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Badlam JB, Badesch DB, Austin ED, Benza RL, Chung WK, Farber HW, Feldkircher K, Frost AE, Poms AD, Lutz KA, Pauciulo MW, Yu C, Nichols WC, Elliott CG. United States Pulmonary Hypertension Scientific Registry: Baseline Characteristics. Chest 2020; 159:311-327. [PMID: 32858008 DOI: 10.1016/j.chest.2020.07.088] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment, genotyping, and phenotyping of patients with World Health Organization Group 1 pulmonary arterial hypertension (PAH) have evolved dramatically in the last decade. RESEARCH QUESTION The United States Pulmonary Hypertension Scientific Registry was established as the first US PAH patient registry to investigate genetic information, reproductive histories, and environmental exposure data in a contemporary patient population. STUDY DESIGN AND METHODS Investigators at 15 US centers enrolled consecutively screened adults diagnosed with Group 1 PAH who had enrolled in the National Biological Sample and Data Repository for PAH (PAH Biobank) within 5 years of a cardiac catheterization demonstrating qualifying hemodynamic criteria. Exposure and reproductive histories were collected by using a structured interview and questionnaire. The biobank provided genetic data. RESULTS Between 2015 and 2018, a total of 499 of 979 eligible patients with clinical diagnoses of idiopathic PAH (IPAH) or familial PAH (n = 240 [48%]), associated PAH (APAH; n = 256 [51%]), or pulmonary venoocclusive disease/pulmonary capillary hemangiomatosis (n = 3 [1%]) enrolled. The mean age was 55.8 years, average BMI was 29.2 kg/m2, and 79% were women. Mean duration between symptom onset and diagnostic catheterization was 1.9 years. Sixty-six percent of patients were treated with more than one PAH medication at enrollment. Past use of prescription weight loss drugs (16%), recreational drugs (27%), and oral contraceptive pills (77%) was common. Women often reported miscarriage (37%), although PAH was rarely diagnosed within 6 months of pregnancy (1.9%). Results of genetic testing identified pathogenic or suspected pathogenic variants in 13% of patients, reclassifying 18% of IPAH patients and 5% of APAH patients to heritable PAH. INTERPRETATION Patients with Group 1 PAH remain predominately middle-aged women diagnosed with IPAH or APAH. Delays in diagnosis of PAH persist. Treatment with combinations of PAH-targeted medications is more common than in the past. Women often report pregnancy complications, as well as exposure to anorexigens, oral contraceptives, and/or recreational drugs. Results of genetic tests frequently identify unsuspected heritable PAH.
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Affiliation(s)
| | | | - Eric D Austin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Raymond L Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH
| | - Wendy K Chung
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | | | | | - Adaani E Frost
- Houston Methodist Hospital, Institute for Academic Medicine & Houston Methodist Research Institute, Houston, TX
| | - Abby D Poms
- E Squared Trials and Registries, Inc., Half Moon Bay, CA
| | - Katie A Lutz
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael W Pauciulo
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - William C Nichols
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - C Gregory Elliott
- Intermountain Medical Center, Department of Medicine and the University of Utah, Pulmonary Division, Salt Lake City, UT
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Neupane B, Sydykov A, Pradhan K, Vroom C, Herden C, Karnati S, Ghofrani HA, Avdeev S, Ergün S, Schermuly RT, Kosanovic D. Influence of gender in monocrotaline and chronic hypoxia induced pulmonary hypertension in obese rats and mice. Respir Res 2020; 21:136. [PMID: 32493503 PMCID: PMC7268383 DOI: 10.1186/s12931-020-01394-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Obesity and pulmonary hypertension (PH) share common characteristics, such as augmented inflammation and oxidative stress. However, the exact role of obesity in the pathology of PH is largely uninvestigated. Therefore, we have hypothesized that in the context of obesity the gender difference may have influence on development of PH in animal models of this disease. METHODS Animal experiments were conducted in monocrotaline (MCT) and chronic hypoxia (HOX) models of PH. Lean and obese Zucker rats or B6 mice of both genders were used for MCT or HOX models, respectively. Echocardiography, hemodynamic measurements, histology and immuno-histochemistry were performed to analyze various parameters, such as right ventricular function and hypertrophy, hemodynamics, pulmonary vascular remodeling and lung inflammation. RESULTS Both lean and obese male and female Zucker rats developed PH after a single MCT injection. However, negligible differences were seen between lean and obese male rats in terms of PH severity at the end stage of disease. Conversely, a more prominent and severe PH was observed in obese female rats compared to their lean counterparts. In contrast, HOX induced PH in lean and obese, male and female mice did not show any apparent differences. CONCLUSION Gender influences PH severity in obese MCT-injected rats. It is also an important factor associated with altered inflammation. However, further research is necessary to investigate and reveal the underlying mechanisms.
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Affiliation(s)
- Balram Neupane
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany
- Medizinischen Klinik I, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Akylbek Sydykov
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany
| | - Kabita Pradhan
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany
- Medizinischen Klinik I, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Christina Vroom
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany
| | - Christiane Herden
- Institute of Veterinary Pathology, Justus-Liebig University, Giessen, Germany
| | - Srikanth Karnati
- Institute of Anatomy and Cell Biology, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Hossein Ardeschir Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany
| | - Sergey Avdeev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Ralph Theo Schermuly
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany.
| | - Djuro Kosanovic
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Aulweg 130, 35392, Giessen, Germany.
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
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Perrino C, Ferdinandy P, Bøtker HE, Brundel BJJM, Collins P, Davidson SM, den Ruijter HM, Engel FB, Gerdts E, Girao H, Gyöngyösi M, Hausenloy DJ, Lecour S, Madonna R, Marber M, Murphy E, Pesce M, Regitz-Zagrosek V, Sluijter JPG, Steffens S, Gollmann-Tepeköylü C, Van Laake LW, Van Linthout S, Schulz R, Ytrehus K. Improving translational research in sex-specific effects of comorbidities and risk factors in ischaemic heart disease and cardioprotection: position paper and recommendations of the ESC Working Group on Cellular Biology of the Heart. Cardiovasc Res 2020; 117:367-385. [PMID: 32484892 DOI: 10.1093/cvr/cvaa155] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/29/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022] Open
Abstract
Ischaemic heart disease (IHD) is a complex disorder and a leading cause of death and morbidity in both men and women. Sex, however, affects several aspects of IHD, including pathophysiology, incidence, clinical presentation, diagnosis as well as treatment and outcome. Several diseases or risk factors frequently associated with IHD can modify cellular signalling cascades, thus affecting ischaemia/reperfusion injury as well as responses to cardioprotective interventions. Importantly, the prevalence and impact of risk factors and several comorbidities differ between males and females, and their effects on IHD development and prognosis might differ according to sex. The cellular and molecular mechanisms underlying these differences are still poorly understood, and their identification might have important translational implications in the prediction or prevention of risk of IHD in men and women. Despite this, most experimental studies on IHD are still undertaken in animal models in the absence of risk factors and comorbidities, and assessment of potential sex-specific differences are largely missing. This ESC WG Position Paper will discuss: (i) the importance of sex as a biological variable in cardiovascular research, (ii) major biological mechanisms underlying sex-related differences relevant to IHD risk factors and comorbidities, (iii) prospects and pitfalls of preclinical models to investigate these associations, and finally (iv) will provide recommendations to guide future research. Although gender differences also affect IHD risk in the clinical setting, they will not be discussed in detail here.
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Affiliation(s)
- Cinzia Perrino
- Department of Advanced Biomedical Sciences, Federico II University, Via Pansini 5, 80131 Naples, Italy
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary.,Pharmahungary Group, Hajnoczy str. 6., H-6722 Szeged, Hungary
| | - Hans E Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark
| | - Bianca J J M Brundel
- Department of Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, Amsterdam, 1108 HV, the Netherlands
| | - Peter Collins
- Imperial College, Faculty of Medicine, National Heart & Lung Institute, South Kensington Campus, London SW7 2AZ, UK.,Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, WC1E 6HX London, UK
| | - Hester M den Ruijter
- Experimental Cardiology Laboratory, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Felix B Engel
- Experimental Renal and Cardiovascular Research, Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Muscle Research Center Erlangen (MURCE), Schwabachanlage 12, 91054 Erlangen, Germany
| | - Eva Gerdts
- Department for Clinical Science, University of Bergen, PO Box 7804, 5020 Bergen, Norway
| | - Henrique Girao
- Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Azinhaga Santa Comba, Celas, 3000-548 Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, and Clinical Academic Centre of Coimbra (CACC), 3000-548 Coimbra, Portugal
| | - Mariann Gyöngyösi
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Derek J Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, 8 College Road, 169857, Singapore.,National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228, Singapore.,The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London WC1E 6HX, UK.,Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, 500, Lioufeng Rd., Wufeng, Taichung 41354, Taiwan
| | - Sandrine Lecour
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, Chris Barnard Building, University of Cape Town, Private Bag X3 7935 Observatory, Cape Town, South Africa
| | - Rosalinda Madonna
- Institute of Cardiology, University of Pisa, Lungarno Antonio Pacinotti 43, 56126 Pisa, Italy.,Department of Internal Medicine, University of Texas Medical School in Houston, 6410 Fannin St #1014, Houston, TX 77030, USA
| | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Elizabeth Murphy
- Laboratory of Cardiac Physiology, Cardiovascular Branch, NHLBI, NIH, 10 Center Drive, Bethesda, MD 20892, USA
| | - Maurizio Pesce
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, IRCCS Via Parea, 4, I-20138 Milan, Italy
| | - Vera Regitz-Zagrosek
- Berlin Institute of Gender in Medicine, Center for Cardiovascular Research, DZHK, partner site Berlin, Geschäftsstelle Potsdamer Str. 58, 10785 Berlin, Germany.,University of Zürich, Rämistrasse 71, 8006 Zürich, Germany
| | - Joost P G Sluijter
- Experimental Cardiology Laboratory, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 8, 3584 CS Utrecht, the Netherlands.,Circulatory Health Laboratory, Regenerative Medicine Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 8, 3584 CS Utrecht, the Netherlands
| | - Sabine Steffens
- Institute for Cardiovascular Prevention and German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Pettenkoferstr. 9, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Can Gollmann-Tepeköylü
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstr.35, A - 6020 Innsbruck, Austria
| | - Linda W Van Laake
- Cardiology and UMC Utrecht Regenerative Medicine Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité, University Medicine Berlin, 10178 Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité, University Medicine Berlin, 10178 Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Rainer Schulz
- Institute of Physiology, Justus-Liebig University Giessen, Ludwigstraße 23, 35390 Giessen, Germany
| | - Kirsti Ytrehus
- Department of Medical Biology, UiT The Arctic University of Norway, Hansine Hansens veg 18, 9037 Tromsø, Norway
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Wilcox SR, Faridi MK, Camargo CA. Demographics and Outcomes of Pulmonary Hypertension Patients in United States Emergency Departments. West J Emerg Med 2020; 21:714-721. [PMID: 32421524 PMCID: PMC7234722 DOI: 10.5811/westjem.2020.2.45187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/27/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a common, yet under-diagnosed, contributor to morbidity and mortality. Our objective was to characterize the prevalence of PH among adult patients presenting to United States (US) emergency departments (ED) and to identify demographic patterns and outcomes of PH patients in the ED. METHODS We analyzed the Nationwide Emergency Department Sample (NEDS) database, with a focus on ED patients aged 18 years and older, with any International Classification of Diseases, Clinical Modification (ICD)-9-CM or ICD-10-CM diagnosis code for PH from 2011 to 2015. The primary outcome was inpatient, all-cause mortality. The secondary outcomes were hospital admission rates and hospital length of stay (LOS). RESULTS From 2011 to 2015, in a sample of 121,503,743 ED visits, representing a weighted estimate of 545,500,486 US ED visits, patients with a diagnosis of PH accounted for 0.78% (95% confidence interval [CI], 0.75-0.80%) of all US ED visits. Of the PH visits, 86.9% were admitted to the hospital, compared to 16.3% for all other ED visits (P <0.001). Likewise, hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients (e.g., inpatient mortality 4.5% vs 2.6%, P < 0.001) with an adjusted odds ratio (aOR) of 1.34 (95% CI, 1.31-1.37). Age had the strongest association with mortality, with an aOR of 10.6 for PH patients over 80 years (95% CI, 10.06-11.22), compared to a reference of ages 18 to 30 years. CONCLUSION In this nationally representative sample, presentations by patients with PH were relatively common, accounting for nearly 0.8% of US ED visits. Patients with PH were significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, and increased risk of inpatient mortality.
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Affiliation(s)
- Susan R Wilcox
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - M Kamal Faridi
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Sex-specific stress response and HMGB1 release in pulmonary endothelial cells. PLoS One 2020; 15:e0231267. [PMID: 32271800 PMCID: PMC7145198 DOI: 10.1371/journal.pone.0231267] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 03/05/2020] [Indexed: 01/03/2023] Open
Abstract
Women are known to be associated with a higher susceptibility to pulmonary arterial hypertension (PAH). In contrast, male PAH patients have a worse survival prognosis. In this study, we investigated whether the contribution of sex goes beyond the effects of sex hormones by comparing the ability of isolated male and female pulmonary endothelial cells to respire, proliferate and tolerate the stress. Mouse lung endothelial cells (MLEC) were isolated from the lungs of male and female 3-week old mice. Male MLEC showed an increased basal mitochondrial respiration rate, elevated maximal respiration, a significantly greater level of mitochondrial polarization, and a higher rate of proliferation. Exposure of cells to hypoxia (2% of O2 for 24 hours) induced a strong apoptotic response in female but not male MLEC. In contrast, treatment with mitochondrial respiratory Complex III inhibitor Antimycin A (AA, 50μM) mediated severe necrosis specifically in male MLEC, while female cells again responded primarily by apoptosis. The same effect with female cells responding to the stress by apoptosis and male cells responding by necrosis was confirmed in starved pulmonary endothelial cells isolated from human donors. Elevated necrosis seen in male cells was associated with a significant release of damage-associated alarmin, HMGB1. No stimuli induced a significant elevation of HMGB1 secretion in females. We conclude that male cells appear to be protected against mild stress conditions, such as hypoxia, possibly due to increased mitochondrial respiration. In contrast, they are more sensitive to impaired mitochondrial function, to which they respond by necrotic death. Necrosis in male vascular cells releases a significant amount of HMGB1 that could contribute to the pro-inflammatory phenotype known to be associated with the male gender.
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Sommer N, Ghofrani HA, Pak O, Bonnet S, Provencher S, Sitbon O, Rosenkranz S, Hoeper MM, Kiely DG. Current and future treatments of pulmonary arterial hypertension. Br J Pharmacol 2020; 178:6-30. [PMID: 32034759 DOI: 10.1111/bph.15016] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 01/25/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
Therapeutic options for pulmonary arterial hypertension (PAH) have increased over the last decades. The advent of pharmacological therapies targeting the prostacyclin, endothelin, and NO pathways has significantly improved outcomes. However, for the vast majority of patients, PAH remains a life-limiting illness with no prospect of cure. PAH is characterised by pulmonary vascular remodelling. Current research focusses on targeting the underlying pathways of aberrant proliferation, migration, and apoptosis. Despite success in preclinical models, using a plethora of novel approaches targeting cellular GPCRs, ion channels, metabolism, epigenetics, growth factor receptors, transcription factors, and inflammation, successful transfer to human disease with positive outcomes in clinical trials is limited. This review provides an overview of novel targets addressed by clinical trials and gives an outlook on novel preclinical perspectives in PAH. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Natascha Sommer
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
| | - Hossein A Ghofrani
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Oleg Pak
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
| | - Sebastien Bonnet
- Groupe de recherche en hypertension pulmonaire Centre de recherche de IUCPQ, Universite Laval Quebec, Quebec City, Quebec, Canada
| | - Steve Provencher
- Groupe de recherche en hypertension pulmonaire Centre de recherche de IUCPQ, Universite Laval Quebec, Quebec City, Quebec, Canada
| | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France. Inserm UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Stephan Rosenkranz
- Klinik III für Innere Medizin, Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Cologne, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research (DZL), Hanover, Germany
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Steiger D, Han D, Yip R, Li K, Chen X, Liu L, Liu J, Ma T, Siddiqi F, Yankelevitz DF, Henschke CI. Increased main pulmonary artery diameter and main pulmonary artery to ascending aortic diameter ratio in smokers undergoing lung cancer screening. Clin Imaging 2020; 63:16-23. [PMID: 32120308 DOI: 10.1016/j.clinimag.2019.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Pulmonary hypertension (PH) is a progressive, potentially fatal disease, difficult to diagnose early due to non-specific nature of symptoms. PH is associated with increased morbidity and death in many respiratory and cardiac disorders, and with all-cause mortality, independent of age and cardiopulmonary disease. The main pulmonary artery diameter (MPA), and ratio of MPA to adjacent ascending aorta (AA), MPA:AA, on Chest CT are strong indicators of suspected PH. Our goal was to determine the prevalence of abnormally high values of these indicators of PH in asymptomatic low-dose CT (LDCT) screening participants at risk of lung cancer, and determine the associated risk factors. METHODS We reviewed consecutive baseline LDCT scans of 1949 smokers in an IRB-approved study. We measured the MPA and AA diameter and calculated MPA:AA ratio. We defined abnormally high values as being more than two standard deviations above the average (MPA ≥ 34 mm and MPA:AA ≥ 1.0). Regression analyses were used to identify risk factors and CT findings of participants associated with high values. RESULTS The prevalence of MPA ≥ 34 mm and MPA:AA ≥ 1.0 was 4.2% and 6.9%, respectively. Multivariable regression demonstrated that BMI was a significant risk factor, both for MPA ≥ 34 mm (OR = 1.07, p < 0.0001) and MPA:AA ≥ 1.0 (OR = 1.04, p = 0.003). Emphysema was significant in the univariate but not in the multivariate analysis. CONCLUSIONS We determined that the possible prevalence of PH as defined by abnormally high values of MPA and of MPA:AA was greater than previously described in the general population and that pulmonary consultation be recommended for these participants, in view of the significance of PH.
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Affiliation(s)
- David Steiger
- Division of Pulmonary Medicine, Icahn School of Medicine, New York, NY, United States of America
| | - Dan Han
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Rowena Yip
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Kunwei Li
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Radiology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xiangmeng Chen
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Radiology, Jiangmen Central Hospital, Jiangmen, China
| | - Li Liu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Diagnostic Radiology, Cancer Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Chaoyang District, Beijing, China
| | - Jiayi Liu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Teng Ma
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Radiology, Tong Ren Hospital, Capital Medical University, Dongcheng District, Beijing, China
| | - Faisal Siddiqi
- Division of Pulmonary Medicine, Icahn School of Medicine, New York, NY, United States of America
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Badlam JB, Badesch D, Brittain E, Cordell S, Ding T, Fox K, Hemnes A, Loyd J, Pugh M, Robbins I, Yu C, Austin ED. Sex hormone exposure and reproductive factors in pulmonary arterial hypertension: a case-control study. Pulm Circ 2020; 10:2045894020908786. [PMID: 32166018 PMCID: PMC7052472 DOI: 10.1177/2045894020908786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/03/2020] [Indexed: 12/15/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a sexually dimorphic disease that for unknown reasons affects women more than men. The role of estrogens, both endogenous and exogenous, and reproductive factors in this female susceptibility is still poorly understood. It has been strongly suggested that sex hormones may influence the development and progression of the disease. We sought to determine whether sex hormone exposures and reproductive factors associate with PAH patients compared to control subjects, using a questionnaire and interview to obtain information regarding these potential risk factors. We conducted a single-center unmatched case-control study. Six hundred and thirty-four women and men with PAH, as well as 27 subjects with BMPR2 mutations but no PAH and 132 healthy population controls were enrolled from the Vanderbilt Pulmonary Hypertension Research Cohort and researchmatch.org. Questionnaires and nurse-led interviews were conducted to obtain information regarding sex hormone exposures and reproductive factors. Additional history was obtained on enrolled patients including disease severity variables and comorbidities. Responses to the questionnaires were analyzed to describe these exposures in this population as well as assess the association between disease severity variables and sex hormone exposures. Reproductive and endogenous factors that determine lifelong estrogen exposure were similar between PAH cases and controls. Patients with associated PAH were significantly more likely to be postmenopausal compared to controls. There were similar rates of "ever-use" and duration of use of oral contraceptive pills and hormone replacement therapy in patients when compared to controls. Disease severity variables were not significantly affected by any exposure after adjusting for PAH sub-group. In contrast to our hypothesis, that a greater exposure to exogenous sources of female sex hormones associates with PAH case status, we found similar rates of endogenous and exogenous sex hormone exposure between PAH patients and unmatched controls.
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Affiliation(s)
- Jessica B. Badlam
- Department of Medicine, Division of
Pulmonary and Critical Care Medicine,
University
of Vermont, Burlington, USA
| | - David Badesch
- Department of Medicine, Pulmonary
Hypertension Center,
University
of Colorado, Aurora, USA
| | - Evan Brittain
- Department of Medicine, Division of
Cardiovascular Medicine,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Shannon Cordell
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Tan Ding
- Department of Biostatistics,
Vanderbilt
University School of Medicine, Nashville,
USA
| | - Kelly Fox
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Anna Hemnes
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - James Loyd
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Meredith Pugh
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Ivan Robbins
- Department of Medicine, Pulmonary
Vascular Center,
Vanderbilt
University Medical Center, Nashville,
USA
| | - Chang Yu
- Department of Biostatistics,
Vanderbilt
University School of Medicine, Nashville,
USA
| | - Eric D. Austin
- Department of Pediatrics, Vanderbilt
Pediatric Pulmonary Hypertension Program,
Vanderbilt
University Medical Center, Nashville,
USA
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59
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Barco S, Klok FA, Konstantinides SV, Dartevelle P, Fadel E, Jenkins D, Kim NH, Madani M, Matsubara H, Mayer E, Pepke-Zaba J, Simonneau G, Delcroix M, Lang IM. Sex-specific differences in chronic thromboembolic pulmonary hypertension. Results from the European CTEPH registry. J Thromb Haemost 2020; 18:151-161. [PMID: 31479557 DOI: 10.1111/jth.14629] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/28/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Women are more susceptible than men to several forms of pulmonary hypertension, but have better survival. Sparse data are available on chronic thromboembolic pulmonary hypertension (CTEPH). METHODS We investigated sex-specific differences in the clinical presentation of CTEPH, performance of pulmonary endarterectomy (PEA), and survival. RESULTS Women constituted one-half of the study population of the European CTEPH registry (N = 679) and were characterized by a lower prevalence of some cardiovascular risk factors, including prior acute coronary syndrome, smoking habit, and chronic obstructive pulmonary disease, but more prevalent obesity, cancer, and thyroid diseases. The median age was 62 (interquartile ratio, 50-73) years in women and 63 (interquartile ratio, 53-70) in men. Women underwent PEA less often than men (54% vs 65%), especially at low-volume centers (48% vs 61%), and were exposed to fewer additional cardiac procedures, notably coronary artery bypass graft surgery (0.5% vs 9.5%). The prevalence of specific reasons for not being operated, including patient's refusal and the proportion of proximal vs distal lesions, did not differ between sexes. A total of 57 (17.0%) deaths in women and 70 (20.7%) in men were recorded over long-term follow-up. Female sex was positively associated with long-term survival (adjusted hazard ratio, 0.66; 95% confidence interval, 0.46-0.94). Short-term mortality was identical in the two groups. CONCLUSIONS Women with CTEPH underwent PEA less frequently than men, especially at low-volume centers. Furthermore, they had a lower prevalence of cardiovascular risk factors and were less often exposed to additional cardiac surgery procedures. Women had better long-term survival.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Medicine - Thrombosis & Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Philippe Dartevelle
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, Paris, France
| | - Elie Fadel
- Faculté de Médecine, University Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Michael Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Eckhard Mayer
- Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marion Delcroix
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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60
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Tofovic SP, Jackson EK. Estradiol Metabolism: Crossroads in Pulmonary Arterial Hypertension. Int J Mol Sci 2019; 21:ijms21010116. [PMID: 31877978 PMCID: PMC6982327 DOI: 10.3390/ijms21010116] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a debilitating and progressive disease that predominantly develops in women. Over the past 15 years, cumulating evidence has pointed toward dysregulated metabolism of sex hormones in animal models and patients with PAH. 17β-estradiol (E2) is metabolized at positions C2, C4, and C16, which leads to the formation of metabolites with different biological/estrogenic activity. Since the first report that 2-methoxyestradiol, a major non-estrogenic metabolite of E2, attenuates the development and progression of experimental pulmonary hypertension (PH), it has become increasingly clear that E2, E2 precursors, and E2 metabolites exhibit both protective and detrimental effects in PH. Furthermore, both experimental and clinical data suggest that E2 has divergent effects in the pulmonary vasculature versus right ventricle (estrogen paradox in PAH). The estrogen paradox is of significant clinical relevance for understanding the development, progression, and prognosis of PAH. This review updates experimental and clinical findings and provides insights into: (1) the potential impacts that pathways of estradiol metabolism (EMet) may have in PAH; (2) the beneficial and adverse effects of estrogens and their precursors/metabolites in experimental PH and human PAH; (3) the co-morbidities and pathological conditions that may alter EMet and influence the development/progression of PAH; (4) the relevance of the intracrinology of sex hormones to vascular remodeling in PAH; and (5) the advantages/disadvantages of different approaches to modulate EMet in PAH. Finally, we propose the three-tier-estrogen effects in PAH concept, which may offer reconciliation of the opposing effects of E2 in PAH and may provide a better understanding of the complex mechanisms by which EMet affects the pulmonary circulation–right ventricular interaction in PAH.
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Affiliation(s)
- Stevan P. Tofovic
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, BST E1240, 200 Lothrop Street, Pittsburgh, PA 15261, USA
- Department of Pharmacology and Chemical Biology University of Pittsburgh School of Medicine, 100 Technology Drive, PA 15219, USA;
- Correspondence: ; Tel.: +1-412-648-3363
| | - Edwin K. Jackson
- Department of Pharmacology and Chemical Biology University of Pittsburgh School of Medicine, 100 Technology Drive, PA 15219, USA;
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61
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Hsu CH, Lin CC, Li WT, Chang HY, Chang WT. Right ventricular dysfunction is associated with the development of chronic thromboembolic pulmonary hypertension but not with mortality post-acute pulmonary embolism. Medicine (Baltimore) 2019; 98:e17953. [PMID: 31770203 PMCID: PMC6890284 DOI: 10.1097/md.0000000000017953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), a late complication of pulmonary embolism (PE), is associated with high mortality. However, whether the right ventricular (RV) echocardiographic parameters can predict - in the short- and long-term - the development of CTEPH and mortality after PE remains unknown. Herein, we aim to investigate the incidence of CTEPH after acute PE and to evaluate the risk factors of CTEPH. In this retrospective cohort, patients with PE were followed for 10 years for the onset of CTEPH. The screening was initially conducted through echocardiography and confirmed by right heart catheterization. Also, transient and permanent risk factors were identified. Among 358 patients with PE, 8 patients (4%) were subsequently diagnosed with CTEPH at a median time of 36 months and 47 died during the follow-up period. Notably, both short- and long-term RV dilatation, hypertrophy, and increased pulmonary pressure increased the incidence of CTEPH. However, RV echocardiographic parameters failed to differentiate survivors from non-survivors. Instead, malignancy, respiratory, or chronic heart failure was strongly associated with post PE mortality in the multivariable analysis. According to our findings, post PE screening of CTEPH may facilitate early diagnosis and intervention for patients at high risk of developing CTEPH. Also, RV echocardiographic parameters are associated with subsequent CTEPH, but mortality is mainly dependent on underlying comorbidities.
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Affiliation(s)
- Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Chih-Chan Lin
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Wei-Ting Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan
| | - Hsien-Yuan Chang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital Douliou Branch, Yun-Lin
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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62
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Keller K, Hobohm L, Münzel T, Ostad MA, Espinola-Klein C, Lavie CJ, Konstantinides S, Lankeit M. Survival Benefit of Obese Patients With Pulmonary Embolism. Mayo Clin Proc 2019; 94:1960-1973. [PMID: 31585580 DOI: 10.1016/j.mayocp.2019.04.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/15/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE). PATIENTS AND METHODS Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes. RESULTS From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P<.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P<.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P<.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P<.001) and II (OR, 0.63; 95% CI 0.58-0.69; P<.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04). CONCLUSION Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research, Partner Site Rhine Main, Rhine Main, Germany
| | - Mir A Ostad
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Carl J Lavie
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine, Berlin, Germany; Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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63
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Han MK, Arteaga-Solis E, Blenis J, Bourjeily G, Clegg DJ, DeMeo D, Duffy J, Gaston B, Heller NM, Hemnes A, Henske EP, Jain R, Lahm T, Lancaster LH, Lee J, Legato MJ, McKee S, Mehra R, Morris A, Prakash YS, Stampfli MR, Gopal-Srivastava R, Laposky AD, Punturieri A, Reineck L, Tigno X, Clayton J. Female Sex and Gender in Lung/Sleep Health and Disease. Increased Understanding of Basic Biological, Pathophysiological, and Behavioral Mechanisms Leading to Better Health for Female Patients with Lung Disease. Am J Respir Crit Care Med 2019; 198:850-858. [PMID: 29746147 DOI: 10.1164/rccm.201801-0168ws] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Female sex/gender is an undercharacterized variable in studies related to lung development and disease. Notwithstanding, many aspects of lung and sleep biology and pathobiology are impacted by female sex and female reproductive transitions. These may manifest as differential gene expression or peculiar organ development. Some conditions are more prevalent in women, such as asthma and insomnia, or, in the case of lymphangioleiomyomatosis, are seen almost exclusively in women. In other diseases, presentation differs, such as the higher frequency of exacerbations experienced by women with chronic obstructive pulmonary disease or greater cardiac morbidity among women with sleep-disordered breathing. Recent advances in -omics and behavioral science provide an opportunity to specifically address sex-based differences and explore research needs and opportunities that will elucidate biochemical pathways, thus enabling more targeted/personalized therapies. To explore the status of and opportunities for research in this area, the NHLBI, in partnership with the NIH Office of Research on Women's Health and the Office of Rare Diseases Research, convened a workshop of investigators in Bethesda, Maryland on September 18 and 19, 2017. At the workshop, the participants reviewed the current understanding of the biological, behavioral, and clinical implications of female sex and gender on lung and sleep health and disease, and formulated recommendations that address research gaps, with a view to achieving better health outcomes through more precise management of female patients with nonneoplastic lung disease. This report summarizes those discussions.
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Affiliation(s)
- MeiLan K Han
- 1 Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Emilio Arteaga-Solis
- 2 Division of Pediatric Pulmonology, Columbia University Medical Center, New York, New York
| | - John Blenis
- 3 Pharmacology Ph.D. Program, Sandra and Edward Meyer Cancer Center, New York, New York
| | - Ghada Bourjeily
- 4 Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah J Clegg
- 5 Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Dawn DeMeo
- 6 Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeanne Duffy
- 7 Department of Medicine and.,8 Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ben Gaston
- 9 Pediatric Pulmonology, Case Western Reserve University, Cleveland, Ohio
| | - Nicola M Heller
- 10 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna Hemnes
- 11 Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth Petri Henske
- 12 Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raksha Jain
- 13 Division of Pulmonary and Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tim Lahm
- 14 Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lisa H Lancaster
- 15 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joyce Lee
- 16 Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, Colorado
| | | | - Sherry McKee
- 18 Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Reena Mehra
- 19 Neurologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alison Morris
- 20 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Y S Prakash
- 21 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Martin R Stampfli
- 22 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rashmi Gopal-Srivastava
- 23 Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland
| | - Aaron D Laposky
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | | | - Lora Reineck
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | - Xenia Tigno
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | - Janine Clayton
- 25 Office of Research on Women's Health, NIH-Office of the Director, Bethesda, Maryland
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64
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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65
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Frump AL, Lahm T. The Y Chromosome Takes the Field to Modify BMPR2 Expression. Am J Respir Crit Care Med 2019; 198:1476-1478. [PMID: 30265580 DOI: 10.1164/rccm.201809-1682ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrea L Frump
- 1 Department of Medicine Indiana University School of Medicine Indianapolis, Indiana
| | - Tim Lahm
- 1 Department of Medicine Indiana University School of Medicine Indianapolis, Indiana.,2 Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis, Indiana and.,3 Richard L. Roudebush VA Medical Center Indianapolis, Indiana
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66
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AMPK breathing and oxygen supply. Respir Physiol Neurobiol 2019; 265:112-120. [DOI: 10.1016/j.resp.2018.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 08/06/2018] [Accepted: 08/31/2018] [Indexed: 01/28/2023]
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67
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Keller K, Rappold L, Gerhold-Ay A, Hobohm L, Hasenfuß G, Konstantinides SV, Dellas C, Lankeit M. Sex-specific differences in pulmonary embolism. Thromb Res 2019; 178:173-181. [DOI: 10.1016/j.thromres.2019.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/12/2019] [Accepted: 04/19/2019] [Indexed: 12/19/2022]
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68
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Shimoda LA. Let's Talk about Sex: A Novel Mechanism by Which Estrogen Receptor β Limits Hypoxia-Inducible Factor Expression in Pulmonary Endothelial Cells. Am J Respir Cell Mol Biol 2019; 59:11-12. [PMID: 29957049 DOI: 10.1165/rcmb.2018-0030ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Larissa A Shimoda
- 1 Division of Pulmonary and Critical Care Medicine Johns Hopkins School of Medicine Baltimore, Maryland
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69
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Frump AL, Selej M, Wood JA, Albrecht M, Yakubov B, Petrache I, Lahm T. Hypoxia Upregulates Estrogen Receptor β in Pulmonary Artery Endothelial Cells in a HIF-1α-Dependent Manner. Am J Respir Cell Mol Biol 2019; 59:114-126. [PMID: 29394091 DOI: 10.1165/rcmb.2017-0167oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
17β-Estradiol (E2) attenuates hypoxia-induced pulmonary hypertension (HPH) through estrogen receptor (ER)-dependent effects, including inhibition of hypoxia-induced endothelial cell proliferation; however, the mechanisms responsible for this remain unknown. We hypothesized that the protective effects of E2 in HPH are mediated through hypoxia-inducible factor 1α (HIF-1α)-dependent increases in ERβ expression. Sprague-Dawley rats and ERα or ERβ knockout mice were exposed to hypobaric hypoxia for 2-3 weeks. The effects of hypoxia were also studied in primary rat or human pulmonary artery endothelial cells (PAECs). Hypoxia increased expression of ERβ, but not ERα, in lungs from HPH rats as well as in rat and human PAECs. ERβ mRNA time dependently increased in PAECs exposed to hypoxia. Normoxic HIF-1α/HIF-2α stabilization increased PAEC ERβ, whereas HIF-1α knockdown decreased ERβ abundance in hypoxic PAECs. In turn, ERβ knockdown in hypoxic PAECs increased HIF-2α expression, suggesting a hypoxia-sensitive feedback mechanism. ERβ knockdown in hypoxic PAECs also decreased expression of the HIF inhibitor prolyl hydroxylase 2 (PHD2), whereas ERβ activation increased PHD2 and decreased both HIF-1α and HIF-2α, suggesting that ERβ regulates the PHD2/HIF-1α/HIF-2α axis during hypoxia. Whereas hypoxic wild-type or ERα knockout mice treated with E2 demonstrated less pulmonary vascular remodeling and decreased HIF-1α after hypoxia compared with untreated hypoxic mice, ERβ knockout mice exhibited increased HIF-2α and an attenuated response to E2 during hypoxia. Taken together, our results demonstrate a novel and potentially therapeutically targetable mechanism whereby hypoxia, via HIF-1α, increases ERβ expression and the E2-ERβ axis targets PHD2, HIF-1α, and HIF-2α to attenuate HPH development.
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Affiliation(s)
- Andrea L Frump
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Mona Selej
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Jordan A Wood
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Marjorie Albrecht
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Bakhtiyor Yakubov
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Irina Petrache
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine.,2 Richard L. Roudebush VA Medical Center, and
| | - Tim Lahm
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine.,2 Richard L. Roudebush VA Medical Center, and.,3 Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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70
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Grinnan D, Trankle C, Andruska A, Bloom B, Spiekerkoetter E. Drug repositioning in pulmonary arterial hypertension: challenges and opportunities. Pulm Circ 2019; 9:2045894019832226. [PMID: 30729869 PMCID: PMC6852366 DOI: 10.1177/2045894019832226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Despite many advances in medical therapy for pulmonary arterial hypertension (PAH) over the past 20 years, long-term survival is still poor. Novel therapies which target the underlying pathology of PAH and which could be added to current vasodilatory therapies to halt disease progression and potentially reverse pulmonary vascular remodeling are highly sought after. Given the high attrition rates, substantial costs, and slow pace of new drug development, repositioning of “old” drugs is increasingly becoming an attractive path to identify novel treatment options, especially for a rare disease such as PAH. We here summarize the limitations of current PAH therapy, the general concept of repurposing and repositioning, success stories of approved repositioned drugs in PAH as well as novel repositioned drugs that show promise in preclinical models of pulmonary hypertension (PH) and are currently tested in clinical trials. We furthermore discuss various data-driven as well as experimental approaches currently used to identify repurposed drug candidates and review challenges for the “repositioning community” with regards to funding and patent and regulatory considerations, and to illustrate opportunities for collaborative solutions for drug repositioning relevant to PAH.
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Affiliation(s)
- Daniel Grinnan
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Cory Trankle
- 2 Department of Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam Andruska
- 3 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,4 Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | | | - Edda Spiekerkoetter
- 3 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,4 Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
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71
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Abstract
Pulmonary arterial hypertension (PAH) is a pulmonary vasculopathy that causes right ventricular dysfunction and exercise limitation and progresses to death. New findings from translational studies have suggested alternative pathways for treatment. These avenues include sex hormones, genetic abnormalities and DNA damage, elastase inhibition, metabolic dysfunction, cellular therapies, and anti-inflammatory approaches. Both novel and repurposed compounds with rationale from preclinical experimental models and human cells are now in clinical trials in patients with PAH. Findings from these studies will elucidate the pathobiology of PAH and may result in clinically important improvements in outcome.
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Affiliation(s)
- Edda Spiekerkoetter
- Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA; ,
| | - Steven M Kawut
- Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6021, USA;
| | - Vinicio A de Jesus Perez
- Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA; ,
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72
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Huang A, Sun D. Sexually Dimorphic Regulation of EET Synthesis and Metabolism: Roles of Estrogen. Front Pharmacol 2018; 9:1222. [PMID: 30420806 PMCID: PMC6215857 DOI: 10.3389/fphar.2018.01222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/08/2018] [Indexed: 01/03/2023] Open
Abstract
Epoxyeicosatrienoic acids (EETs) are metabolites of arachidonic acid via cytochrome P450 (CYP)/epoxygenase and are hydrolyzed by soluble epoxide hydrolase (sEH). Circulating and tissue levels of EETs are controlled by CYP (EET synthesis) and sEH (EET degradation). Therefore, both increases in CYP activity and decreases in sEH expression potentiate EET bioavailability, responses that prevail in the female sex as a function of estrogen. This mini review, based on subtitles listed, briefly summarizes studies focusing specifically on (1) female-specific potentiation of CYP/epoxygenase activity to compensate for the endothelial dysfunction; and (2) estrogen-dependent downregulation of sEH expression, which yields divergent actions in both systemic and pulmonary circulation, respectively. Estrogen-Potentiating EET Synthesis in Response to Endothelial Dysfunction: This section summarizes the current understanding regarding the roles of estrogen in facilitating EET synthesis in response to endothelial dysfunction. In this regard, estrogen recruitment of EET-driven signaling serves as a back-up mechanism, which compensates for NO deficiency to preserve endothelium-dependent vasodilator responses and maintain normal blood pressure. Estrogen-Dependent Downregulation of Ephx2/sEH Expression: This section focuses on molecular mechanisms responsible for the female-specific downregulation of sEH expression. Roles of EETs in Systemic Circulation, as a Function of Estrogen-Dependent Downregulation of sEH: This section summarizes studies conducted on animals that are either deficient in the Ephx2 gene (sEH-KO) or have been treated with sEH inhibitors (sEHIs), and exhibit EET-mediated cardiovascular protections in the cerebral, coronary, skeletal, and splanchnic circulations. In particular, the estrogen-inherent silencing of the Ephx2 gene duplicates the action of sEH deficiency, yielding comparable adaptations in attenuated myogenic vasoconstriction, enhanced shear stress-induced vasodilation, and improved cardiac contractility among female WT mice, male sEH-KO and sEHI-treated mice. Roles of Estrogen-Driven EET Production in Pulmonary Circulation: This section reviews epidemiological and clinical studies that provide the correlation between the polymorphism, or mutation of gene(s) involving estrogen metabolism and female predisposition to pulmonary hypertension, and specifically addresses an intrinsic causation between the estrogen-dependent downregulation of Ephx2 gene/sEH expression and female-susceptibility of being pulmonary hypertensive, a topic that has never been explored before. Additionally, the issue of the “estrogen paradox” in the incidence and prognosis of pulmonary hypertension is discussed.
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Affiliation(s)
- An Huang
- Department of Physiology, New York Medical College, Valhalla, NY, United States
| | - Dong Sun
- Department of Physiology, New York Medical College, Valhalla, NY, United States
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73
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Wang YD, Li YD, Ding XY, Wu XP, Li C, Guo DC, Shi YP, Lu XZ. 17β-estradiol preserves right ventricular function in rats with pulmonary arterial hypertension: an echocardiographic and histochemical study. Int J Cardiovasc Imaging 2018; 35:441-450. [PMID: 30350115 PMCID: PMC6454076 DOI: 10.1007/s10554-018-1468-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/12/2018] [Indexed: 11/18/2022]
Abstract
Pulmonary arterial hypertension (PAH) is more prevalent in females. Paradoxically, female patients have better right ventricular (RV) function and higher survival rates than males. However, the effects of 17β-estradiol (E2) on RV function in PAH has not been studied. Twenty-four male rats were exposed to monocrotaline (MCT) to induce experimental PAH, while treated with E2 or vehicle respectively. Together with eight control rats, thirty-two rats were examined by echocardiography 4 weeks after drug administration. Echocardiographic measurement of RV function included: tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), RV fractional area change (RVFAC) and tricuspid annular systolic velocity (s′). RV free wall longitudinal strain (RVLSFW) and RV longitudinal shortening fraction (RVLSF) were also used to quantify RV function. RV morphology was determined by echocardiographic and histological analysis. TAPSE, RVFAC and s′ were reduced, and RIMP was elevated in the MCT-treated group and vehicle-treated group, when compared with control group (P < 0.01). TAPSE, RVFAC and s′ in the E2 group were higher, while RIMP was lower than those in the MCT-treated group and vehicle-treated group (P < 0.01). Myocardial functional parameters (RVLSFW and RVLSF) were also higher in the E2 group. Enhanced serum E2 levels were closely correlated with the improvement in RV functional parameters and enhancement of serum BNP levels (P < 0.01 for all groups). RV function decreased significantly in male rats with MCT-induced PAH, while E2 exhibited a protective effect on RV function, suggesting that E2 is a critical modulator of sex differences in PAH.
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Affiliation(s)
- Yi-Dan Wang
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.,Beijing Key Laboratory of Hypertension, Beijing, 100020, China
| | - Yi-Dan Li
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xue-Yan Ding
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xiao-Peng Wu
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Cheng Li
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Di-Chen Guo
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yan-Ping Shi
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xiu-Zhang Lu
- Department of Echocardiography, Heart Center, Beijing Chao Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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74
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Wilkins MR, Aman J, Harbaum L, Ulrich A, Wharton J, Rhodes CJ. Recent advances in pulmonary arterial hypertension. F1000Res 2018; 7. [PMID: 30079232 PMCID: PMC6058465 DOI: 10.12688/f1000research.14984.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 12/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disorder with a high mortality rate. Treatment options have improved in the last 20 years, but patients still die prematurely of right heart failure. Though rare, it is heterogeneous at the genetic and molecular level, and understanding and exploiting this is key to the development of more effective treatments.
BMPR2, encoding bone morphogenetic receptor type 2, is the most commonly affected gene in both familial and non-familial PAH, but rare mutations have been identified in other genes. Transcriptomic, proteomic, and metabolomic studies looking for endophenotypes are under way. There is no shortage of candidate new drug targets for PAH, but the selection and prioritisation of these are challenges for the research community.
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Affiliation(s)
| | - Jurjan Aman
- Department of Medicine, Imperial College London, London, UK
| | - Lars Harbaum
- Department of Medicine, Imperial College London, London, UK
| | - Anna Ulrich
- Department of Medicine, Imperial College London, London, UK
| | - John Wharton
- Department of Medicine, Imperial College London, London, UK
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75
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Ahmed M, Miller E. Macrophage migration inhibitory factor (MIF) in the development and progression of pulmonary arterial hypertension. Glob Cardiol Sci Pract 2018; 2018:14. [PMID: 30083544 PMCID: PMC6062764 DOI: 10.21542/gcsp.2018.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
Macrophage migration inhibitory factor (MIF) has been described as a pro-inflammatory cytokine and regulator of neuro-endocrine function. It plays an important upstream role in the inflammatory cascade by promoting the release of other inflammatory cytokines such as TNF-alpha and IL-6, ultimately triggering a chronic inflammatory immune response. As lungs can synthesize and release MIF, many studies have investigated the potential role of MIF as a biomarker in assessment of patients with pulmonary arterial hypertension (PAH) and using anti-MIFs as a new therapeutic modality for PAH.
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Affiliation(s)
- Mohamed Ahmed
- Neonatal-Perinatal Medicine, Pediatrics Department Cohen Children’s Hospital at New York, Northwell Health System
- The Center for Heart and Lung Research, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- School of Medicine, Hofstra University, Hempstead, New York, USA
| | - Edmund Miller
- The Center for Heart and Lung Research, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- School of Medicine, Hofstra University, Hempstead, New York, USA
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA
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76
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Sharma D, Coridon H, Aubry E, Houeijeh A, Houfflin-Debarge V, Besson R, Deruelle P, Storme L. Vasodilator effects of dehydroepiandrosterone (DHEA) on fetal pulmonary circulation: An experimental study in pregnant sheep. PLoS One 2018; 13:e0198778. [PMID: 29949623 PMCID: PMC6021043 DOI: 10.1371/journal.pone.0198778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/24/2018] [Indexed: 11/25/2022] Open
Abstract
Persistent pulmonary hypertension (PPHN) remains a severe complication of the transition to extra-uterine life with significant morbidity and mortality in the newborns. Dehydroepiandrosterone (DHEA) represents a new pharmacological agent with vascular effects, including improvement of PPHN in several animal models. We hypothesized that DHEA could decrease pulmonary vascular resistance (PVR) in the pulmonary circulation of fetal sheep. We studied the effect of intravenous infusion of DHEA in fetal lambs using chronically instrumented sheep at 128 days of gestation. PVR was computed before and after intravenous infusion of increasing doses of DHEA. We assessed pre-treatment by L-nitroarginine, an inhibitor of NO production. Blood gases and doses of DHEA were measured in both sheep and fetus before/after DHEA infusion. Intravenous infusion of DHEA had a vasodilator effect with a significant decrease in PVR (respectively -11%, -14% and -36% after infusion of 6, 12 and 24 mg DHEA, p<0.01) without damaging effects on systemic circulation or on blood gases. The inhibitory effect of pre-treatment with L-nitroarginine resulted in a significant increase in PVR. We demonstrated a potent vasodilator effect of DHEA on fetal pulmonary circulation without deleterious effects. DHEA might represent a new treatment for PPHN.
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Affiliation(s)
- Dyuti Sharma
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Pediatric Surgery, Hospital Jeanne de Flandre, Lille, France
| | - Hélène Coridon
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- Hospital MFME, Department of Pediatric Surgery, Fort-de‐France, Martinique, France
| | - Estelle Aubry
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Pediatric Surgery, Hospital Jeanne de Flandre, Lille, France
| | - Ali Houeijeh
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Neonatology, Hospital Jeanne de Flandre, CHRU Lille, Lille, France
| | - Véronique Houfflin-Debarge
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics and Gynecology, Hospital Jeanne de Flandre, Lille, France
| | - Rémi Besson
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Pediatric Surgery, Hospital Jeanne de Flandre, Lille, France
| | - Philippe Deruelle
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics and Gynecology, Hospital Jeanne de Flandre, Lille, France
| | - Laurent Storme
- Univ. Lille, EA 4489 – Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Neonatology, Hospital Jeanne de Flandre, CHRU Lille, Lille, France
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77
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Osman MS, Michelakis ED. Immunity Comes to Play in the “Sex Paradox” of Pulmonary Arterial Hypertension. Circ Res 2018; 122:1635-1637. [DOI: 10.1161/circresaha.118.313075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mohammed S. Osman
- From the Department of Medicine, University of Alberta, Edmonton, Canada
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78
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Batton KA, Austin CO, Bruno KA, Burger CD, Shapiro BP, Fairweather D. Sex differences in pulmonary arterial hypertension: role of infection and autoimmunity in the pathogenesis of disease. Biol Sex Differ 2018; 9:15. [PMID: 29669571 PMCID: PMC5907450 DOI: 10.1186/s13293-018-0176-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/09/2018] [Indexed: 01/14/2023] Open
Abstract
Registry data worldwide indicate an overall female predominance for pulmonary arterial hypertension (PAH) of 2–4 over men. Genetic predisposition accounts for only 1–5% of PAH cases, while autoimmune diseases and infections are closely linked to PAH. Idiopathic PAH may include patients with undiagnosed autoimmune diseases based on the relatively high presence of autoantibodies in this group. The two largest PAH registries to date report a sex ratio for autoimmune connective tissue disease-associated PAH of 9:1 female to male, highlighting the need for future studies to analyze subgroup data according to sex. Autoimmune diseases that have been associated with PAH include female-dominant systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, and thyroiditis as well as male-dominant autoimmune diseases like myocarditis which has been linked to HIV-associated PAH. The sex-specific association of PAH to certain infections and autoimmune diseases suggests that sex hormones and inflammation may play an important role in driving the pathogenesis of disease. However, there is a paucity of data on sex differences in inflammation in PAH, and more research is needed to better understand the pathogenesis underlying PAH in men and women. This review uses data on sex differences in PAH and PAH-associated autoimmune diseases from registries to provide insight into the pathogenesis of disease.
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Affiliation(s)
- Kyle A Batton
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Katelyn A Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Brian P Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA.
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79
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de Wijs-Meijler DPM, Danser AHJ, Reiss IKM, Duncker DJ, Merkus D. Sex differences in pulmonary vascular control: focus on the nitric oxide pathway. Physiol Rep 2018; 5:5/11/e13200. [PMID: 28596298 PMCID: PMC5471427 DOI: 10.14814/phy2.13200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/17/2017] [Accepted: 02/17/2017] [Indexed: 01/23/2023] Open
Abstract
Although the incidence of pulmonary hypertension is higher in females, the severity and prognosis of pulmonary vascular disease in both neonates and adults have been shown to be worse in male subjects. Studies of sex differences in pulmonary hypertension have mainly focused on the role of sex hormones. However, the contribution of sex differences in terms of vascular signaling pathways regulating pulmonary vascular function remains incompletely understood. Consequently, we investigated pulmonary vascular function of male and female swine in vivo, both at rest and during exercise, and in isolated small pulmonary arteries in vitro, with a particular focus on the NO‐cGMP‐PDE5 pathway. Pulmonary hemodynamics at rest and during exercise were virtually identical in male and female swine. Moreover, NO synthase inhibition resulted in a similar degree of pulmonary vasoconstriction in male and female swine. However, NO synthase inhibition blunted bradykinin‐induced vasodilation in pulmonary small arteries to a greater extent in male than in female swine. PDE5 inhibition resulted in a similar degree of vasodilation in male and female swine at rest, while during exercise there was a trend towards a larger effect in male swine. In small pulmonary arteries, PDE5 inhibition failed to augment bradykinin‐induced vasodilation in either sex. Finally, in the presence of NO synthase inhibition, the pulmonary vasodilator effect of PDE5 inhibition was significantly larger in female swine both in vivo and in vitro. In conclusion, the present study demonstrated significant sex differences in the regulation of pulmonary vascular tone, which may contribute to understanding sex differences in incidence, treatment response, and prognosis of pulmonary vascular disease.
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Affiliation(s)
- Daphne P M de Wijs-Meijler
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands .,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A H Jan Danser
- Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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80
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Tamosiuniene R, Manouvakhova O, Mesange P, Saito T, Qian J, Sanyal M, Lin YC, Nguyen LP, Luria A, Tu AB, Sante JM, Rabinovitch M, Fitzgerald DJ, Graham BB, Habtezion A, Voelkel NF, Aurelian L, Nicolls MR. Dominant Role for Regulatory T Cells in Protecting Females Against Pulmonary Hypertension. Circ Res 2018; 122:1689-1702. [PMID: 29545367 DOI: 10.1161/circresaha.117.312058] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE Pulmonary arterial hypertension (PH) is a life-threatening condition associated with immune dysregulation and abnormal regulatory T cell (Treg) activity, but it is currently unknown whether and how abnormal Treg function differentially affects males and females. OBJECTIVE To evaluate whether and how Treg deficiency differentially affects male and female rats in experimental PH. METHODS AND RESULTS Male and female athymic rnu/rnu rats, lacking Tregs, were treated with the VEGFR2 (vascular endothelial growth factor receptor 2) inhibitor SU5416 or chronic hypoxia and evaluated for PH; some animals underwent Treg immune reconstitution before SU5416 administration. Plasma PGI2 (prostacyclin) levels were measured. Lung and right ventricles were assessed for the expression of the vasoprotective proteins COX-2 (cyclooxygenase 2), PTGIS (prostacyclin synthase), PDL-1 (programmed death ligand 1), and HO-1 (heme oxygenase 1). Inhibitors of these pathways were administered to athymic rats undergoing Treg immune reconstitution. Finally, human cardiac microvascular endothelial cells cocultured with Tregs were evaluated for COX-2, PDL-1, HO-1, and ER (estrogen receptor) expression, and culture supernatants were assayed for PGI2 and IL (interleukin)-10. SU5416-treatment and chronic hypoxia produced more severe PH in female than male athymic rats. Females were distinguished by greater pulmonary inflammation, augmented right ventricular fibrosis, lower plasma PGI2 levels, decreased lung COX-2, PTGIS, HO-1, and PDL-1 expression and reduced right ventricular PDL-1 levels. In both sexes, Treg immune reconstitution protected against PH development and raised levels of plasma PGI2 and cardiopulmonary COX-2, PTGIS, PDL-1, and HO-1. Inhibiting COX-2, HO-1, and PD-1 (programmed death 1)/PDL-1 pathways abrogated Treg protection. In vitro, human Tregs directly upregulated endothelial COX-2, PDL-1, HO-1, ERs and increased supernatant levels of PGI2 and IL-10. CONCLUSIONS In 2 animal models of PH based on Treg deficiency, females developed more severe PH than males. The data suggest that females are especially reliant on the normal Treg function to counteract the effects of pulmonary vascular injury leading to PH.
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Affiliation(s)
- Rasa Tamosiuniene
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Olga Manouvakhova
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Paul Mesange
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Toshie Saito
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Jin Qian
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Mrinmoy Sanyal
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Yu-Chun Lin
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Linh P Nguyen
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Amir Luria
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.).,VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Allen B Tu
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Joshua M Sante
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Marlene Rabinovitch
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | | | - Brian B Graham
- University of Colorado Denver, School of Medicine, Department of Medicine, Aurora (B.B.G.)
| | - Aida Habtezion
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Norbert F Voelkel
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Richmond (N.F.V.)
| | - Laure Aurelian
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.).,University of Maryland School of Medicine, Baltimore (L.A.)
| | - Mark R Nicolls
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.) .,VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
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81
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Abstract
PURPOSE OF REVIEW Prevalence and outcome differences between women and men with pulmonary arterial hypertension (PAH) raise questions about the role of sex hormones in disease pathobiology. This review will summarize the current understanding of sex and sex hormone pathways and their influence on heart-lung function in health and in disease. RECENT FINDINGS Female sex has been shown to be a risk factor for the development of PAH, but women have improved survival compared to men with PAH. These paradoxical observations are likely driven in part by complex sex hormone signaling and processing pathways and their interaction with the pulmonary vasculature and the right ventricle. These relationships may vary depending on an individual's underlying sex, age, and/or genetic substrate. The study of the connections between sex, sex hormones, the pulmonary circulation, and the right ventricle may improve our understanding of disease epidemiology and outcomes and lead to new treatment strategies for PAH.
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Affiliation(s)
- Andrew Foderaro
- Division of Pulmonary, Critical Care and Sleep, Brown University, Providence, RI, USA
- Department of Medicine, Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care and Sleep, Brown University, Providence, RI, USA.
- Department of Medicine, Brown University, Providence, RI, USA.
- Health Services, Policy, and Practice, Brown University, Providence, RI, USA.
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82
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Strielkov I, Weissmann N. Role of the Aryl Hydrocarbon Receptor in Su5416/Hypoxia-induced Pulmonary Hypertension: A New Mechanism for an “Old” Model. Am J Respir Cell Mol Biol 2018; 58:279-281. [DOI: 10.1165/rcmb.2017-0359ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ievgen Strielkov
- Excellence Cluster Cardiopulmonary SystemJustus Liebig University GiessenGiessen, Germany
| | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary SystemJustus Liebig University GiessenGiessen, Germany
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83
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Schäfer M, Collins KK, Browne LP, Ivy DD, Abman S, Friesen R, Frank B, Fonseca B, DiMaria M, Hunter KS, Truong U, von Alvensleben JC. Effect of electrical dyssynchrony on left and right ventricular mechanics in children with pulmonary arterial hypertension. J Heart Lung Transplant 2018; 37:870-878. [PMID: 29496397 DOI: 10.1016/j.healun.2018.01.1308] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/12/2017] [Accepted: 01/31/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Electrical and right ventricular (RV) mechanical dyssynchrony has been previously described in pediatric pulmonary arterial hypertension (PAH), but less is known about the relationship between electrical dyssynchrony and biventricular function. In this study we applied cardiac magnetic resonance (CMR) imaging to evaluate biventricular size and function with a focus on left ventricular (LV) strain mechanics in pediatric PAH patients with and without electrical dyssynchrony. METHODS Fifty-six children with PAH and comprehensive CMR evaluation were stratified based on QRS duration z-score, with electrical dyssynchrony defined as z-score ≥2. Comprehensive biventricular volumetric, dyssynchrony, and strain analysis was performed. RESULTS Nineteen PAH patients had or developed electrical dyssynchrony. Patients with electrical dyssynchrony had significantly reduced RV ejection fraction (35% vs 50%, p = 0.003) and greater end-diastolic (168 vs 112 ml/m2, p = 0.041) and end-systolic (119 vs 57, ml/m2, p = 0.026) volumes. Patients with electrical dyssynchrony had reduced RV longitudinal strain (-14% vs -19%, p = 0.007), LV circumferential strain measured at the free wall (-19% vs -22%, p = 0.047), and the LV longitudinal strain in the septal region (-10% vs -15%, p = 0.0268). LV mechanical intraventricular dyssynchrony was reduced in patients with electrical dyssynchrony at the LV free wall (43 vs 19 ms, p = 0.019). CONCLUSIONS The electrical dyssynchrony is associated with the reduced LV strain, enlarged RV volumes, and reduced biventricular function in children with PAH. CMR assessment of biventricular mechanical function with respect to QRS duration may help to detect pathophysiologic processes associated with progressed PAH.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado.
| | - Kathryn K Collins
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Lorna P Browne
- Department of Radiology, Breathing Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Steven Abman
- Division of Pulmonology, Breathing Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Richard Friesen
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Benjamin Frank
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Michael DiMaria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Kendall S Hunter
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Uyen Truong
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Johannes C von Alvensleben
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
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84
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Yang YM, Sehgal PB. Smooth Muscle-Specific BCL6+/- Knockout Abrogates Sex Bias in Chronic Hypoxia-Induced Pulmonary Arterial Hypertension in Mice. Int J Endocrinol 2018; 2018:3473105. [PMID: 30140283 PMCID: PMC6081567 DOI: 10.1155/2018/3473105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/07/2018] [Accepted: 06/24/2018] [Indexed: 12/18/2022] Open
Abstract
The "estrogen paradox" in pulmonary arterial hypertension (PAH) refers to observations that while there is a higher incidence of idiopathic PAH in women, rodent models of PAH show male dominance and estrogens are protective. To explain these differences, we previously proposed the neuroendocrine-STAT5-BCL6 hypothesis anchored in the sex-biased and species-specific patterns of growth hormone (GH) secretion by the pituitary, the targeting of the hypothalamus by estrogens to feminize GH secretion patterns, and the role of the transcription factors STAT5a/b and BCL6 as downstream mediators of this patterned GH-driven sex bias. As a test of this hypothesis, we previously reported that vascular smooth muscle cell- (SMC-) specific deletion of the STAT5a/b locus abrogated the male-dominant sex bias in the chronic hypoxia model of PAH in mice. In the present study, we confirmed reduced BCL6 expression in pulmonary arterial (PA) segments in both male and female SMC:STAT5a/b-/- mice. In order to test the proposed contribution of BCL6 to sex bias in PAH, we developed mice with SMC-specific deletion of BCL6+/- by crossing SM22α-Cre mice with BCL6-floxed mice and investigated sex bias in these mutant mice in the chronic hypoxia model of PAH. We observed that the male-bias observed in wild-type- (wt-) SM22α-Cre-positive mice was abrogated in the SMC:BCL6+/- knockouts-both males and females showed equivalent enhancement of indices of PAH. The new data confirm BCL6 as a contributor to the sex-bias phenotype observed in hypoxic PAH in mice and support the neuroendocrine-STAT5-BCL6 hypothesis of sex bias in this experimental model of vascular disease.
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Affiliation(s)
- Yang-Ming Yang
- Department of Cell Biology and Anatomy, New York Medical College, Valhalla, NY 10595, USA
| | - Pravin B. Sehgal
- Department of Cell Biology and Anatomy, New York Medical College, Valhalla, NY 10595, USA
- Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
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85
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Hemnes AR, Humbert M. Pathobiology of pulmonary arterial hypertension: understanding the roads less travelled. Eur Respir Rev 2017; 26:26/146/170093. [DOI: 10.1183/16000617.0093-2017] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/08/2017] [Indexed: 01/09/2023] Open
Abstract
The pathobiology of pulmonary arterial hypertension (PAH) is complex and incompletely understood. Although three pathogenic pathways have been relatively well characterised, it is widely accepted that dysfunction in a multitude of other cellular processes is likely to play a critical role in driving the development of PAH. Currently available therapies, which all target one of the three well-characterised pathways, provide significant benefits for patients; however, PAH remains a progressive and ultimately fatal disease. The development of drugs to target alternative pathogenic pathways is, therefore, an attractive proposition and one that may complement existing treatment regimens to improve outcomes for patients. Considerable research has been undertaken to identify the role of the less well-understood pathways and in this review we will highlight some of the key discoveries and the potential for utility as therapeutic targets.
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86
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Affiliation(s)
- R James White
- 1 Aab Cardiovascular Research Institute University of Rochester Rochester, New York and.,2 Division of Pulmonary and Critical Care Medicine University of Rochester Rochester, New York
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87
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Lahm T, Frump AL. Toward Harnessing Sex Steroid Signaling as a Therapeutic Target in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2017; 195:284-286. [PMID: 28145752 DOI: 10.1164/rccm.201609-1906ed] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Tim Lahm
- 1 Division of Pulmonary, Critical Care, Occupational and Sleep Medicine Indiana University School of Medicine Indianapolis, Indiana.,2 Richard L. Roudebush VA Medical Center Indianapolis, Indiana
| | - Andrea L Frump
- 1 Division of Pulmonary, Critical Care, Occupational and Sleep Medicine Indiana University School of Medicine Indianapolis, Indiana
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88
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Frump AL, Bonnet S, de Jesus Perez VA, Lahm T. Emerging role of angiogenesis in adaptive and maladaptive right ventricular remodeling in pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2017; 314:L443-L460. [PMID: 29097426 DOI: 10.1152/ajplung.00374.2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Right ventricular (RV) function is the primary prognostic factor for both morbidity and mortality in pulmonary hypertension (PH). RV hypertrophy is initially an adaptive physiological response to increased overload; however, with persistent and/or progressive afterload increase, this response frequently transitions to more pathological maladaptive remodeling. The mechanisms and disease processes underlying this transition are mostly unknown. Angiogenesis has recently emerged as a major modifier of RV adaptation in the setting of pressure overload. A novel paradigm has emerged that suggests that angiogenesis and angiogenic signaling are required for RV adaptation to afterload increases and that impaired and/or insufficient angiogenesis is a major driver of RV decompensation. Here, we summarize our current understanding of the concepts of maladaptive and adaptive RV remodeling, discuss the current literature on angiogenesis in the adapted and failing RV, and identify potential therapeutic approaches targeting angiogenesis in RV failure.
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Affiliation(s)
- Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University , Quebec City, Quebec , Canada
| | - Vinicio A de Jesus Perez
- Division of Pulmonary/Critical Care, Stanford University School of Medicine , Stanford, California.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine , Stanford, California
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center , Indianapolis, Indiana.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine , Indianapolis, Indiana
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89
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Adir Y, Guazzi M, Offer A, Temporelli PL, Cannito A, Ghio S. Pulmonary hemodynamics in heart failure patients with reduced or preserved ejection fraction and pulmonary hypertension: Similarities and disparities. Am Heart J 2017; 192:120-127. [PMID: 28938958 DOI: 10.1016/j.ahj.2017.06.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The current understanding of pulmonary hypertension (PH) due to left ventricular diseases does not distinguish heart failure (HF) with reduced ejection fraction (HFrEF) from HF and preserved ejection fraction (HFpEF), in terms of pulmonary hemodynamics. The value of pulmonary vascular compliance (PCa) and diastolic pulmonary gradient (DPG) as predictors of survival in either HF syndrome is controversial. The aims of our study were to compare the pulmonary hemodynamics in the two HF phenotypes, given similar values of pulmonary artery wedge pressure (PAWP), and to evaluate the impact of PCa and DPG on survival. METHODS We retrospectively reviewed the charts of 168 PH-HFrEF and 86 PH-HFpEF patients. The independent association of PCa and DPG with prognosis was assessed by means of a Cox proportional hazard model. All cause survival was analyzed over an average follow-up period of 50 months. RESULTS PH-HFpEF patients had a significantly higher DPG than PH-HFrEF patients (6.1±7.1 vs 1.8±4.5 mmHg, adjusted P=.025). PCa was similar in PH-HFpEF and PH-HFrEF. PCa was a significant predictor of survival, according to previously described preset cutoffs (2.15 mL/mmHg in HFrEF and 1.1 mL/mmHg in HFpEF) and based on a continuous scale; whereas DPG had no impact on survival in both patients groups. CONCLUSION Our findings suggest that for similar levels of PAWP, pulmonary circulation may be stiffer in patients with HFpEF-PH than patients with HFrEF-PH, leading to higher DPGs. Nonetheless, PCa rather than DPG emerged as the stronger predictor of survival in both left-sided PH phenotypes.
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90
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Chen X, Austin ED, Talati M, Fessel JP, Farber-Eger EH, Brittain EL, Hemnes AR, Loyd JE, West J. Oestrogen inhibition reverses pulmonary arterial hypertension and associated metabolic defects. Eur Respir J 2017; 50:50/2/1602337. [PMID: 28775043 DOI: 10.1183/13993003.02337-2016] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 04/15/2017] [Indexed: 12/11/2022]
Abstract
Increased oestrogen is a strong epidemiological risk factor for development of pulmonary arterial hypertension (PAH) in patients, associated with metabolic defects. In addition, oestrogens drive penetrance in mice carrying mutations in bone morphogenetic protein receptor type II (BMPR2), the cause of most heritable PAH. The goal of the present study was to determine whether inhibition of oestrogens was effective in the treatment of PAH in these mice.The oestrogen inhibitors fulvestrant and anastrozole were used in a prevention and treatment paradigm in BMPR2 mutant mice, and tamoxifen was used for treatment. In addition, BMPR2 mutant mice were crossed onto oestrogen receptor (ESR)1 and ESR2 knockout backgrounds to assess receptor specificity. Haemodynamic and metabolic outcomes were measured.Oestrogen inhibition both prevented and treated PAH in BMPR2 mutant mice. This was associated with reduction in metabolic defects including oxidised lipid formation, insulin resistance and rescue of peroxisome proliferator-activated receptor-γ and CD36. The effect was mediated primarily through ESR2, but partially through ESR1.Our data suggest that trials of oestrogen inhibition in human PAH are warranted, and may improve pulmonary vascular disease through amelioration of metabolic defects. Although fulvestrant and anastrozole were more effective than tamoxifen, tamoxifen may be useful in premenopausal females, because of a reduced risk of induction of menopause.
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Affiliation(s)
- Xinping Chen
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Austin
- Dept of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megha Talati
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua P Fessel
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Dept of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric H Farber-Eger
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN, USA.,Vanderbilt Translational and Clinical Cardiovascular Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan L Brittain
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Translational and Clinical Cardiovascular Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna R Hemnes
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James E Loyd
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James West
- Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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91
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Kawut SM, Archer-Chicko CL, DeMichele A, Fritz JS, Klinger JR, Ky B, Palevsky HI, Palmisciano AJ, Patel M, Pinder D, Propert KJ, Smith KA, Stanczyk F, Tracy R, Vaidya A, Whittenhall ME, Ventetuolo CE. Anastrozole in Pulmonary Arterial Hypertension. A Randomized, Double-Blind, Placebo-controlled Trial. Am J Respir Crit Care Med 2017; 195:360-368. [PMID: 27602993 DOI: 10.1164/rccm.201605-1024oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE The aromatase inhibitor anastrozole blocks the conversion of androgens to estrogen and blunts pulmonary hypertension in animals, but its efficacy in treating patients with pulmonary arterial hypertension (PAH) is unknown. OBJECTIVES We aimed to determine the safety and efficacy of anastrozole in PAH. METHODS We performed a randomized, double-blind, placebo-controlled trial of anastrozole in patients with PAH who received background therapy at two centers. MEASUREMENTS AND MAIN RESULTS A total of 18 patients with PAH were randomized to anastrozole 1 mg or matching placebo in a 2:1 ratio. The two co-primary outcomes were percent change from baseline in 17β-estradiol levels (E2) and tricuspid annular plane systolic excursion (TAPSE) at 3 months. Anastrozole significantly reduced E2 levels compared with placebo (percent change: -40%; interquartile range [IQR], -61 to -26% vs. -4%; IQR, -14 to +4%; P = 0.003), but there was no difference in TAPSE. Anastrozole significantly increased the 6-minute-walk distance (median change = +26 m) compared with placebo (median change = -12 m) (median percent change: anastrozole group, 8%; IQR, 2 to 17% vs. placebo -2%; IQR, -7 to +1%; P = 0.042). Anastrozole had no effect on circulating biomarkers, functional class, or health-related quality of life. There was no difference in adverse events. CONCLUSIONS Anastrozole significantly reduced E2 levels in patients with PAH but had no effect on TAPSE. Anastrozole was safe, well tolerated, and improved 6-minute-walk distance in this small "proof-of-principle" study. Larger and longer phase II clinical trials of anastrozole may be warranted in patients with PAH. Clinical trial registered with www.clinicaltrials.gov (NCT 1545336).
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Affiliation(s)
- Steven M Kawut
- 1 Department of Medicine and.,2 Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - James R Klinger
- 3 Rhode Island Hospital, Providence, Rhode Island.,4 Department of Medicine, and
| | | | | | | | | | | | - Kathleen J Propert
- 2 Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Frank Stanczyk
- 5 Department of Obstetrics and Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, California; and
| | - Russell Tracy
- 6 Department of Laboratory Medicine, University of Vermont School of Medicine, Burlington, Vermont
| | | | - Mary E Whittenhall
- 3 Rhode Island Hospital, Providence, Rhode Island.,4 Department of Medicine, and
| | - Corey E Ventetuolo
- 3 Rhode Island Hospital, Providence, Rhode Island.,4 Department of Medicine, and.,7 Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
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92
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Sex-specific cardiopulmonary exercise testing parameters as predictors in patients with idiopathic pulmonary arterial hypertension. Hypertens Res 2017; 40:868-875. [PMID: 28566737 DOI: 10.1038/hr.2017.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 01/07/2017] [Accepted: 02/23/2017] [Indexed: 01/11/2023]
Abstract
Cardiopulmonary exercise testing (CPET) has been used for prognosis in idiopathic pulmonary arterial hypertension (IPAH). We explored whether sex differences had an impact on prognostic assessments of CPET in IPAH. Data were retrieved from 21 male and 36 female incident IPAH patients who underwent both right heart catheterization and CPET from 2010 to 2016 at Shanghai Pulmonary Hospital. Cox proportional hazards analysis was used to assess the prognostic value of CPET. The mean duration of follow-up was 22±15 months. Nine men and 15 women had an event. The differences in clinical parameters in the whole population were not the same as the inter-subgroup differences. Event-free women had significantly higher cardiac output, lower pulmonary vascular resistance and percentage of predicted FVC compared with event men (all P<0.05). Event-free men had significantly higher end-tidal partial pressure of CO2 (PETCO2) at anaerobic threshold (AT), peak workload, PETCO2, maximum oxygen consumption (VO2)/minute ventilation (VE), and oxygen uptake efficiency slope and lower end-tidal partial pressure of O2 (PETO2) at AT, peak PETO2, and lowest VE/VCO2 compared with event men. Event-free women had dramatically higher peak VO2, VCO2, VE and O2 pulse than event women (all P<0.05). Peak PETCO2 was the independent predictor of event-free survival in all patients and males, whereas peak O2 pulse was the independent predictor of event-free survival in females. Men with peak PETCO2⩾20.50 mm Hg, women with peak O2 pulse ⩾6.25 ml per beat and all patients with peak PETCO2⩾27.03 mm Hg had significantly better event-free survival. Sex-specific CPET parameters are predictors of poor outcomes. Decreased peak PETCO2 in men and peak O2 pulse in women were associated with lower event-free survival in IPAH.
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93
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Frump AL, Albrecht ME, McClintick JN, Lahm T. Estrogen receptor-dependent attenuation of hypoxia-induced changes in the lung genome of pulmonary hypertension rats. Pulm Circ 2017; 7:232-243. [PMID: 28680582 PMCID: PMC5448529 DOI: 10.1177/2045893217702055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/27/2016] [Indexed: 12/19/2022] Open
Abstract
17β-estradiol (E2) exerts complex and context-dependent effects in pulmonary hypertension. In hypoxia-induced pulmonary hypertension (HPH), E2 attenuates lung vascular remodeling through estrogen receptor (ER)-dependent effects; however, ER target genes in the hypoxic lung remain unknown. In order to identify the genome regulated by the E2-ER axis in the hypoxic lung, we performed a microarray analysis in lungs from HPH rats treated with E2 (75 mcg/kg/day) ± ER-antagonist ICI182,780 (3 mg/kg/day). Untreated HPH rats and normoxic rats served as controls. Using a false discovery rate of 10%, we identified a significantly differentially regulated genome in E2-treated versus untreated hypoxia rats. Genes most upregulated by E2 encoded matrix metalloproteinase 8, S100 calcium binding protein A8, and IgA Fc receptor; genes most downregulated by E2 encoded olfactory receptor 63, secreted frizzled-related protein 2, and thrombospondin 2. Several genes affected by E2 changed in the opposite direction after ICI182,780 co-treatment, indicating an ER-regulated genome in HPH lungs. The bone morphogenetic protein antagonist Grem1 (gremlin 1) was upregulated by hypoxia, but found to be among the most downregulated genes after E2 treatment. Gremlin 1 protein was reduced in E2-treated versus untreated hypoxic animals, and ER-blockade abolished the inhibitory effect of E2 on Grem1 mRNA and protein. In conclusion, E2 ER-dependently regulates several genes involved in proliferative and inflammatory processes during hypoxia. Gremlin 1 is a novel target of the E2-ER axis in HPH. Understanding the mechanisms of E2 gene regulation in HPH may allow for selectively harnessing beneficial transcriptional activities of E2 for therapeutic purposes.
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Affiliation(s)
- Andrea L Frump
- Department of Medicine; Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marjorie E Albrecht
- Department of Medicine; Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeanette N McClintick
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA.,Center for Medical Genomics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Department of Medicine; Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
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94
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The impact of age and gender on right ventricular diastolic function among healthy adults. J Cardiol 2017; 70:387-395. [PMID: 28325518 DOI: 10.1016/j.jjcc.2016.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/28/2016] [Accepted: 12/05/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Doppler echocardiography is ideally suited for assessment of diastolic function, being widely available, non-invasive, and less expensive than other techniques. However, data regarding age- and gender-matched reference values of right ventricular diastolic function are limited. This study aims to explore the physiologic variations of right ventricle (RV) diastolic function in a large cohort of healthy adults, and to investigate clinical and echocardiographic correlates. METHODS From June 2007 to February 2014, 1168 healthy Caucasian subjects [mean age 45.1±15.6 years, range 16-92; 555 (47.5%) men] underwent comprehensive transthoracic echocardiography (TTE) following current guidelines. The following RV main diastolic measurements were measured: peak early inflow velocity (E), annular both early (e') and atrial (a') velocities, E/e' ratio. RESULTS RV E/e' constantly increases with age in females, but do not change substantially in males. RV E/A constantly decreases with age in both genders. Stepwise multiple linear regression analysis underlined a close significant association of RV diastolic function with both right and left heart morphologic measurements (right atrial area, RV diameters, left atrial volume) and functional indexes (TAPSE, RV tissue Doppler peak systolic velocity, left ventricular E/Ee'), as well as with indexes of increased pulmonary resistance. CONCLUSION Our data highlight the potential usefulness of different normal reference values according to the age and gender to correctly evaluate RV diastolic function. Differences in terms of demographic and anthropometric parameters could be useful to avoid potential misclassification of RV diastolic function when based on dichotomously suggested normal cut-off values.
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95
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Abstract
Pulmonary hypertension (PH) is a multifaceted vascular disease where development and severity are determined by both genetic and environmental factors. Over the past decade, there has been an acceleration of the discovery of molecular effectors that mediate PH pathogenesis, including large numbers of microRNA molecules that are expressed in pulmonary vascular cell types and exert system-wide regulatory functions in all aspects of vascular health and disease. Due to the inherent pleiotropy, overlap, and redundancy of these molecules, it has been challenging to define their integrated effects on overall disease manifestation. In this review, we summarize our current understanding of the roles of microRNAs in PH with an emphasis on potential methods to discern the hierarchical motifs governing their multifunctional and interconnected activities. Deciphering this higher order of regulatory structure will be crucial for overcoming the challenges of developing these molecules as biomarkers or therapeutic targets, in isolation or combination.
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96
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Badlam JB, Bull TM. Steps forward in the treatment of pulmonary arterial hypertension: latest developments and clinical opportunities. Ther Adv Chronic Dis 2017; 8:47-64. [PMID: 28348727 PMCID: PMC5354132 DOI: 10.1177/2040622317693218] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/18/2017] [Indexed: 12/29/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic disease that results in narrowing of the small pre-capillary pulmonary arteries leading to elevation of pulmonary artery pressure and pulmonary vascular resistance, subsequent right ventricular failure, and if unchecked, death. Advances in the treatment of PAH over the last two decades have markedly improved survival. These improvements reflect a combination of changes in treatments, improved patient care strategies, and varying disease phenotypes in the PAH population. Currently approved therapies for PAH are directed at the recognized abnormalities within the pulmonary vasculature and include endothelin receptor antagonists, phosphodiesterase-5 inhibitors, soluble guanylate cyclase stimulators, and prostacyclin pathway agents. Most of these drugs have been approved on the basis of short-term trials that mainly demonstrated improvements in exercise capacity. More recently, long-term, event-driven trials of novel drugs have been performed, demonstrating new efficacy parameters. There have also been exciting advances in the understanding of right heart failure pathophysiology in PAH that have the potential to inspire the development of right ventricular targeted therapy and continued discoveries in the heterogeneity of disease and response to treatment has great potential for developing more 'personalized' therapeutic options. In this article, we review the current available data regarding the management of PAH, with an emphasis on the pharmacologic therapies and discussion of novel therapeutic directions for the treatment of this fatal disease.
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Affiliation(s)
- Jessica B. Badlam
- University of Colorado at Denver - Anschutz Medical Campus, 12700 East 19th Avenue, Mail stop C272, Aurora, CO 80045-0508, USA
| | - Todd M. Bull
- University of Colorado at Denver - Anschutz Medical Campus, Aurora, CO, USA
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97
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Yuan P, Chen TX, Pudasaini B, Zhang J, Guo J, Zhang SJ, Wang L, Zhao QH, Gong SG, Jiang R, Wu WH, He J, Liu JM, Hu QH. Sex-specific cardiopulmonary exercise testing indices related to hemodynamics in idiopathic pulmonary arterial hypertension. Ther Adv Respir Dis 2017; 11:135-145. [PMID: 28043202 PMCID: PMC5933651 DOI: 10.1177/1753465816684424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Many studies have highlighted sex preponderance in idiopathic pulmonary
arterial hypertension (IPAH). It is well established that there are
differences in exercise capacities in the two sexes but how much of that
difference reflects on disease severity or correlates to markers of severity
in the two sexes is still not clear. Right heart catheterization (RHC) and
cardiopulmonary exercise testing (CPET) have been widely used for assessing
functional capacity, prognosis and treatment response in IPAH. We aimed to
investigate the ‘sex-specific’ CPET parameters in relation to hemodynamics
in IPAH. Methods: Data were retrieved from 30 males and 53 females [mean ± standard deviation
(SD) age: 39.6 ± 17.2 and 37.5 ± 12.0] stable IPAH patients who underwent
both RHC and CPET at Shanghai Pulmonary Hospital from 2010 to 2016.
Univariate and forward/backward multiple stepwise regression analysis was
performed to assess the prognostic value of CPET and hemodynamic
parameters. Results: There were no significant differences in clinical variables between men and
women. Peak workload, peak oxygen uptake, anaerobic threshold (AT), peak
minute ventilation, carbon dioxide output, O2 pulse and oxygen
uptake efficiency slope were significantly higher in men compared with women
(p < 0.05). Several CPET indexes correlated with
hemodynamics. Pulmonary vascular resistance (PVR) and cardiac output (CO)
were distinctly different between the sexes. Peak end-tidal partial pressure
of CO2 (PETCO2) was an independent
predictor of PVR elevation in all patients and in men. Peak maximum oxygen
consumption (VO2) was independently predictive of CO decline in
all patients and in men. Only peak O2 pulse was an independent
predictor of increased PVR and decreased CO in women. Conclusions: Even after adjusting for age, body mass index and World Health Organization
functional class, different CPET parameters correlated with PVR elevation
and CO decline in men and women differently, which could potentially better
predict severity in men and women with IPAH.
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Affiliation(s)
- Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Tian-Xiang Chen
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jie Zhang
- The Organization and Personnel Department, Qilu Children's Hospital of Shandong University, Shandong University, Shandong, China
| | - Jian Guo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Si-Jin Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai 200433, China
| | - Qing-Hua Hu
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai 200433, China
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98
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Targeting Vascular Remodeling to Treat Pulmonary Arterial Hypertension. Trends Mol Med 2017; 23:31-45. [DOI: 10.1016/j.molmed.2016.11.005] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 12/13/2022]
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99
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Huetsch JC, Suresh K, Bernier M, Shimoda LA. Update on novel targets and potential treatment avenues in pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2016; 311:L811-L831. [PMID: 27591245 PMCID: PMC5130539 DOI: 10.1152/ajplung.00302.2016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/29/2016] [Indexed: 02/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a condition marked by a combination of constriction and remodeling within the pulmonary vasculature. It remains a disease without a cure, as current treatments were developed with a focus on vasodilatory properties but do not reverse the remodeling component. Numerous recent advances have been made in the understanding of cellular processes that drive pathologic remodeling in each layer of the vessel wall as well as the accompanying maladaptive changes in the right ventricle. In particular, the past few years have yielded much improved insight into the pathways that contribute to altered metabolism, mitochondrial function, and reactive oxygen species signaling and how these pathways promote the proproliferative, promigratory, and antiapoptotic phenotype of the vasculature during PH. Additionally, there have been significant advances in numerous other pathways linked to PH pathogenesis, such as sex hormones and perivascular inflammation. Novel insights into cellular pathology have suggested new avenues for the development of both biomarkers and therapies that will hopefully bring us closer to the elusive goal: a therapy leading to reversal of disease.
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Affiliation(s)
- John C Huetsch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Karthik Suresh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Meghan Bernier
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Larissa A Shimoda
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and
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100
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Joshi SR, Lakhkar A, Dhagia V, Zias AL, Soldatos V, Oshima K, Jiang H, Gotlinger K, Capdevila JH, Schwartzman ML, McMurtry IF, Gupte SA. Cyp2c44 gene disruption exacerbated pulmonary hypertension and heart failure in female but not male mice. Pulm Circ 2016; 6:360-8. [PMID: 27683613 DOI: 10.1086/688060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Epoxyeicosatrienoicacids (EETs), synthesized from arachidonic acid by epoxygenases of the CYP2C and CYP2J gene subfamilies, contribute to hypoxic pulmonary vasoconstriction (HPV) in mice. Despite their roles in HPV, it is controversial whether EETs mediate or ameliorate pulmonary hypertension (PH). A recent study showed that deficiency of Cyp2j did not protect male and female mice from hypoxia-induced PH. Since CYP2C44 is a functionally important epoxygenase, we hypothesized that knockout of the Cyp2c44 gene would protect both sexes of mice from hypoxia-induced PH. We tested this hypothesis in wild-type (WT) and Cyp2c44 knockout (Cyp2c44 (-/-)) mice exposed to normoxia (room air) and hypoxia (10% O2) for 5 weeks. Exposure of WT and Cyp2c44 (-/-) mice to hypoxia resulted in pulmonary vascular remodeling, increased pulmonary artery resistance, and decreased cardiac function in both sexes. However, in female Cyp2c44 (-/-) mice, compared with WT mice, (1) pulmonary artery resistance and right ventricular hypertrophy were greater, (2) cardiac index was lower, (3) left ventricular and arterial stiffness were higher, and (4) plasma aldosterone levels were higher, but (5) there was no difference in levels of EET in lungs and heart. Paradoxically and unexpectedly, we found that Cyp2c44 disruption exacerbated hypoxia-induced PH in female but not male mice. We attribute exacerbated PH in female Cyp2c44 (-/-) mice to elevated aldosterone and as-yet-unknown systemic factors. Therefore, we suggest a role for the human CYP2C genes in protecting women from severe PH and that this could be one of the underlying causes for a better 5-year survival rate in women than in men.
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Affiliation(s)
- Sachindra Raj Joshi
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anand Lakhkar
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vidhi Dhagia
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ariadne L Zias
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vasiliki Soldatos
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Kaori Oshima
- Department of Pharmacology, University of South Alabama, Mobile, Alabama, USA
| | - Houli Jiang
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Katherine Gotlinger
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jorge H Capdevila
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michal L Schwartzman
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ivan F McMurtry
- Department of Pharmacology, University of South Alabama, Mobile, Alabama, USA
| | - Sachin A Gupte
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
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