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Klinger JR, Chakinala MM, Langleben D, Rosenkranz S, Sitbon O. Riociguat: Clinical research and evolving role in therapy. Br J Clin Pharmacol 2020; 87:2645-2662. [PMID: 33242341 PMCID: PMC8359233 DOI: 10.1111/bcp.14676] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
Riociguat is a first-in-class soluble guanylate cyclase stimulator, approved for the treatment of adults with pulmonary arterial hypertension (PAH), inoperable chronic thromboembolic pulmonary hypertension (CTEPH), or persistent or recurrent CTEPH after pulmonary endarterectomy. Approval was based on the results of the phase III PATENT-1 (PAH) and CHEST-1 (CTEPH) studies, with significant improvements in the primary endpoint of 6-minute walk distance vs placebo of +36 m and +46 m, respectively, as well as improvements in secondary endpoints such as pulmonary vascular resistance and World Health Organization functional class. Riociguat acts as a stimulator of cyclic guanosine monophosphate synthesis rather than as an inhibitor of cGMP metabolism. As with other approved therapies for PAH, riociguat has antifibrotic, antiproliferative and anti-inflammatory effects, in addition to vasodilatory properties. This has led to further clinical studies in patients who do not achieve a satisfactory clinical response with phosphodiesterase type-5 inhibitors. Riociguat has also been evaluated in patients with World Health Organization group 2 and 3 pulmonary hypertension, and other conditions including diffuse cutaneous systemic sclerosis, Raynaud's phenomenon and cystic fibrosis. This review evaluates the results of the original clinical trials of riociguat for the treatment of PAH and CTEPH, and summarises the body of work that has examined the safety and efficacy of riociguat for the treatment of other types of pulmonary hypertension.
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Affiliation(s)
- James R Klinger
- Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology), and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - Olivier Sitbon
- Universite Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
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52
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Tonelli AR, Sahay S, Gordon KW, Edwards LD, Allmon AG, Broderick M, Nelsen AC. Impact of inhaled treprostinil on risk stratification with noninvasive parameters: a post hoc analysis of the TRIUMPH and BEAT studies. Pulm Circ 2020; 10:2045894020977025. [PMID: 33403101 PMCID: PMC7739096 DOI: 10.1177/2045894020977025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
The 2015 European Society of Cardiology/European Respiratory Society treatment guidelines recommend frequent risk assessment in pulmonary arterial hypertension utilizing risk variables. Our objectives were: (1) to investigate the impact of inhaled treprostinil on risk stratification using the French noninvasive approach and REVEAL 2.0, and (2) to analyze the prognostic utility of both risk stratification methods in the predominantly New York Heart Association/World Health Organization functional class III/IV cohorts of TRIUMPH and BEAT. A post hoc analysis was performed to assess risk at baseline and follow-up at Week 12 in the TRIUMPH cohort (n = 148) and at Week 16, 21, and 30 in the inhaled treprostinil naïve placebo BEAT cohort (n = 73). Overall survival, clinical worsening-free survival, and pulmonary arterial hypertension-related hospitalization-free survival were all assessed in the pooled TRIUMPH and inhaled treprostinil naïve placebo BEAT cohorts based on risk group/strata at Week 12/16 follow-up. Inhaled treprostinil improved REVEAL 2.0 risk stratum (OR: 2.38, 95% CI: 1.09–5.19, p = 0.0298) and REVEAL 2.0 score (p = 0.0008) compared to placebo in the TRIUMPH cohort at Week 12. REVEAL 2.0 risk stratum and the number of low-risk criteria by the French approach improved at Weeks 16, 21, and 30 in the inhaled treprostinil naïve placebo BEAT cohort. Combining cohorts, REVEAL 2.0 risk stratification at follow-up was prognostic for clinical worsening-free, pulmonary arterial hypertension hospitalization-free, and overall survival, whereas the number of low-risk criteria was not. These post-hoc pooled analyses suggest inhaled treprostinil improves risk status and indicates that the REVEAL 2.0 calculator may be more suitable than the French noninvasive method for evaluating short-term clinical change in the New York Heart Association/World Health Organization functional class III/IV population.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH, USA
| | - Sandeep Sahay
- Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Lung Center, Houston Methodist Hospital, Houston, TX, USA
| | - Kathryn W Gordon
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Lisa D Edwards
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Andrew G Allmon
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Andrew C Nelsen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
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53
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Sitbon O, Nikkho S, Benza R, Cq Deng C, W Farber H, Gomberg-Maitland M, Hassoun P, Meier C, Pepke-Zaba J, Prasad K, Seeger W, Corris PA. Novel composite clinical endpoints and risk scores used in clinical trials in pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020962960. [PMID: 33282190 PMCID: PMC7682238 DOI: 10.1177/2045894020962960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022] Open
Abstract
This manuscript on endpoints incorporates the broad experience of members of Pulmonary Vascular Research Institute’s Innovative Drug Development Initiative as an open debate platform for academia, the pharmaceutical industry and regulatory experts surrounding the future design of clinical trials in pulmonary hypertension. It reviews our current understanding of endpoints used in phase 2 and 3 trials for pulmonary hypertension and discusses in detail the value of newer approaches. These include the roles of composite endpoints and how these can be developed and validated. The newer concept of risk analysis is also discussed, including how such risk scores might be utilised as endpoints in clinical trials.
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Affiliation(s)
- Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | - Paul Hassoun
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Paul A Corris
- Clinical and Translational Research Institute Newcastle University, Newcastle upon Tyne, UK
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54
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He YY, Yan Y, Jiang X, Zhao JH, Wang Z, Wu T, Wang Y, Guo SS, Ye J, Lian TY, Xu XQ, Zhang JL, Sun K, Peng FH, Zhou YP, Mao YM, Zhang X, Chen JW, Zhang SY, Jing ZC. Spermine promotes pulmonary vascular remodelling and its synthase is a therapeutic target for pulmonary arterial hypertension. Eur Respir J 2020; 56:13993003.00522-2020. [PMID: 32513782 DOI: 10.1183/13993003.00522-2020] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
Pathological mechanisms of pulmonary arterial hypertension (PAH) remain largely unexplored. Effective treatment of PAH remains a challenge. The aim of this study was to discover the underlying mechanism of PAH through functional metabolomics and to help develop new strategies for prevention and treatment of PAH.Metabolomic profiling of plasma in patients with idiopathic PAH was evaluated through high-performance liquid chromatography mass spectrometry, with spermine identified to be the most significant and validated in another independent cohort. The roles of spermine and spermine synthase were examined in pulmonary arterial smooth muscle cells (PASMCs) and rodent models of pulmonary hypertension.Using targeted metabolomics, plasma spermine levels were found to be higher in patients with idiopathic PAH compared to healthy controls. Spermine administration promoted proliferation and migration of PASMCs and exacerbated vascular remodelling in rodent models of pulmonary hypertension. The spermine-mediated deteriorative effect can be attributed to a corresponding upregulation of its synthase in the pathological process. Inhibition of spermine synthase in vitro suppressed platelet-derived growth factor-BB-mediated proliferation of PASMCs, and in vivo attenuated monocrotaline-mediated pulmonary hypertension in rats.Plasma spermine promotes pulmonary vascular remodelling. Inhibiting spermine synthesis could be a therapeutic strategy for PAH.
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Affiliation(s)
- Yang-Yang He
- State Key Laboratory of Cardiovascular Disease and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Y-Y. He, Y. Yan and X. Jiang contributed equally to this work
| | - Yi Yan
- Dept of Cardiopulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Y-Y. He, Y. Yan and X. Jiang contributed equally to this work
| | - Xin Jiang
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Y-Y. He, Y. Yan and X. Jiang contributed equally to this work
| | - Jun-Han Zhao
- State Key Laboratory of Cardiovascular Disease and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Wang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Wu
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Wang
- Dept of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Shan-Shan Guo
- Dept of Biochemistry, Pharmaceutical College, Henan University, Kaifeng, China
| | - Jue Ye
- State Key Laboratory of Cardiovascular Disease and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tian-Yu Lian
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin-Lan Zhang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Hua Peng
- State Key Laboratory of Cardiovascular Disease and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Min Mao
- Dept of Respiratory Medicine, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Xue Zhang
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji-Wang Chen
- Section of Pulmonary, Critical Care Medicine, Sleep and Allergy, Dept of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Shu-Yang Zhang
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,S-Y. Zhang and Z-C. Jing contributed equally to this article as lead authors and supervised the work
| | - Zhi-Cheng Jing
- Dept of Cardiology and Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,S-Y. Zhang and Z-C. Jing contributed equally to this article as lead authors and supervised the work
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55
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Blood carbon dioxide tension and risk in pulmonary arterial hypertension. Int J Cardiol 2020; 318:131-137. [DOI: 10.1016/j.ijcard.2020.06.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
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56
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Gratsianskaya SE, Valieva ZS, Martynyuk TV. [The achievements of the modern specific therapy of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: focus on the stimulator of soluble guanylate cyclase riociguat]. TERAPEVT ARKH 2020; 92:77-84. [PMID: 33346435 DOI: 10.26442/00403660.2020.09.000717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022]
Abstract
Currently, treatment of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) is focused on three signaling pathways: the NO pathway, the endothelin pathway, and the prostacyclin pathway. Riociguat is the only representative of stimulators of the soluble guanylate cyclase (sGC) class that is approved for the treatment of PAH and inoperable and persistent/recurrent CTEPH. The review presents data from clinical trials showing a positive effect of riociguat on the functional and hemodynamic profile of patients with PAH and CTEPH. In recent years there has been much discussion about the possibility of optimizing therapy by switching to drugs that affect a single pathogenesis target. Thus, sGC stimulants have obvious advantages over phosphodiesterase type 5 (PDE-5) inhibitors, including the ability of riociguat to exert pharmacological effects (due to a NO-independent mechanism of action) even in conditions of reduced NO production. Switching from PDE-5 to riociguat may be safe and appropriate, according to clinical trials presented in the review. In accordance with the guidelines for the diagnosis and treatment of pulmonary hypertension of the Eurasian Association of cardiologists from 2019, this strategy is approved when PDE5 therapy is ineffective in patients with PAH FC III (WHO).
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Affiliation(s)
- S E Gratsianskaya
- Myasnikov Institute of Clinical Cardiology, National Medical Research Center for Cardiology
| | - Z S Valieva
- Myasnikov Institute of Clinical Cardiology, National Medical Research Center for Cardiology
| | - T V Martynyuk
- Myasnikov Institute of Clinical Cardiology, National Medical Research Center for Cardiology.,Pirogov Russian National Research Medical University
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57
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Nikkho S, Fernandes P, White RJ, Deng C(CQ, Farber HW, Corris PA. Clinical trial design in phase 2 and 3 trials for pulmonary hypertension. Pulm Circ 2020; 10:2045894020941491. [PMID: 33282181 PMCID: PMC7682228 DOI: 10.1177/2045894020941491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 11/15/2022] Open
Abstract
This article on clinical trial design incorporates the broad experience of members of the Pulmonary Vascular Research Institute's (PVRI) Innovative Drug Development Initiative (IDDI) as an open debate platform for academia, the pharmaceutical industry and regulatory experts surrounding the future design of clinical trials in pulmonary hypertension. It is increasingly clear that the design of phase 2 and 3 trials in pulmonary hypertension will have to diversify from the traditional randomised double-blind design, given the anticipated need to trial novel therapeutic approaches in the immediate future. This article reviews a wide range of differing approaches and places these into context within the field of pulmonary hypertension.
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Affiliation(s)
| | | | - R. James White
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Paul A Corris
- Translational and Clinical Science Institute, Newcastle University, Newcastle upon Tyne, UK
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58
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van Thor M, Snijder R, Kelder J, Mager J, Post M. Does combination therapy work in chronic thromboembolic pulmonary hypertension? IJC HEART & VASCULATURE 2020; 29:100544. [PMID: 32518816 PMCID: PMC7270605 DOI: 10.1016/j.ijcha.2020.100544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/20/2020] [Indexed: 11/25/2022]
Abstract
Long-term overall survival of CTEPH patients receiving PH-specific medial therapy is very reasonable. Despite worse baseline characteristics at baseline, combination therapy showed similar survival as monotherapy. Combination therapy strategy showed no difference in survival outcome.
Objective The current experience with combination therapy in chronic thromboembolic pulmonary hypertension (CTEPH) is limited. We present the first survival results up to 5 years for dual combination therapy versus monotherapy in CTEPH. Methods All consecutive, non-operated CTEPH or residual PH after pulmonary endarterectomy patients treated with PH-specific medical therapy between January 2002 and November 2019 were included. We report and compare survival between monotherapy and (upfront or sequential) dual combination therapy until five years after medication initiation. Results In total, 183 patients (mean age 65 ± 14 years, 60% female, 66% WHO FC III/IV, 86% non-operated) were included, of which 83 patients received monotherapy and 100 patients received dual combination therapy. At baseline, patients receiving combination therapy had a higher NT-proBNP (p = 0.02) mean pulmonary artery pressure (p = 0.0001) and pulmonary vascular resistance (p = 0.02), while cardiac index was lower (p = 0.03). Total follow-up duration was 3.3 ± 1.8 years, during which 31 (17%) patients died. Estimated 1-, 3- and 5-year survival for monotherapy were 99%, 92% and 79%, respectively. For combination therapy percentages were 98%, 89% and 70%, respectively. Survival did not significantly differ between both groups (p = 0.22). Conclusion Survival up to 5 years for patients treated with combination therapy, regardless of the combination strategy, was similar as patients with monotherapy, despite worse clinical and haemodynamic baseline characteristics.
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59
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Goncharova EA, Chan SY, Ventetuolo CE, Weissmann N, Schermuly RT, Mullin CJ, Gladwin MT. Update in Pulmonary Vascular Diseases and Right Ventricular Dysfunction 2019. Am J Respir Crit Care Med 2020; 202:22-28. [PMID: 32311291 PMCID: PMC7328315 DOI: 10.1164/rccm.202003-0576up] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Elena A. Goncharova
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute
- Division of Pulmonary, Allergy and Critical Care Medicine
| | - Stephen Y. Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute
- Center for Pulmonary Vascular Biology and Medicine, and
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Medicine, Alpert Medical School, and
| | - Corey E. Ventetuolo
- Department of Medicine, Alpert Medical School, and
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island; and
| | - Norbert Weissmann
- Department of Internal Medicine, Justus-Liebig University Giessen, Giessen, Germany
| | - Ralph T. Schermuly
- Department of Internal Medicine, Justus-Liebig University Giessen, Giessen, Germany
| | | | - Mark T. Gladwin
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute
- Division of Pulmonary, Allergy and Critical Care Medicine
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Sandqvist A, Kylhammar D, Bartfay SE, Hesselstrand R, Hjalmarsson C, Kavianipour M, Nisell M, Rådegran G, Wikström G, Kjellström B, Söderberg S. Risk stratification in chronic thromboembolic pulmonary hypertension predicts survival. SCAND CARDIOVASC J 2020; 55:43-49. [PMID: 32586166 DOI: 10.1080/14017431.2020.1783456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To investigate if the pulmonary arterial hypertension (PAH) risk assessment tool presented in the 2015 ESC/ERS guidelines is valid for patients with chronic thromboembolic pulmonary hypertension (CTEPH) when taking pulmonary endarterectomy (PEA) into account. Design. Incident CTEPH patients registered in the Swedish PAH Registry (SPAHR) between 2008 and 2016 were included. Risk stratification performed at baseline and follow-up classified the patients as low-, intermediate-, or high-risk using the proposed ESC/ERS risk algorithm. Results. There were 250 CTEPH patients with median age (interquartile range) 70 (14) years, and 53% were male. Thirty-two percent underwent PEA within 5 (6) months. In a multivariable model adjusting for age, sex, and pharmacological treatment, patients with intermediate-risk or high-risk profiles at baseline displayed an increased mortality risk (Hazard Ratio [95% confidence interval]: 1.64 [0.69-3.90] and 5.39 [2.13-13.59], respectively) compared to those with a low-risk profile, whereas PEA was associated with better survival (0.38 [0.18-0.82]). Similar impact of risk profile and PEA was seen at follow-up. Conclusion. The ESC/ERS risk assessment tool identifies CTEPH patients with reduced survival. Furthermore, PEA improves survival markedly independently of risk group and age. Take home message: The ESC/ERS risk stratification for PAH predicts survival also in CTEPH patients, even when taking PEA into account.
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Affiliation(s)
- Anna Sandqvist
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Actelion a Division of Janssen-Cilag AB, Stockholm, Sweden
| | - David Kylhammar
- Department of Medical and Health Sciences and department of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Sven-Erik Bartfay
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Hesselstrand
- Department of Clinical Sciences Section of Rheumatology, Lund University, Lund, Sweden
| | - Clara Hjalmarsson
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mohammad Kavianipour
- Department of Public Health and Clinical Medicine, Sundsvall Research Unit, Umeå University, Umeå, Sweden
| | - Magnus Nisell
- Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.,The Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Barbro Kjellström
- Department of Medicine, Cardiology Unit, Karolinska Institute, Stockholm, Sweden.,Department of Clinical Sciences Lund, Clinical Physiology, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Umeå, Sweden
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61
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Kuwana M, Blair C, Takahashi T, Langley J, Coghlan JG. Initial combination therapy of ambrisentan and tadalafil in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) in the modified intention-to-treat population of the AMBITION study: post hoc analysis. Ann Rheum Dis 2020; 79:626-634. [PMID: 32161055 PMCID: PMC7213337 DOI: 10.1136/annrheumdis-2019-216274] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate initial combination therapy with ambrisentan plus tadalafil (COMB) compared with monotherapy of either agent (MONO), and the utility of baseline characteristics and risk stratification in predicting outcomes, in patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) and the systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) subpopulation. METHODS This post hoc analysis of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) study included patients with CTD-PAH from the modified intention-to-treat population. Time to clinical failure (TtCF) was assessed by baseline characteristics, treatment assignment and risk group (low, intermediate and high) at baseline and week 16. TtCF was compared between groups using Kaplan-Meier curves and Cox proportional hazards regression modelling. RESULTS The analysis included 216 patients (COMB, n=117; MONO, n=99). The risk of clinical failure was lower with COMB versus MONO (risk reduction: CTD-PAH 51.7%, SSc-PAH 53.7%), particularly in patients with haemodynamic parameters characteristic of typical PAH without features of left heart disease and/or restrictive lung disease at baseline. The risk of clinical failure was lower with COMB versus MONO in the baseline low-risk group (HR not calculated due to no events in COMB), baseline intermediate-risk group (HR 0.519, 95% CI 0.297 to 0.905) and in the week 16 low-risk group (HR 0.069, 95% CI 0.009 to 0.548). CONCLUSIONS The benefit of COMB over MONO was demonstrated in patients with CTD-PAH, particularly in those with typical PAH haemodynamic characteristics at baseline. COMB is appropriate for patients categorised as low risk and intermediate risk at baseline and low risk at follow-up. TRIAL REGISTRATION NUMBER NCT01178073.
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Affiliation(s)
- Masataka Kuwana
- Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Christiana Blair
- Research and Development, Gilead Sciences, Inc, Foster City, California, USA
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62
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Sitbon O, Chin KM, Channick RN, Benza RL, Di Scala L, Gaine S, Ghofrani HA, Lang IM, McLaughlin VV, Preiss R, Rubin LJ, Simonneau G, Tapson VF, Galiè N, Hoeper MM. Risk assessment in pulmonary arterial hypertension: Insights from the GRIPHON study. J Heart Lung Transplant 2020; 39:300-309. [PMID: 32061506 DOI: 10.1016/j.healun.2019.12.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/26/2019] [Accepted: 12/29/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Approaches to risk assessment in pulmonary arterial hypertension (PAH) include the noninvasive French risk assessment approach (number of low-risk criteria based on the European Society of Cardiology and European Respiratory Society guidelines) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) 2.0 risk calculator. The prognostic and predictive value of these methods for morbidity/mortality was evaluated in the predominantly prevalent population of GRIPHON, the largest randomized controlled trial in PAH. METHODS GRIPHON randomized 1,156 patients with PAH to selexipag or placebo. Post-hoc analyses were performed on the primary composite end-point of morbidity/mortality by the number of low-risk criteria (World Health Organization functional class I-II; 6-minute walk distance >440 m; N-terminal pro-brain natriuretic peptide <300 ng/liter) and REVEAL 2.0 risk category. Hazard ratios and 95% confidence intervals were calculated using Cox proportional hazard models. RESULTS Both the number of low-risk criteria and the REVEAL 2.0 risk category were prognostic for morbidity/mortality at baseline and any time-point during the study. Patients with 3 low-risk criteria at baseline had a 94% reduced risk of morbidity/mortality compared to patients with 0 low-risk criteria and were all categorized as low-risk by REVEAL 2.0. The treatment effect of selexipag on morbidity/mortality was consistent irrespective of the number of low-risk criteria or the REVEAL 2.0 risk category at any time-point during the study. Selexipag-treated patients were more likely to increase their number of low-risk criteria from baseline to week 26 than placebo-treated patients (odds ratio 1.69, p = 0.0002); similar results were observed for REVEAL 2.0 risk score. CONCLUSIONS These results support the association between risk profile and long-term outcome and suggest that selexipag treatment may improve risk profile.
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Affiliation(s)
- Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France.
| | | | | | | | | | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, member of the German Center of Lung Research, Giessen, Germany; Department of Medicine, Imperial College London, London, United Kingdom
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | - Vallerie V McLaughlin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ralph Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, California
| | - Gérald Simonneau
- Hôpital Universitaire de Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France
| | | | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Center of Lung Research, Hannover Medical School, Hannover, Germany
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63
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Halank M, Tausche K, Grünig E, Ewert R, Preston IR. Practical management of riociguat in patients with pulmonary arterial hypertension. Ther Adv Respir Dis 2019; 13:1753466619868938. [PMID: 31438774 PMCID: PMC6710674 DOI: 10.1177/1753466619868938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/21/2019] [Indexed: 12/15/2022] Open
Abstract
Riociguat is one of several approved therapies available for patients with pulmonary arterial hypertension (PAH). Treatment should be initiated and monitored at an expert center by a physician experienced in treating PAH, and the dose adjusted in the absence of signs and symptoms of hypotension. In certain populations, including patients with hepatic or renal impairment, the elderly, and smokers, riociguat exposure may differ, and dose adjustments should therefore be made with caution according to the established scheme. Common adverse events are often easily managed, particularly if they are discussed before starting therapy. Combination therapy with riociguat and other PAH-targeted agents is feasible and generally well tolerated, although the coadministration of phosphodiesterase type 5 inhibitors (PDE5i) and riociguat is contraindicated. An open-label, randomized study is currently ongoing to assess whether patients who do not achieve treatment goals while receiving PDE5i may benefit from switching to riociguat. In this review, we provide a clinical view on the practical management of patients with PAH receiving riociguat, with a focus on the opinions and personal experience of the authors. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Michael Halank
- Internal Clinical I, University Hospital Carl Gustav Carus, Fetscherstrasse 74, Dresden, 01307, Germany
| | - Kristin Tausche
- Medical Clinic 1/Pneumology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic at University Hospital, Heidelberg, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine B, Ernst-Moritz-Arndt-University Greifswald, Greifswald, Germany
| | - Ioana R. Preston
- Pulmonary, Critical Care and Sleep Division, Tufts University Medical Center, Boston, Massachusetts, USA
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