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Grunig G, Baghdassarian A, Park SH, Pylawka S, Bleck B, Reibman J, Berman-Rosenzweig E, Durmus N. Challenges and Current Efforts in the Development of Biomarkers for Chronic Inflammatory and Remodeling Conditions of the Lungs. Biomark Insights 2016; 10:59-72. [PMID: 26917944 PMCID: PMC4756863 DOI: 10.4137/bmi.s29514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 02/06/2023] Open
Abstract
This review discusses biomarkers that are being researched for their usefulness to phenotype chronic inflammatory lung diseases that cause remodeling of the lung's architecture. The review focuses on asthma, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension. Bio-markers of environmental exposure and specific classes of biomarkers (noncoding RNA, metabolism, vitamin, coagulation, and microbiome related) are also discussed. Examples of biomarkers that are in clinical use, biomarkers that are under development, and biomarkers that are still in the research phase are discussed. We chose to present examples of the research in biomarker development by diseases, because asthma, COPD, and pulmonary hypertension are distinct entities, although they clearly share processes of inflammation and remodeling.
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Affiliation(s)
- Gabriele Grunig
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA.; Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Aram Baghdassarian
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Sung-Hyun Park
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Serhiy Pylawka
- College of Dental Medicine, Columbia University, New York, NY, USA
| | - Bertram Bleck
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Joan Reibman
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Nedim Durmus
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
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Abstract
In patients with pulmonary hypertension (PH), the primary cause of death is right ventricular (RV) failure. Improvement in RV function is therefore one of the most important treatment goals. In order to be able to reverse RV dysfunction and also prevent RV failure, a detailed understanding of the pathobiology of RV failure and the underlying mechanisms concerning the transition from a pressure-overloaded adapted right ventricle to a dilated and failing right ventricle is required. Here, we propose that insufficient RV contractility, myocardial fibrosis, capillary rarefaction, and a disturbed metabolism are important features of a failing right ventricle. Furthermore, an overview is provided about the potential direct RV effects of PH-targeted therapies and the effects of RV-directed medical treatments.
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Affiliation(s)
- Mariëlle C van de Veerdonk
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Harm J Bogaard
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Norbert F Voelkel
- The Victoria Johnson Pulmonary Research Laboratory, Virginia Commonwealth University, 1220 East Broad Street, Richmond, VA, 23298, USA.
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Abstract
Previously considered a disease isolated to the pulmonary circulation, pulmonary arterial hypertension is now being recognized as a systemic disorder that is associated with significant metabolic dysfunction. Numerous animal models have demonstrated the development of pulmonary arterial hypertension following the onset of insulin resistance, indicating that insulin resistance may be causal. Recent publications highlighting alterations in aerobic glycolysis, fatty acid oxidation, and the tricarboxylic acid cycle in the pulmonary circulation and right ventricle have expanded our understanding of the complex pathobiology of this disease. By targeting these derangements in metabolism, numerous researchers are investigating noninvasive techniques to monitor disease activity and therapeutics that address the underlying metabolic condition. In the following review, we will explore pre-clinical and clinical studies investigating the metabolic dysfunction seen in pulmonary arterial hypertension.
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Affiliation(s)
- Tufik R Assad
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, T1218 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
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Heiskanen MA, Leskinen T, Eskelinen JJ, Heinonen IHA, Löyttyniemi E, Virtanen K, Pärkkä JP, Hannukainen JC, Kalliokoski KK. Different Predictors of Right and Left Ventricular Metabolism in Healthy Middle-Aged Men. Front Physiol 2015; 6:389. [PMID: 26733882 PMCID: PMC4685066 DOI: 10.3389/fphys.2015.00389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 11/30/2015] [Indexed: 11/13/2022] Open
Abstract
Dysfunction of the right ventricle (RV) plays a crucial role in the outcome of various cardiovascular diseases. Previous studies on RV metabolism are sparse although evidence implies it may differ from left ventricular (LV) metabolism. Therefore, the aims of this study were (1) to determine predictors of RV glucose uptake (GU) and free fatty acid uptake (FFAU) and (2) to compare them to predictors of LV metabolism in healthy middle-aged men. Altogether 28 healthy, sedentary, middle-aged (40-55 years) men were studied. Insulin-stimulated GU and fasting FFAU were measured by positron emission tomography and RV and LV structural and functional parameters by cardiac magnetic resonance. Several parameters related to whole-body health were also measured. Predictors of RV and LV metabolism were determined by pairwise correlation analysis, lasso regression models, and variable clustering using heatmap. RVGU was most strongly predicted by age and moderately by RV ejection fraction (EF). The strongest determinants of RVFFAU were exercise capacity (peak oxygen uptake), resting heart rate, LVEF, and whole-body insulin-stimulated glucose uptake rate. When considering LV metabolism, age and RVEF were associated also with LVGU. In addition, LVGU was strongly, and negatively, influenced by whole-body insulin-stimulated glucose uptake rate. LVFFAU was predicted only by LVEF. This study shows that while RV and LV metabolism have shared characteristics, they also have unique properties. Age of the subject should be taken into account when measuring myocardial glucose utilization. Ejection fraction is related to myocardial metabolism, and even so that RVEF may be more closely related to GU of both ventricles and LVEF to FFAU of both ventricles, a finding supporting the ventricular interdependence. However, only RV fatty acid utilization associates with exercise capacity so that better physical fitness in a relatively sedentary population is related with decreased RV fat metabolism. To conclude, this study highlights the need for further study designed specifically on less-known RV, as the results on LV metabolism and physiology may not be directly applicable to the RV.
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Affiliation(s)
| | | | | | - Ilkka H A Heinonen
- Turku PET Centre, University of TurkuTurku, Finland; School of Sport Science, Exercise and Health, University of Western AustraliaCrawley, WA, Australia
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Right ventricle dysfunction in pulmonary hypertension: mechanisms and modes of detection. Curr Opin Pulm Med 2015; 21:446-53. [PMID: 26176967 DOI: 10.1097/mcp.0000000000000192] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW This review highlights the right ventricular (RV) involvement in pulmonary hypertension from pathophysiologic changes to current imaging tools used to screen, diagnose and follow up RV function in patients with pulmonary hypertension. RECENT FINDINGS Although right heart catheterization is the gold standard for the diagnosis of pulmonary hypertension, other diagnostic methods such as echocardiography, magnetic resonance and nuclear imaging are of great utility in the assessment of the RV in pulmonary hypertension. Apart from its conventional use as a screening tool for pulmonary hypertension, echocardiography allows assessment of RV size and function and has prognostic value. Among the novel applications of echocardiography, exercise echocardiography and measurements of RV strain might help unveil subclinical pulmonary hypertension, whereas three-dimensional echocardiography allows more accurate measures of RV morphology and function. Cardiac magnetic resonance imaging is currently the gold standard noninvasive imaging method to assess RV volume, mass and function and has prognostic value in the assessment of pulmonary hypertension. Finally, positron emission tomography is a promising tool in the metabolic assessment of the RV and pulmonary circulation. SUMMARY RV assessment is essential in the overall evaluation of pulmonary hypertension. Despite the availability of several methods and measurements for this assessment, there is, however, no standard approach or broad consensus on their application.
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Wang L, Li W, Yang Y, Wu W, Cai Q, Ma X, Xiong C, He J, Fang W. Quantitative assessment of right ventricular glucose metabolism in idiopathic pulmonary arterial hypertension patients: a longitudinal study. Eur Heart J Cardiovasc Imaging 2015; 17:1161-8. [DOI: 10.1093/ehjci/jev297] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/13/2015] [Indexed: 11/13/2022] Open
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Vonk Noordegraaf A, Haddad F, Bogaard HJ, Hassoun PM. Noninvasive imaging in the assessment of the cardiopulmonary vascular unit. Circulation 2015; 131:899-913. [PMID: 25753343 DOI: 10.1161/circulationaha.114.006972] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anton Vonk Noordegraaf
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.).
| | - Francois Haddad
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
| | - Harm J Bogaard
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
| | - Paul M Hassoun
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
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Graham BB, Kumar R, Mickael C, Sanders L, Gebreab L, Huber KM, Perez M, Smith-Jones P, Serkova NJ, Tuder RM. Severe pulmonary hypertension is associated with altered right ventricle metabolic substrate uptake. Am J Physiol Lung Cell Mol Physiol 2015; 309:L435-40. [PMID: 26115672 DOI: 10.1152/ajplung.00169.2015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 06/24/2015] [Indexed: 11/22/2022] Open
Abstract
In severe pulmonary hypertension (SPH), prior studies have shown an increase in right ventricle (RV) uptake of glucose, but it is unclear whether there is a change in the relative utilization of fatty acids. We hypothesized that in the RV in SPH, as in left ventricular (LV) failure, there is altered substrate utilization, with increased glucose uptake and decreased fatty acid uptake. SPH was induced in rats by treatment with the VEGF receptor inhibitor SU5416 and 3 wk of hypoxia (10% FiO2 ), followed by an additional 4 wk of normoxia (SU-Hx group). Control rats were treated with carboxymethylcellulose vehicle and 7 wk of normoxia (CMC-Nx group). The rodents then underwent positron emission tomography with sequential administration of two radiotracers, 2-deoxy-2-[(18)F]fluoroglucose ((18)F-FDG) and 14-(R,S)-[(18)F]fluoro-6-thia-heptadecanoic acid ((18)F-FTHA), analogs of glucose and fatty acid, respectively. Five CMC-Nx and 3 SU-Hx rats completed the entire experimental protocol. In the RV, there was a mild increase in (18)F-FDG uptake (1.35-fold, P = 0.085) and a significant decrease in (18)F-FTHA uptake (-2.1-fold, P < 0.05) in the SU-Hx rats relative to the CMC-Nx rats. In the LV, SU-Hx rats had less uptake of both radiotracers compared with CMC-Nx rats. Less RV fatty acid uptake in SPH was corroborated by decreased fatty acid transporters and enzymes in the RV tissue, and specifically a decrease in lipoprotein lipase. In the RV in rats with SPH, there is a major shift in metabolic substrate preference, largely due to decreased fatty acid uptake.
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Affiliation(s)
- Brian B Graham
- Department of Medicine, University of Colorado Denver, Aurora, Colorado;
| | - Rahul Kumar
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Claudia Mickael
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Linda Sanders
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Liya Gebreab
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Kendra M Huber
- Department of Anesthesiology, University of Colorado Denver, Aurora, Colorado; and
| | - Mario Perez
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Peter Smith-Jones
- Department of Psychiatry, Stony Brook School of Medicine, Stony Brook, New York
| | - Natalie J Serkova
- Department of Anesthesiology, University of Colorado Denver, Aurora, Colorado; and
| | - Rubin M Tuder
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
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Talati M, Hemnes A. Fatty acid metabolism in pulmonary arterial hypertension: role in right ventricular dysfunction and hypertrophy. Pulm Circ 2015; 5:269-78. [PMID: 26064451 DOI: 10.1086/681227] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 12/30/2014] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a complex, multifactorial disease in which an increase in pulmonary vascular resistance leads to increased afterload on the right ventricle (RV), causing right heart failure and death. Our understanding of the pathophysiology of RV dysfunction in PAH is limited but is constantly improving. Increasing evidence suggests that in PAH RV dysfunction is associated with various components of metabolic syndrome, such as insulin resistance, hyperglycemia, and dyslipidemia. The relationship between RV dysfunction and fatty acid/glucose metabolites is multifaceted, and in PAH it is characterized by a shift in utilization of energy sources toward increased glucose utilization and reduced fatty acid consumption. RV dysfunction may be caused by maladaptive fatty acid metabolism resulting from an increase in fatty acid uptake by fatty acid transporter molecule CD36 and an imbalance between glucose and fatty acid oxidation in mitochondria. This leads to lipid accumulation in the form of triglycerides, diacylglycerol, and ceramides in the cytoplasm, hallmarks of lipotoxicity. Current interventions in animal models focus on improving RV dysfunction through altering fatty acid oxidation rates and limiting lipid accumulation, but more specific and effective therapies may be available in the coming years based on current research. In conclusion, a deeper understanding of the complex mechanisms of the metabolic remodeling of the RV will aid in the development of targeted treatments for RV failure in PAH.
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Affiliation(s)
- Megha Talati
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anna Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ryan JJ, Huston J, Kutty S, Hatton ND, Bowman L, Tian L, Herr JE, Johri AM, Archer SL. Right ventricular adaptation and failure in pulmonary arterial hypertension. Can J Cardiol 2015; 31:391-406. [PMID: 25840092 PMCID: PMC4385216 DOI: 10.1016/j.cjca.2015.01.023] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/19/2015] [Accepted: 01/19/2015] [Indexed: 01/22/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is an obstructive pulmonary vasculopathy, characterized by excess proliferation, apoptosis resistance, inflammation, fibrosis, and vasoconstriction. Although PAH therapies target some of these vascular abnormalities (primarily vasoconstriction), most do not directly benefit the right ventricle (RV). This is suboptimal because a patient's functional state and prognosis are largely determined by the success of the adaptation of the RV to the increased afterload. The RV initially hypertrophies but might ultimately decompensate, becoming dilated, hypokinetic, and fibrotic. A number of pathophysiologic abnormalities have been identified in the PAH RV, including: ischemia and hibernation (partially reflecting RV capillary rarefaction), autonomic activation (due to G protein receptor kinase 2-mediated downregulation and desensitization of β-adrenergic receptors), mitochondrial-metabolic abnormalities (notably increased uncoupled glycolysis and glutaminolysis), and fibrosis. Many RV abnormalities are detectable using molecular imaging and might serve as biomarkers. Some molecular pathways, such as those regulating angiogenesis, metabolism, and mitochondrial dynamics, are similarly deranged in the RV and pulmonary vasculature, offering the possibility of therapies that treat the RV and pulmonary circulation. An important paradigm in PAH is that the RV and pulmonary circulation constitute a unified cardiopulmonary unit. Clinical trials of PAH pharmacotherapies should assess both components of the cardiopulmonary unit.
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Affiliation(s)
- John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jessica Huston
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shelby Kutty
- Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Nathan D Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay Bowman
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Julia E Herr
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Khan SS, Rich JD. Novel technologies and devices for monitoring and treating pulmonary arterial hypertension. Can J Cardiol 2015; 31:478-88. [PMID: 25840097 DOI: 10.1016/j.cjca.2015.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/20/2014] [Accepted: 01/06/2015] [Indexed: 01/28/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature associated with significant morbidity and mortality. Despite significant advances in the past 2 decades with the development of pharmacological therapies to target key molecular pathways of PAH, there remains an ongoing need for novel technologies and devices for diagnosis, monitoring, and treatment to improve PAH outcomes. The advent of sophisticated imaging tools, including cardiac magnetic resonance imaging, positron emission tomography, and speckle tracking echocardiography, offer novel opportunities for advanced, noninvasive assessment of right ventricular function, the most powerful predictor of death in patients with PAH. Noninvasive cardiac output monitors and implantable hemodynamic sensors are among the additional promising novel technologies that might offer daily access to hemodynamic data to influence clinical decision-making and potentially improve outcomes. Percutaneous interventional therapeutics might offer a nonpharmacological treatment option in select patients with PAH, ranging from the percutaneous creation of right to left shunts, pulmonary artery denervation, and right ventricular pacing. Finally, mechanical circulatory support with durable ventricular assist devices offers hope to one day provide a realistic strategy to treat life-threatening right ventricular failure in PAH. Future clinical trials and carefully designed prospective observational studies will be needed to evaluate the full potential of many of these novel devices and technologies for monitoring and treating PAH.
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Affiliation(s)
- Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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63
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Barnes JW, Tian L, Heresi GA, Farver CF, Asosingh K, Comhair SAA, Aulak KS, Dweik RA. O-linked β-N-acetylglucosamine transferase directs cell proliferation in idiopathic pulmonary arterial hypertension. Circulation 2015; 131:1260-8. [PMID: 25663381 DOI: 10.1161/circulationaha.114.013878] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/26/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Idiopathic pulmonary arterial hypertension (IPAH) is a cardiopulmonary disease characterized by cellular proliferation and vascular remodeling. A more recently recognized characteristic of the disease is the dysregulation of glucose metabolism. The primary link between altered glucose metabolism and cell proliferation in IPAH has not been elucidated. We aimed to determine the relationship between glucose metabolism and smooth muscle cell proliferation in IPAH. METHODS AND RESULTS Human IPAH and control patient lung tissues and pulmonary artery smooth muscle cells (PASMCs) were used to analyze a specific pathway of glucose metabolism, the hexosamine biosynthetic pathway. We measured the levels of O-linked β-N-acetylglucosamine modification, O-linked β-N-acetylglucosamine transferase (OGT), and O-linked β-N-acetylglucosamine hydrolase in control and IPAH cells and tissues. Our data suggest that the activation of the hexosamine biosynthetic pathway directly increased OGT levels and activity, triggering changes in glycosylation and PASMC proliferation. Partial knockdown of OGT in IPAH PASMCs resulted in reduced global O-linked β-N-acetylglucosamine modification levels and abrogated PASMC proliferation. The increased proliferation observed in IPAH PASMCs was directly impacted by proteolytic activation of the cell cycle regulator, host cell factor-1. CONCLUSIONS Our data demonstrate that hexosamine biosynthetic pathway flux is increased in IPAH and drives OGT-facilitated PASMC proliferation through specific proteolysis and direct activation of host cell factor-1. These findings establish a novel regulatory role for OGT in IPAH, shed a new light on our understanding of the disease pathobiology, and provide opportunities to design novel therapeutic strategies for IPAH.
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Affiliation(s)
- Jarrod W Barnes
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Liping Tian
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Gustavo A Heresi
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Carol F Farver
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Kewal Asosingh
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Suzy A A Comhair
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Kulwant S Aulak
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH
| | - Raed A Dweik
- From Department of Pathobiology, Lerner Research Institute (J.W.B., L.T., K.A., S.A.A.C., K.S.A. R.A.D.), Pulmonary and Critical Care Medicine, Respiratory Institute (G.A.H., R.A.D.), and Department of Pathology (C.F.F.), Cleveland Clinic, OH.
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Pulmonary hypertension: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S178-85. [PMID: 24754827 DOI: 10.1513/annalsats.201312-443ld] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Pulmonary vascular dysfunction (PVD) precedes the onset of clinical signs and symptoms of pulmonary arterial hypertension (PAH). PAH is defined by the elevation of pulmonary arterial pressure, which often progresses to right ventricular (RV) dysfunction and failure. PAH affects subjects of all ages, and is associated with diverse medical conditions, most of which are rare. Several factors pose immediate challenges to the development of strategies for primary prevention of PAH, including: (1) the idiopathic or primary form of the disease is extremely rare, limiting screening practicality; (2) methods for the detection of preclinical PVD are currently not established; (3) the understanding of determinants of pulmonary vascular growth, structure, and function in normal and PAH states is insufficient; (4) relatively small numbers of "at-risk" subjects are available for long-term studies to accurately assess disease development; and (5) preventative therapies for PVD are lacking. Despite these limitations, leveraging known at-risk patient populations for study, as well as growing progress across multiple disciplines, ranging from systems biology to advanced and more sensitive functional imaging modalities, may facilitate the opportunity to significantly improve primary prevention research and implementation over the next decade.
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65
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Cardiac MRI and PET Scanning in Right Ventricular Failure. THE RIGHT VENTRICLE IN HEALTH AND DISEASE 2015. [DOI: 10.1007/978-1-4939-1065-6_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Ahmadi A, Ohira H, Mielniczuk LM. FDG PET Imaging for Identifying Pulmonary Hypertension and Right Heart Failure. Curr Cardiol Rep 2014; 17:555. [DOI: 10.1007/s11886-014-0555-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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67
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Ryan JJ, Archer SL. The right ventricle in pulmonary arterial hypertension: disorders of metabolism, angiogenesis and adrenergic signaling in right ventricular failure. Circ Res 2014; 115:176-88. [PMID: 24951766 DOI: 10.1161/circresaha.113.301129] [Citation(s) in RCA: 319] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The right ventricle (RV) is the major determinant of functional state and prognosis in pulmonary arterial hypertension. RV hypertrophy (RVH) triggered by pressure overload is initially compensatory but often leads to RV failure. Despite similar RV afterload and mass some patients develop adaptive RVH (concentric with retained RV function), while others develop maladaptive RVH, characterized by dilatation, fibrosis, and RV failure. The differentiation of adaptive versus maladaptive RVH is imprecise, but adaptive RVH is associated with better functional capacity and survival. At the molecular level, maladaptive RVH displays greater impairment of angiogenesis, adrenergic signaling, and metabolism than adaptive RVH, and these derangements often involve the left ventricle. Clinically, maladaptive RVH is characterized by increased N-terminal pro-brain natriuretic peptide levels, troponin release, elevated catecholamine levels, RV dilatation, and late gadolinium enhancement on MRI, increased (18)fluorodeoxyglucose uptake on positron emission tomography, and QTc prolongation on the ECG. In maladaptive RVH there is reduced inotrope responsiveness because of G-protein receptor kinase-mediated downregulation, desensitization, and uncoupling of β-adrenoreceptors. RV ischemia may result from capillary rarefaction or decreased right coronary artery perfusion pressure. Maladaptive RVH shares metabolic abnormalities with cancer including aerobic glycolysis (resulting from a forkhead box protein O1-mediated transcriptional upregulation of pyruvate dehydrogenase kinase), and glutaminolysis (reflecting ischemia-induced cMyc activation). Augmentation of glucose oxidation is beneficial in experimental RVH and can be achieved by inhibition of pyruvate dehydrogenase kinase, fatty acid oxidation, or glutaminolysis. Therapeutic targets in RV failure include chamber-specific abnormalities of metabolism, angiogenesis, adrenergic signaling, and phosphodiesterase-5 expression. The ability to restore RV function in experimental models challenges the dogma that RV failure is irreversible without regression of pulmonary vascular disease.
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Affiliation(s)
- John J Ryan
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.); and Department of Medicine, Queen's University, Kingston, Ontario, Canada (S.L.A.)
| | - Stephen L Archer
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.); and Department of Medicine, Queen's University, Kingston, Ontario, Canada (S.L.A.).
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Sharp J, Farha S, Park MM, Comhair SA, Lundgrin EL, Tang WHW, Bongard RD, Merker MP, Erzurum SC. Coenzyme Q supplementation in pulmonary arterial hypertension. Redox Biol 2014; 2:884-91. [PMID: 25180165 PMCID: PMC4143816 DOI: 10.1016/j.redox.2014.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 12/18/2022] Open
Abstract
Mitochondrial dysfunction is a fundamental abnormality in the vascular endothelium and smooth muscle of patients with pulmonary arterial hypertension (PAH). Because coenzyme Q (CoQ) is essential for mitochondrial function and efficient oxygen utilization as the electron carrier in the inner mitochondrial membrane, we hypothesized that CoQ would improve mitochondrial function and benefit PAH patients. To test this, oxidized and reduced levels of CoQ, cardiac function by echocardiogram, mitochondrial functions of heme synthesis and cellular metabolism were evaluated in PAH patients (N=8) in comparison to healthy controls (N=7), at baseline and after 12 weeks oral CoQ supplementation. CoQ levels were similar among PAH and control individuals, and increased in all subjects with CoQ supplementation. PAH patients had higher CoQ levels than controls with supplementation, and a tendency to a higher reduced-to-oxidized CoQ ratio. Cardiac parameters improved with CoQ supplementation, although 6-minute walk distances and BNP levels did not significantly change. Consistent with improved mitochondrial synthetic function, hemoglobin increased and red cell distribution width (RDW) decreased in PAH patients with CoQ, while hemoglobin declined slightly and RDW did not change in healthy controls. In contrast, metabolic and redox parameters, including lactate, pyruvate and reduced or oxidized gluthathione, did not change in PAH patients with CoQ. In summary, CoQ improved hemoglobin and red cell maturation in PAH, but longer studies and/or higher doses with a randomized placebo-controlled controlled design are necessary to evaluate the clinical benefit of this simple nutritional supplement.
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Affiliation(s)
- Jacqueline Sharp
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Samar Farha
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Margaret M Park
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Suzy A Comhair
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Erika L Lundgrin
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - W H Wilson Tang
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Robert D Bongard
- Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, United States
| | - Marilyn P Merker
- Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, United States ; Department of Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, 53226, United States ; Zablocki VAMC, 5000 W National Ave., Milwaukee, WI 53295, United States
| | - Serpil C Erzurum
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States ; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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van de Veerdonk MC, Marcus JT, Bogaard HJ, Vonk Noordegraaf A. State of the art: advanced imaging of the right ventricle and pulmonary circulation in humans (2013 Grover Conference series). Pulm Circ 2014; 4:158-68. [PMID: 25006434 DOI: 10.1086/675978] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 12/03/2013] [Indexed: 12/27/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease characterized by remodeling and vasoconstriction of the pulmonary vasculature, ultimately leading to right ventricular (RV) failure and death. Recent developments in echocardiography, cardiovascular magnetic resonance imaging, computed tomography, and positron emission tomography allow advanced, noninvasive, in vivo assessment of the RV and have contributed to the identification of risk factors, prognostic factors, and monitoring of therapeutic responses in patients with PAH. Although far from reaching its future potential, these techniques have not only provided global RV assessment but also allowed evaluation of changes in cellular and molecular tissue processes, such as metabolism, oxygen balance and ischemia, angiogenesis, and apoptosis. Integrated application of these techniques could provide full insights into the different pathophysiological aspects of a failing RV in the setting of PAH. Recent advances in hybrid imaging have implemented simultaneous measurements of myocardial and vascular interactions and will be one of the most important potential future developments.
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Affiliation(s)
- Mariëlle C van de Veerdonk
- Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Physics and Medical Technology, ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
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Ventetuolo CE, Gabler NB, Fritz JS, Smith KA, Palevsky HI, Klinger JR, Halpern SD, Kawut SM. Are hemodynamics surrogate end points in pulmonary arterial hypertension? Circulation 2014; 130:768-75. [PMID: 24951771 DOI: 10.1161/circulationaha.114.009690] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although frequently assessed in trials and clinical practice, hemodynamic response to therapy has never been validated as a surrogate end point for clinical events in pulmonary arterial hypertension (PAH). METHODS AND RESULTS We performed a patient-level pooled analysis of 4 randomized, placebo-controlled trials to determine whether treatment-induced changes in hemodynamic values at 12 weeks accounted for the relationship between treatment assignment and the probability of early clinical events (death, lung transplantation, atrial septostomy, PAH hospitalization, withdrawal for clinical worsening, or escalation in PAH therapy). We included 1119 subjects with PAH. The median (interquartile range) age was 48 years (37-59 years), and 23% were men. A total of 656 patients (59%) received active therapy (101 [15%] iloprost, 118 [18%] sitaxsentan, 204 [31%] sildenafil, and 233 [36%] subcutaneous treprostinil). Active treatment significantly lowered right atrial pressure, mean pulmonary artery pressure, and pulmonary vascular resistance and increased cardiac output and index (P<0.01 for all). Changes in hemodynamic values (except for right atrial pressure and mean pulmonary artery pressure) were significantly associated with the risk of a clinical event (P<0.02 for all). Although active treatment approximately halved the odds of a clinical event compared with placebo (P<0.001), changes in hemodynamics accounted for only 1.2% to 13.9% of the overall treatment effect. CONCLUSIONS Treatment-induced changes in hemodynamics at 12 weeks only partially explain the impact of therapy on the probability of early clinical events in PAH. These findings suggest that resting hemodynamics are not valid surrogate end points for short-term events in PAH clinical trials.
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Affiliation(s)
- Corey E Ventetuolo
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicole B Gabler
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jason S Fritz
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Akaya Smith
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harold I Palevsky
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James R Klinger
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott D Halpern
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven M Kawut
- From the Division of Pulmonary, Critical Care and Sleep, Department of Medicine (C.E.V., J.R.K.) and Department of Health Services, Policy, and Practice (C.E.V.), Alpert Medical School of Brown University, Providence, RI; Center for Clinical Epidemiology and Biostatistics (N.B.G., S.D.H., S.M.K.), Department of Medicine (J.S.F., K.A.S., H.I.P., S.D.H., S.M.K.), Penn Cardiovascular Institute (S.D.H., S.M.K.), and Leonard Davis Institute of Health Economics (S.D.H.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Affiliation(s)
- Roxane Paulin
- From the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Dweik RA, Rounds S, Erzurum SC, Archer S, Fagan K, Hassoun PM, Hill NS, Humbert M, Kawut SM, Krowka M, Michelakis E, Morrell NW, Stenmark K, Tuder RM, Newman J. An official American Thoracic Society Statement: pulmonary hypertension phenotypes. Am J Respir Crit Care Med 2014; 189:345-55. [PMID: 24484330 DOI: 10.1164/rccm.201311-1954st] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Current classification of pulmonary hypertension (PH) is based on a relatively simple combination of patient characteristics and hemodynamics. This limits customization of treatment, and lacks the clarity of a more granular identification based on individual patient phenotypes. Rapid advances in mechanistic understanding of the disease, improved imaging methods, and innovative biomarkers now provide an opportunity to define PH phenotypes on the basis of biomarkers, advanced imaging, and pathobiology. This document organizes our current understanding of PH phenotypes and identifies gaps in our knowledge. METHODS A multidisciplinary committee with expertise in clinical care (pulmonary, cardiology, pediatrics, and pathology), clinical research, and/or basic science in the areas of PH identified important questions and reviewed and synthesized the literature. RESULTS This document describes selected PH phenotypes and serves as an initial platform to define additional relevant phenotypes as new knowledge is generated. The biggest gaps in our knowledge stem from the fact that our present understanding of PH phenotypes has not come from any particularly organized effort to identify such phenotypes, but rather from reinterpreting studies and reports that were designed and performed for other purposes. CONCLUSIONS Accurate phenotyping of PH can be used in research studies to increase the homogeneity of study cohorts. Once the ability of the phenotypes to predict outcomes has been validated, phenotyping may also be useful for determining prognosis and guiding treatment. This important next step in PH patient care can optimally be addressed through a consortium of study sites with well-defined goals, tasks, and structure. Planning and support for this could include the National Institutes of Health and the U.S. Food and Drug Administration, with industry and foundation partnerships.
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Tuder RM, Archer SL, Dorfmüller P, Erzurum SC, Guignabert C, Michelakis E, Rabinovitch M, Schermuly R, Stenmark KR, Morrell NW. Relevant issues in the pathology and pathobiology of pulmonary hypertension. J Am Coll Cardiol 2014; 62:D4-12. [PMID: 24355640 DOI: 10.1016/j.jacc.2013.10.025] [Citation(s) in RCA: 402] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 11/18/2022]
Abstract
Knowledge of the pathobiology of pulmonary hypertension (PH) continues to accelerate. However, fundamental gaps remain in our understanding of the underlying pathological changes in pulmonary arteries and veins in the different forms of this syndrome. Although PH primarily affects the arteries, venous disease is increasingly recognized as an important entity. Moreover, prognosis in PH is determined largely by the status of the right ventricle, rather than the levels of pulmonary artery pressures. It is increasingly clear that although vasospasm plays a role, PH is an obstructive lung panvasculopathy. Disordered metabolism and mitochondrial structure, inflammation, and dysregulation of growth factors lead to a proliferative, apoptosis-resistant state. These abnormalities may be acquired, genetically mediated as a result of mutations in bone morphogenetic protein receptor-2 or activin-like kinase-1, or epigenetically inherited (as a result of epigenetic silencing of genes such as superoxide dismutase-2). There is a pressing need to better understand how the pathobiology leads to severe disease in some patients versus mild PH in others. Recent recognition of a potential role of acquired abnormalities of mitochondrial metabolism in the right ventricular myocytes and pulmonary vascular cells suggests new therapeutic approaches, diagnostic modalities, and biomarkers. Finally, dissection of the role of pulmonary inflammation in the initiation and promotion of PH has revealed a complex yet fascinating interplay with pulmonary vascular remodeling, promising to lead to novel therapeutics and diagnostics. Emerging concepts are also relevant to the pathobiology of PH, including a role for bone marrow and circulating progenitor cells and microribonucleic acids. Continued interest in the interface of the genetic basis of PH and cellular and molecular pathogenetic links should further expand our understanding of the disease.
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Affiliation(s)
- Rubin M Tuder
- Program in Translational Lung Research, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Peter Dorfmüller
- Department of Pathology, Marie Lannelongue Hospital, University Paris-Sud, Le Plessis-Robinson, France
| | - Serpil C Erzurum
- Lerner Research Institute and Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christophe Guignabert
- INSERM UMR 999, LabEx LERMIT, Marie Lannelongue Hospital and University Paris-Sud, School of Medicine, Kremlin-Bicêtre, France
| | | | - Marlene Rabinovitch
- Cardiovascular Institute and Department of Pediatrics and The Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, California
| | - Ralph Schermuly
- Excellence Cluster Cardio-Pulmonary System, German Lung Center, Universities of Giessen and Marburg Lung Center, Justus-Liebig-University, Giessen, Germany
| | - Kurt R Stenmark
- Cardiovascular Pulmonary Laboratory, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom.
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Colvin KL, Dufva MJ, Delaney RP, Ivy DD, Stenmark KR, Yeager ME. Biomarkers for pediatric pulmonary arterial hypertension - a call to collaborate. Front Pediatr 2014; 2:7. [PMID: 24551834 PMCID: PMC3910125 DOI: 10.3389/fped.2014.00007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/21/2014] [Indexed: 01/07/2023] Open
Abstract
Therapeutic approaches in pediatric pulmonary arterial hypertension (PAH) are based primarily on clinician experience, in contrast to the evidence-based approach in adults with pulmonary hypertension. There is a clear and present need for non-invasive and objective biomarkers to guide the accurate diagnosis, treatment, and prognosis of this disease in children. The multifaceted spectrum of disease, clinical presentation, and association with other diseases makes this a formidable challenge. However, as more progress is being made in the understanding and management of adult PAH, the potential to apply this knowledge to children has never been greater. This review explores the state of the art with regard to non-invasive biomarkers in PAH, with an eye toward those adult PAH biomarkers potentially suitable for application in pediatric PAH.
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Affiliation(s)
- Kelley L Colvin
- Department of Bioengineering, University of Colorado Denver , Aurora, CO , USA ; Department of Pediatrics-Critical Care, University of Colorado Denver , Aurora, CO , USA ; Cardiovascular Pulmonary Research, University of Colorado Denver , Aurora, CO , USA ; Linda Crnic Institute for Down Syndrome, University of Colorado Denver , Aurora, CO , USA
| | - Melanie J Dufva
- Department of Bioengineering, University of Colorado Denver , Aurora, CO , USA ; Department of Pediatrics-Critical Care, University of Colorado Denver , Aurora, CO , USA
| | - Ryan P Delaney
- Department of Bioengineering, University of Colorado Denver , Aurora, CO , USA ; Department of Pediatrics-Critical Care, University of Colorado Denver , Aurora, CO , USA
| | | | - Kurt R Stenmark
- Department of Pediatrics-Critical Care, University of Colorado Denver , Aurora, CO , USA ; Cardiovascular Pulmonary Research, University of Colorado Denver , Aurora, CO , USA
| | - Michael E Yeager
- Department of Bioengineering, University of Colorado Denver , Aurora, CO , USA ; Department of Pediatrics-Critical Care, University of Colorado Denver , Aurora, CO , USA ; Cardiovascular Pulmonary Research, University of Colorado Denver , Aurora, CO , USA ; Linda Crnic Institute for Down Syndrome, University of Colorado Denver , Aurora, CO , USA
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Abstract
Abnormalities in myocardial substrate metabolism play a central role in the manifestations of most forms of cardiac disease such as ischemic heart disease, heart failure, hypertensive heart disease, and the cardiomyopathy due to either obesity or diabetes mellitus. Their importance is exemplified by both the development of numerous imaging tools designed to detect the specific metabolic perturbations or signatures related to these different diseases, and the vigorous efforts in drug discovery/development targeting various aspects of myocardial metabolism. Since the prior review in 2005, we have gained new insights into how perturbations in myocardial metabolism contribute to various forms of cardiac disease. For example, the application of advanced molecular biologic techniques and the development of elegant genetic models have highlighted the pleiotropic actions of cellular metabolism on energy transfer, signal transduction, cardiac growth, gene expression, and viability. In parallel, there have been significant advances in instrumentation, radiopharmaceutical design, and small animal imaging, which now permit a near completion of the translational pathway linking in-vitro measurements of metabolism with the human condition. In this review, most of the key advances in metabolic imaging will be described, their contribution to cardiovascular research highlighted, and potential new clinical applications proposed.
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Affiliation(s)
- Robert J Gropler
- Division of Radiological Sciences, Cardiovascular Imaging Laboratory, Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway, St. Louis, MO, 63110, USA,
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A metabolic remodeling in right ventricular hypertrophy is associated with decreased angiogenesis and a transition from a compensated to a decompensated state in pulmonary hypertension. J Mol Med (Berl) 2013; 91:1315-27. [DOI: 10.1007/s00109-013-1059-4] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 04/28/2013] [Accepted: 05/23/2013] [Indexed: 01/19/2023]
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Drake JI, Gomez-Arroyo J, Dumur CI, Kraskauskas D, Natarajan R, Bogaard HJ, Fawcett P, Voelkel NF. Chronic carvedilol treatment partially reverses the right ventricular failure transcriptional profile in experimental pulmonary hypertension. Physiol Genomics 2013; 45:449-61. [PMID: 23632417 DOI: 10.1152/physiolgenomics.00166.2012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Right ventricular failure (RVF) is the most frequent cause of death in patients with pulmonary arterial hypertension (PAH); however, specific therapies targeted to treat RVF have not been developed. Chronic treatment with carvedilol has been shown to reduce established maladaptive right ventricle (RV) hypertrophy and to improve RV function in experimental PAH. However, the mechanisms by which carvedilol improves RVF are unknown. We have previously demonstrated by microarray analysis that RVF is characterized by a distinct gene expression profile when compared with functional, compensatory hypertrophy. We next sought to identify the effects of carvedilol on gene expression on a genome-wide basis. PAH and RVF were induced in male Sprague-Dawley rats by the combination of VEGF-receptor blockade and chronic hypoxia. After RVF was established, rats were treated with carvedilol or vehicle for 4 wk. RNA was isolated from RV tissue and hybridized for microarray analysis. An initial prediction analysis of carvedilol-treated RVs showed that the gene expression profile resembled the RVF prediction set. However, a more extensive analysis revealed a small group of genes differentially expressed after carvedilol treatment. Further analysis categorized these genes in pathways involved in cardiac hypertrophy, mitochondrial dysfunction, and protein ubiquitination. Genes encoding proteins in the cardiac hypertrophy and protein ubiquitination pathways were downregulated in the RV by carvedilol, while genes encoding proteins in the mitochondrial dysfunction pathway were upregulated by carvedilol. These gene expression changes may explain some of the mechanisms that underlie the functional improvement of the RV after carvedilol treatment.
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Affiliation(s)
- Jennifer I Drake
- Victoria Johnson Center for Lung Obstructive Disease Research, Virginia Commonwealth University, Richmond, Virginia, USA
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