therapy should be used.
  • Patients with elevated TRV alone or elevated NT-pro-BNP alone should not be treated with  targeted pulmonary arterial hypertension therapies, including prostanoid, endothelin  receptor antagonist, and phosphodiesterase-5 inhibitor therapy
  • Most patients with RHC-confirmed pulmonary  hypertension should not be treated with targeted therapy
  • In  select patents with RHC-confirmed marked elevation of pulmonary vascular  resistance, normal pulmonary capillary wedge pressure, and related symptoms, a  trial of either a prostanoid or an endothelin receptor antagonist may be  performed.
  • Patients  with RHC-confirmed marked elevation of pulmonary vascular resistance, normal pulmonary  capillary wedge pressure, and related symptoms should not receive phosphodiesterase-5 inhibitor therapy as first-line treatment.

 “As our understanding of sickle cell disease develops, so will our ability to  detect disease earlier and to tailor treatment approaches. We need to continue  our research efforts into this disease and its management to understand what  the optimal treatment regimen for these patients is.  Most of our current recommendations are  limited by a lack of large-scale clinical trials in this population.” said Dr.  Klings. “Management of patients with sickle cell  disease with an increased risk for mortality and pulmonary hypertension will ultimately  be a collaborative effort including adult and pediatric pulmonologists,  cardiologists, and hematologists.”

World TB Day 2014 – A New Commitment to Stopping TB

March  24, 2014, will mark World TB Day. On this day around the world, the public  health and scientific community will raise public awareness about tuberculosis  and the challenges that remain in controlling it globally, such as preventing  the spread of drug resistant TB and as the urgent need to develop new TB  diagnostic, treatment and prevention tools. The ATS, originally founded as the  American Sanatorium Association, is a leader in domestic and global TB control.  The ATS holds key memberships in the lead advocacy organizations on TB,  including Stop TB USA and the global Stop TB Partnership.

The  ATS wishes to thank the co-chairs of the House Tuberculosis Elimination  Caucus,  Representatives Eliot Engel  (D-NY), Gene Green (D-TX) and Don Young (R-AK) for their leadership on TB. The ATS  is pleased to cosponsor the World TB congressional briefing, Tuberculosis: The Threat to the U.S., with  the Caucus and our partners. ATS member Philip Hopewell, M.D., will speak at  the briefing about new edition of the International  Standards of Tuberculosis Care.

ATS  President Patricia Finn, MD, said, "There are 3 million people with TB around  the world who are not identified and treated, despite the fact that TB is a  treatable disease." Dr. Finn continued,"Reaching the 3 million is  one of our key challenges to halting the TB pandemic. The continued spread of  drug resistant TB is another. Here in the U.S., federal funding cuts are  eroding needed TB expertise and resources at a time when drug resistant TB,  including dangerous XDR-TB, appears to be on the rise in the U.S. I urge the  Congress to restore funding for CDC's national TB program and all ATS members  to do their part to stop TB in our lifetime."