201
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Relief of chronic neuropathic pain through endothelin antagonism. Am J Med 2010; 123:e7. [PMID: 20193818 DOI: 10.1016/j.amjmed.2009.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 07/20/2009] [Accepted: 07/21/2009] [Indexed: 11/21/2022]
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Steele P, Strange G, Wlodarczyk J, Dalton B, Stewart S, Gabbay E, Keogh A. Hemodynamics in pulmonary arterial hypertension (PAH): do they explain long-term clinical outcomes with PAH-specific therapy? BMC Cardiovasc Disord 2010; 10:9. [PMID: 20170553 PMCID: PMC2841582 DOI: 10.1186/1471-2261-10-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 02/22/2010] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) has witnessed dramatic treatment advances over the past decade. However, with the exception of epoprostenol, data from short-term randomized controlled trials (RCTs) have not shown a benefit of these drugs on survival. There remains a need to differentiate between available therapies and current endpoint responses which in turn, could be used to guide treatment selection and provide long-term prognostic information for patients. Methods We performed a systematic literature search of MEDLINE and EMBASE databases for RCTs of PAH-specific therapy published between January 1980 and May 2009. Articles were selected if they contained a placebo comparator and described hemodynamic changes from baseline. We applied the weighted mean change in hemodynamic variables to the equation developed by the National Institutes of Health (NIH) Registry to estimate long-term survival with each therapy. Results Ten RCTs involving 1,635 patients met the inclusion criteria. Suitable hemodynamic data were identified for bosentan, sitaxentan, sildenafil, epoprostenol, beraprost and treprostinil. 77.6% of patients were female and the mean (SD) age was 46.5 ± 4.9 years. 55.5% of patients had idiopathic PAH (iPAH), 23.9% PAH related to connective tissue disease, and 18.2% PAH related to congenital heart disease. Based on the effects observed in short-term trials and, relative to placebo, all analyzed therapies improved survival. The estimated 1-year survival was 78.4%, 77.8%, 76.1%, 75.8%, 75.2%, and 74.1% for epoprostenol, bosentan, treprostinil, sitaxentan, sildenafil, and beraprost, respectively. These estimates are considerably lower than the 1-year observed survival reported in several open-label and registry studies with PAH-specific therapies: 88% - 97%. Conclusion When applied to the NIH Registry equation, hemodynamic changes from baseline appear to underestimate the survival benefits observed with long-term PAH therapy.
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Affiliation(s)
- Peter Steele
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia
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203
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Olschewski H, Hoeper MM, Behr J, Ewert R, Meyer A, Borst MM, Winkler J, Pfeifer M, Wilkens H, Ghofrani HA, Nikkho S, Seeger W. Long-term therapy with inhaled iloprost in patients with pulmonary hypertension. Respir Med 2010; 104:731-40. [PMID: 20153158 DOI: 10.1016/j.rmed.2010.01.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 12/29/2009] [Accepted: 01/10/2010] [Indexed: 11/25/2022]
Abstract
AIMS To investigate the long-term safety of inhaled iloprost in patients with pulmonary hypertension (pH), including idiopathic PAH (IPAH group) and other forms of pulmonary hypertension (PHother). METHODS AND RESULTS Sixty-three patients (IPAH group, n=40, PHother n=23) were enrolled to receive inhaled iloprost either from baseline or after 3 months in a prospective, open-label 2-year study. Iloprost was inhaled 6-9 times daily with a night pause employing a jet nebulizer delivering an inhaled single dose of 4microg at the mouthpiece. In the case of side effects the single dose was reduced to 2microg. Sixty patients received at least 1 dose of inhaled iloprost. Thirty-six patients completed at least 630 days of therapy (25 IPAH, 11 PHother), 19 patients dropped out prematurely and 8 patients died (3 IPAH, 5 PHother). There were no drug-induced toxicities and only mild to moderate side effects. The most common side effects were coughing and flushing. Two-year survival was estimated at 85% (IPAH group 91%, PHother 78%). A modified analysis was performed to correct for differential drop-out. It included follow-up data from the premature discontinuations and revealed a 2-year survival of 87% [95% CI, 76%-98%] in the IPAH group while the predicted survival was 63%. The iloprost dose increased by 16% over 2 years. CONCLUSION Inhaled iloprost is well tolerated as long-term therapy and no substantial dose increase is required. Although uncontrolled, the data suggest a long-term clinical benefit from continued therapy with inhaled iloprost.
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Affiliation(s)
- Horst Olschewski
- University Hospital Giessen and Marburg GmbH, Klinikstr 36, Giessen, Germany.
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204
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Efficacy, safety and tolerability of bosentan in Chinese patients with pulmonary arterial hypertension. J Heart Lung Transplant 2010; 29:150-6. [DOI: 10.1016/j.healun.2009.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 09/16/2009] [Accepted: 09/20/2009] [Indexed: 01/03/2023] Open
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205
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Mubarak KK. A review of prostaglandin analogs in the management of patients with pulmonary arterial hypertension. Respir Med 2010; 104:9-21. [DOI: 10.1016/j.rmed.2009.07.015] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 06/25/2009] [Accepted: 07/19/2009] [Indexed: 10/20/2022]
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206
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Launay D, Sitbon O, Le Pavec J, Savale L, Tchérakian C, Yaïci A, Achouh L, Parent F, Jais X, Simonneau G, Humbert M. Long-term outcome of systemic sclerosis-associated pulmonary arterial hypertension treated with bosentan as first-line monotherapy followed or not by the addition of prostanoids or sildenafil. Rheumatology (Oxford) 2009; 49:490-500. [PMID: 20015974 DOI: 10.1093/rheumatology/kep398] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Launay
- Universite Paris-Sud, Faculte de Medecine, Kremlin-Bice tre, France
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Wu SC, Caravita S, Lisi E, Pierini S, Dadone V, Todd SE, Gentile F, Secchi MB. Pulmonary arterial hypertension. Intern Emerg Med 2009; 4:459-70. [PMID: 19504164 DOI: 10.1007/s11739-009-0263-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 05/04/2009] [Indexed: 10/20/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease with significant disability and mortality, and it has much higher prevalence than previously thought. During the past 15 years, we have witnessed remarkable advances in our understanding of pathogenesis, in diagnostic process and in the development of disease-specific treatments for PAH. Nowadays, the diagnosis is more clearly defined, non-invasive markers of disease severity can be widely applied, and finally we can adopt evidence-based treatment. Newer drugs availability has resulted in radical change in the management of this disease. The article reviews established approaches to evaluation and treatment of this disorder.
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Affiliation(s)
- Sheng Chin Wu
- Dipartimento Medico, U.O. Medicina Ospedale Bassini, Azienda Ospedaliera ICP, Cinisello Balsamo, MI, Italy
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208
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barberá JA, Beghetti M, Corris P, Gaine S, Simon Gibbs J, Gómez-Sánchez MÁ, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guía de práctica clínica para el diagnóstico y tratamiento de la hipertensión pulmonar. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73130-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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209
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Blalock SE, Matulevicius S, Mitchell LC, Reimold S, Warner J, Peshock R, Torres F, Chin KM. Long-term outcomes with ambrisentan monotherapy in pulmonary arterial hypertension. J Card Fail 2009; 16:121-7. [PMID: 20142023 DOI: 10.1016/j.cardfail.2009.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 08/30/2009] [Accepted: 09/29/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study evaluated long-term outcomes in patients with pulmonary arterial hypertension (PAH) undergoing treatment with ambrisentan monotherapy, a selective oral endothelin-1 receptor antagonist. METHODS AND RESULTS Patients who participated in the Ambrisentan in Pulmonary Arterial Hypertension: A Phase 3, Randomized, Double-Blind, Placebo-Controlled Multicenter Efficacy Study (ARIES-1) clinical trial and extension phase at our institution were included. Cardiac catheterization, 6-minute walk distance (6MWD), and cardiac magnetic resonance (MRI) data were retrospectively reviewed. Twelve patients with PAH (11 idiopathic, 1 fenfluramine) had follow-up from 3 to 5.5 years from the initiation of ARIES-1. Patients received ambrisentan therapy throughout the study period and were on ambrisentan monotherapy for the first 2 years. At year 1, improvements in median mean pulmonary arterial pressure (PA), cardiac output, and pulmonary vascular resistance (PVR) were seen (P = .02, P = .03, P < .01), and the improvement in PVR persisted at 2 years. 6MWD also improved significantly between baseline (350 m) and 1 and 2 years (397 m, P < .01 and 393 m, P = .01). Cardiac MRI results were more varied, with an increase in RV ejection fraction from 29% at baseline to 46% at 2 years (P = .02), but other MRI variables did not improve. CONCLUSIONS Ambrisentan monotherapy led to improvements in catheterization, 6MWD, and RV ejection fraction, and shows promise as a long-term treatment for pulmonary arterial hypertension.
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210
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Stevenson MD, Macdonald FC, Langley J, Hunsche E, Akehurst R. The cost-effectiveness of bosentan in the United Kingdom for patients with pulmonary arterial hypertension of WHO functional class III. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:1100-1105. [PMID: 19558373 DOI: 10.1111/j.1524-4733.2009.00568.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To assess whether bosentan or no active intervention, in addition to palliative care, is the more cost-effective first-line treatment option for patients with idiopathic pulmonary arterial hypertension (iPAH) or PAH associated with connective tissue disease (PAH-CTD) of WHO functional classification (FC) III in the United Kingdom. METHODS A cost-utility model simulated the treatment of patients with PAH of FC III. Patients remained on the selected intervention until death or clinical deterioration to FC IV, which would trigger initiation of epoprostenol treatment. The initial first-line treatment choice was assumed to not affect survival, but to affect the time until clinical deterioration, with this assumption being relaxed in sensitivity analyses. The distribution of time to clinical deterioration was estimated from long-term clinical trial databases of bosentan and from published literature. Utility associated with FC was taken from published literature. Costs were sourced from published literature and from specialist PAH centers. The time horizon was that of patients' lifetimes, with costs and benefits discounted at 3.5% per annum. RESULTS In the base case, bosentan dominated no active intervention because of the longer time to clinical deterioration and therefore the reduced time, per patient, spent in FC IV, which was associated with high costs of epoprostenol and reduced utility. In sensitivity analyses, bosentan was estimated to be more cost-effective than no active intervention, provided that any survival benefit was not greater than 2 years for patients with iPAH and 1 year for those with PAH-CTD. CONCLUSIONS Bosentan is likely to be a more cost-effective first-line therapy for patients with PAH FC III in the UK than no active intervention.
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Affiliation(s)
- Matt D Stevenson
- School of Health and Related Research, University of Sheffield, 30 Regent Street, Sheffield, UK.
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211
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Long-Term Ambrisentan Therapy for the Treatment of Pulmonary Arterial Hypertension. J Am Coll Cardiol 2009; 54:1971-81. [DOI: 10.1016/j.jacc.2009.07.033] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 07/08/2009] [Accepted: 07/21/2009] [Indexed: 11/24/2022]
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212
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Badano LP, Ginghina C, Easaw J, Muraru D, Grillo MT, Lancellotti P, Pinamonti B, Coghlan G, Marra MP, Popescu BA, De Vita S. Right ventricle in pulmonary arterial hypertension: haemodynamics, structural changes, imaging, and proposal of a study protocol aimed to assess remodelling and treatment effects. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:27-37. [DOI: 10.1093/ejechocard/jep152] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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213
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Frantz RP. Bosentan for pulmonary hypertension and other pulmonary diseases: emerging evidence. Future Cardiol 2009; 4:459-68. [PMID: 19804340 DOI: 10.2217/14796678.4.5.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Endothelin-1 is a potent vasoconstrictor and mitogen that is primarily synthesized and released from vascular endothelial cells. Bosentan is a dual endothelin-receptor antagonist that initially received approval for treatment of WHO group I pulmonary arterial hypertension (PAH) for patients in functional classes III and IV. Analysis of a study conducted in functional class II patients (Endothelin Antagonist Trial in Mildly Symptomatic PAH Patients [EARLY] trial) suggest its efficacy for these less symptomatic patients. In addition, bosentan has demonstrated efficacy in patients with congenital heart disease and Eisenmengers syndrome with right to left shunting and in HIV-related PAH. Studies of bosentan in inoperable or residual chronic thromboembolic pulmonary hypertension suggest possible efficacy. Bosentan appears promising in patients with idiopathic pulmonary fibrosis who do not have pulmonary hypertension. Combinations of bosentan with other PAH therapies such as iloprost and sildenafil may have incremental benefit over monotherapy.
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Affiliation(s)
- Robert P Frantz
- Mayo Pulmonary Hypertension Clinic, 200 First St SW, Rochester, MN 55905, USA.
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214
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Roberts KE, Preston IR. Safety and tolerability of bosentan in the management of pulmonary arterial hypertension. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 3:111-8. [PMID: 19920927 PMCID: PMC2769225 DOI: 10.2147/dddt.s3786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endothelin receptor antagonism has emerged as an important therapeutic approach in pulmonary arterial hypertension (PAH). Bench to bedside scientific research has clearly shown that endothelin-1 (ET-1) is over-expressed in several forms of pulmonary vascular disease and plays an important pathogenetic role in the development and progression of PAH. Oral endothelin receptor antagonists (ERAs) have been shown to improve exercise capacity, functional status, pulmonary hemodynamics, and delay the time to clinical worsening in several randomized placebo-controlled trials. Bosentan, the first oral ERA, was approved in 2001 and since that time it has established a strong record of safety and efficacy in PAH. More recently, two additional ERAs, ambrisentan and sitaxsentan, have been approved for use. The objective of this review is to evaluate the available evidence supporting the efficacy, pharmacology, safety and tolerability, and patient-focused perspectives for bosentan, the first approved ERA for PAH. Ongoing and forthcoming randomized trials are also highlighted including the application of bosentan in combination with other PAH therapies.
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Affiliation(s)
- Kari E Roberts
- Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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215
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, Beghetti M, Corris P, Gaine S, Gibbs JS, Gomez-Sanchez MA, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30:2493-537. [PMID: 19713419 DOI: 10.1093/eurheartj/ehp297] [Citation(s) in RCA: 2205] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, Bologna University Hospital, Via Massarenti, 9, 40138 Bologna, Italy.
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216
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Badesch DB, Champion HC, Gomez Sanchez MA, Hoeper MM, Loyd JE, Manes A, McGoon M, Naeije R, Olschewski H, Oudiz RJ, Torbicki A. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 2009; 54:S55-S66. [PMID: 19555859 DOI: 10.1016/j.jacc.2009.04.011] [Citation(s) in RCA: 741] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 04/15/2009] [Indexed: 12/23/2022]
Abstract
The diagnosis and assessment of pulmonary arterial hypertension is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. The definition of pulmonary hypertension has been simplified, and is now based on currently available evidence. There has been substantial progress in advancing the imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. The importance of accurate assessment of right ventricular function in following up the clinical course and response to therapy is more fully appreciated. As new therapies are developed for pulmonary arterial hypertension, screening, prompt diagnosis, and accurate assessment of disease severity become increasingly important. A clear definition of pulmonary hypertension and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to deriving maximal benefit from our expanding therapeutic armamentarium.
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Affiliation(s)
- David B Badesch
- Divisions of Pulmonary Sciences and Critical Care Medicine and Cardiology, University of Colorado Health Sciences Center, Denver, Colorado.
| | - Hunter C Champion
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Marius M Hoeper
- Department of Respiratory Medicine, University of Hannover Medical School, Hannover, Germany
| | - James E Loyd
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Robert Naeije
- Departments of Pathophysiology and Cardiology, Erasme Academic Hospital, Free University of Brussels, Brussels, Belgium
| | - Horst Olschewski
- Pulmonology Division, University Clinic of Internal Medicine, Medical University Graz, Graz, Austria
| | - Ronald J Oudiz
- Liu Center for Pulmonary Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Adam Torbicki
- Department of Chest Medicine, Institute of Tuberculosis and Lung Diseases, Medical University of Warsaw, Warsaw, Poland
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217
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Kingman M, Ruggiero R, Torres F. Ambrisentan, an endothelin receptor type A-selective endothelin receptor antagonist, for the treatment of pulmonary arterial hypertension. Expert Opin Pharmacother 2009; 10:1847-58. [DOI: 10.1517/14656560903061275] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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218
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Abstract
BACKGROUND Pulmonary arterial hypertension is a devastating disease, which leads to right heart failure and premature death. Recent evidence suggests that endothelin receptor antagonists may be promising drugs in the treatment of pulmonary arterial hypertension. OBJECTIVES To evaluate the efficacy of endothelin receptor antagonists in pulmonary arterial hypertension. SEARCH STRATEGY We searched CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, EMBASE, and the reference section of retrieved articles. Searches are current as of Februray 2008. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-randomised controlled trials involving patients with pulmonary arterial hypertension. DATA COLLECTION AND ANALYSIS Five review authors independently selected studies, assessed study quality and extracted data. MAIN RESULTS Five new studies have been added to this updated review, which now includes 11 randomised controlled trials involving 1457 patients. All the trials were of relatively short duration (12 weeks to 6 months). After treatment, patients treated with endothelin receptor antagonists could walk on average 33.7 metres (95% confidence interval [CI] 24.9 to 42.5 metres) further than those treated with placebo in a 6 minute walk test. Endothelin receptor antagonists improved more patients' World Health Organization/New York Heart Association (WHO/NYHA) functional class status than placebo (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.1), and reduced the odds of functional class deterioration compared to placebo (OR 0.26; 95% CI 0.16 to 0.42 ). There was a trend for endothelin receptor antagonists to reduce mortality (OR 0.48; 95% CI 0.21 to 1.09), and limited data suggest that endothelin receptor antagonists improve Borg dyspnoea score and cardiopulmonary haemodynamics in symptomatic patients. Hepatic toxicity was not common, and endothelin receptor antagonists were well tolerated in this population. AUTHORS' CONCLUSIONS Endothelin receptor antagonists can increase exercise capacity, improve WHO/NYHA functional class, prevent WHO/NYHA functional class deterioration, reduce dyspnoea and improve cardiopulmonary haemodynamic variables in patients with pulmonary arterial hypertension with WHO/NYHA functional class II and III. However, there was only a trend towards endothelin receptor antagonists reducing mortality in patients with pulmonary arterial hypertension. Efficacy data are strongest in those with idiopathic pulmonary hypertension.
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Affiliation(s)
- Chao Liu
- The First Hospital of Hebei Medical University, Donggang Road, Shijiazhuang, Hebei Province, China, 050031
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219
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McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ, Tapson VF, Varga J. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009; 53:1573-619. [PMID: 19389575 DOI: 10.1016/j.jacc.2009.01.004] [Citation(s) in RCA: 1134] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Davie NJ, Schermuly RT, Weissmann N, Grimminger F, Ghofrani HA. The science of endothelin-1 and endothelin receptor antagonists in the management of pulmonary arterial hypertension: current understanding and future studies. Eur J Clin Invest 2009; 39 Suppl 2:38-49. [PMID: 19335746 DOI: 10.1111/j.1365-2362.2009.02120.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Pathological vascular remodelling is a key contributor to the symptomatology of pulmonary arterial hypertension (PAH), and reversing this process may offer the best hope for improving this debilitating condition. The vascular remodelling process is believed to be due to endothelial cell dysfunction and to involve altered production of endothelial cell-derived vasoactive mediators. The observation that circulating plasma levels of the vasoactive peptide endothelin (ET)-1 are raised in patients with PAH, and that ET-1 production is increased in the pulmonary tissue of affected individuals, makes it a particularly interesting target for a therapeutic intervention in PAH. Clinical trials with ET receptor antagonists (ETRAs) show that they provide symptomatic benefit in patients with PAH, thereby proving the clinical relevance of the ET system as a therapeutic target. In this paper, we review the role of ET-1 together with the available data on the roles of the specific ET receptors and ETRAs in PAH. In particular, we discuss the possible role of ET receptor selectivity in the vascular remodelling process in PAH and whether selective ET(A) or nonselective ET(A)/ET(B) blockade offers the greatest potential to improve symptoms and alter the clinical course of the disease.
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221
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Strange G, Fowler R, Jary C, Dalton B, Stewart S, Gabbay E. Integrated care and optimal management of pulmonary arterial hypertension. J Multidiscip Healthc 2009; 2:67-78. [PMID: 21197349 PMCID: PMC3004560 DOI: 10.2147/jmdh.s3085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Indexed: 01/21/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) may occur as an idiopathic process or as a component of a variety of diseases, including connective tissue diseases, congenital heart disease, and exposure to appetite suppressants or infectious agents such as HIV. Untreated, it is a potentially devastating disease; however, diagnosis can be difficult due to the non-specific nature of symptoms during the early stages, and the fact that patients often present to a range of different medical specialties. The past decade has seen remarkable improvements in our understanding of the pathology associated with the condition and the development of PAH-specific therapies with the ability to alter the natural history of the disease. This article reviews the evidence for screening and diagnosis of susceptible patient groups and discusses treatment selection and recommendations based on data available from randomized controlled trials. In addition, due to the complexity of the diagnostic evaluation required and the treatment options available, this review mandates for a multidisciplinary approach to the management of PAH. We discuss the roles and organizational structure of a specialized PAH center in Perth, Western Australia to highlight these issues.
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Affiliation(s)
- Geoff Strange
- Epidemiology and Preventative Medicine, Monash University, VIC, Australia
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222
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Duffels MG, Vis JC, van Loon RL, Nieuwkerk PT, van Dijk AP, Hoendermis ES, de Bruin-Bon RH, Bouma BJ, Bresser P, Berger RM, Mulder BJ. Effect of bosentan on exercise capacity and quality of life in adults with pulmonary arterial hypertension associated with congenital heart disease with and without Down's syndrome. Am J Cardiol 2009; 103:1309-15. [PMID: 19406277 DOI: 10.1016/j.amjcard.2009.01.021] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Revised: 01/05/2009] [Accepted: 01/05/2009] [Indexed: 11/25/2022]
Abstract
Pulmonary arterial hypertension associated with congenital heart disease caused by systemic-to-pulmonary shunting was associated with a high risk of morbidity and mortality. In this retrospective study, the longer term treatment effect of bosentan on exercise capacity and quality of life (QoL) were evaluated in 58 adult patients (>18 years) with pulmonary arterial hypertension associated with congenital heart disease, including patients with Down's syndrome. All patients were evaluated at baseline and during follow-up using laboratory tests, 6-minute walk test, QoL questionnaires, and Doppler echocardiography. Treatment efficacy was analyzed separately for patients without (n = 30) and with Down's syndrome (n = 28). Median follow-up of all patients treated with bosentan was 22 months (range 3 to 36). In patients without Down's syndrome, mean 6-minute walk distance increased from 427 +/- 97 to 461 +/- 104 m (p <0.01) after 6 months of treatment, followed by a gradual return to baseline and disease stabilization. QoL improved significantly during treatment and was maintained during 18 months of follow-up (p <0.05). In patients with Down's syndrome, 6-minute walk distance and QoL were stable during treatment. In conclusion, findings suggested that in patients without Down's syndrome, longer term bosentan treatment resulted in a persistent improvement in QoL and stabilization of exercise capacity.
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Ulrich S, Hersberger M, Fischler M, Huber LC, Senn O, Treder U, Speich R, Schmid C. Bone mineral density and secondary hyperparathyroidism in pulmonary hypertension. Open Respir Med J 2009; 3:53-60. [PMID: 19461899 PMCID: PMC2684713 DOI: 10.2174/1874306400903010053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 01/15/2009] [Accepted: 01/23/2009] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Low bone mineral density (BMD) is common in chronic lung diseases and associated with reduced quality of life. Little is known about BMD in pulmonary hypertension (PH). METHODS Steroid-naïve patients with PH (n=34; 19 idiopathic, 15 chronic thromboembolic) had BMD measured by DXA at the time of diagnostic right heart catheterization. Exercise capacity, quality of life and various parameters related to PH severity and bone metabolism were also assessed. 24 patients with left heart failure (LHF) were similarly assessed as controls. RESULTS The prevalence of osteopenia was high both in PH (80%) and in controls with LHF (75%). Low BMD was associated with lean body mass, age, lower BMI, impaired exercise capacity and in PH with higher pulmonary vascular resistance. Serum parathyroid hormone (PTH) was elevated and considerably higher in PH than in LHF (above normal, in 55 vs 29%). Secondary hyperparathyroidism was not related to impaired renal function but possibly to low vitamin D status. CONCLUSIONS Osteopenia is common in PH and in chronically ill patients with LHF. Osteopenia is associated with known risk factors but in PH also with disease severity. Preventive measures in an increasingly chronic ill PH population should be considered. Secondary hyperparathyroidism is highly prevalent in PH and might contribute to bone and possibly pulmonary vascular disease. Whether adequate vitamin D substitution could prevent low BMD in PH remains to be determined.
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Affiliation(s)
- Silvia Ulrich
- Department of Internal Medicine, University Hospital of Zurich, Switzerland
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225
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McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ, Tapson VF, Varga J, Harrington RA, Anderson JL, Bates ER, Bridges CR, Eisenberg MJ, Ferrari VA, Grines CL, Hlatky MA, Jacobs AK, Kaul S, Lichtenberg RC, Lindner JR, Moliterno DJ, Mukherjee D, Pohost GM, Rosenson RS, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Weitz HH, Wesley DJ. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation 2009; 119:2250-94. [PMID: 19332472 DOI: 10.1161/circulationaha.109.192230] [Citation(s) in RCA: 745] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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226
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Sohn DW, Kim HK, Kim MA, Song YW, Noh CI, Kim DK, Kang IS, Kim H, Lee SD, Kim YH, Youn HJ, Chung N, Choi JY, Jun JB, Shin J. Beneficial and adverse effects of bosentan treatment in korean patients with pulmonary artery hypertension. Korean Circ J 2009; 39:105-10. [PMID: 19949596 PMCID: PMC2771800 DOI: 10.4070/kcj.2009.39.3.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Accepted: 12/06/2008] [Indexed: 01/15/2023] Open
Abstract
Background and Objectives The purpose of this study was to investigate 1) the beneficial effect of bosentan treatment (125 mg twice daily) on exercise capacity and echocardiographic variables and 2) the profiles and frequency of adverse events in Korean patients with World Health Organization (WHO) class III or IV pulmonary artery hypertension (PAH). Subjects and Methods Twelve patients who received bosentan treatment were investigated in an open label manner. One patient was excluded in the final analyses due to a prohibited concomitant medication. A 6-minute walk test and echocardiography were performed at baseline and after 12 weeks of treatment. Results The administration of bosentan for 12 weeks resulted in a significant improvement in exercise capacity (measured with the 6-minute walking distance), WHO functional capacity, and in echocardiographic variables. Bosentan treatment was associated with a decrease in the maximal tricuspid regurgitation jet velocity {from 4.7 m/sec (95% confidence interval, 3.89-5.45) at baseline to 4.4 m/sec (95% confidence interval, 3.61-5.1) at 12 weeks, p=0.03} and systolic pulmonary arterial pressure {from 105 mmHg (95% confidence interval, 74.4-135.6) at baseline to 93 mmHg (95% confidence interval, 66.3-120.1) at 12 weeks, p=0.04}. Treatment with bosentan at a dose of 125 mg twice a day was not associated with life-threatening side effects, although a higher incidence of elevated liver enzymes compared to previous studies was noted. Conclusion Bosentan at a dose of 125 mg twice daily is considered a clinically optimal, safe dose and can be used as a valuable treatment option in Korean PAH patients with WHO functional capacity III or IV, though close monitoring of liver function is required.
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Affiliation(s)
- Dae-Won Sohn
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Clinical significance of plasma endothelin-1 level after bosentan administration in pulmonary arterial hypertension. J Cardiol 2009; 53:374-80. [PMID: 19477379 DOI: 10.1016/j.jjcc.2009.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 01/07/2009] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Endothelin (ET)-1 has been shown to play a significant pathogenic role in pulmonary arterial hypertension (PAH). However, the pathobiological significance of increased ET-1 concentration after administration of ET receptor antagonist in patients with PAH has not yet been fully examined. METHODS In 16 PAH patients, plasma ET-1 concentration was measured at 0, 1, 3, 6, and 24h after a single 62.5mg dose of bosentan, a dual ET receptor antagonist, and the peak and 24-h change in ET-1 concentration from baseline were examined. The severity of PAH was evaluated by hemodynamic parameters, 6-min walk distance, New York Heart Association (NYHA) functional class, and brain natriuretic peptide (BNP). RESULTS Plasma ET-1 concentration significantly increased from 1.93+/-0.12 to 3.36+/-0.18 pg/ml after bosentan administration in PAH patients (p<0.01). The peak-to-baseline ratio of ET-1 concentration after bosentan administration showed a significant positive correlation with baseline ET-1 concentration (p<0.05). After 4-week bosentan administration, NYHA functional class improved in 7 patients but was not changed in 9 patients. The optimal cut-off point of % change of ET-1 concentration at 24h for discriminating the two groups was 30%. According to this cut-off point, patients were divided into the higher (n=7) and the lower (n=9) groups. NYHA functional class did not change in the lower group, but significantly improved (p<0.01) in the higher group after 4-week bosentan administration. In addition, plasma BNP levels significantly decreased from baseline in the higher group compared with those in the lower group after 12-week bosentan administration (-44+/-11% vs. 7+/-20%, p<0.05). CONCLUSIONS Although the population in this study is small and heterogeneous, measurement of plasma ET-1 concentration after bosentan administration might predict the responsiveness to bosentan treatment, and be useful in the determination of effective therapy in treatment of PAH patients.
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228
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Steiner MK, Preston IR. Optimizing endothelin receptor antagonist use in the management of pulmonary arterial hypertension. Vasc Health Risk Manag 2009; 4:943-52. [PMID: 19183742 PMCID: PMC2605321 DOI: 10.2147/vhrm.s2270] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endothelin receptor antagonism has emerged as an important therapeutic approach in pulmonary arterial hypertension (PAH). Bench to bedside scientific research has shown that endothelin-1 (ET-1) is overexpressed in several forms of pulmonary vascular disease and may play an important pathogenetic role in the development and progression of PAH. Oral endothelin receptor antagonists (ERAs) improved exercise capacity, functional status, pulmonary hemodymanics, and delayed the time to clinical worsening in several randomized placebo-controlled trials. Two ERAs are currently approved by the US Food and Drug Administration: bosentan, a dual ERA for patients with class III and IV PAH, and ambrisentan, a selective ERA for patients with class II and III PAH. Sitaxsentan, another selective ERA, has been approved in Europe, Canada, and Australia. The objective of this review is to evaluate the available evidence describing the pharmacology, efficacy, safety, and tolerability, and patient-focused perspectives regarding the different types of endothelin receptor antagonists. Ongoing and forthcoming randomized trials are also highlighted including the approach of combining this class of drugs with other drugs that target different cellular pathways believed to be etiologically important in PAH.
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Affiliation(s)
- M Kathryn Steiner
- Pulmonary Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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229
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Román Broto A, Monforte Torres V. [Combination therapy for pulmonary arterial hypertension]. Arch Bronconeumol 2009; 45:36-40. [PMID: 19186297 DOI: 10.1016/j.arbres.2008.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022]
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Abstract
Pulmonary arterial hypertension is a progressive, symptomatic, and ultimately fatal disorder for which substantial advances in treatment have been made during the past decade. Effective management requires timely recognition and accurate diagnosis of the disorder and appropriate selection among therapeutic alternatives. Despite progress in treatment, obstacles remain that impede the achievement of optimal outcomes. The current article provides an overview of the pathobiologic mechanisms of pulmonary arterial hypertension, including genetic substrates and molecular and cellular mechanisms, and describes the clinical manifestations and classification of pulmonary arterial hypertension. The article also reviews established approaches to evaluation and treatment, with emphasis on the appropriate application of calcium channel blockers, prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors. In addition, the authors discuss unresolved issues that may complicate patient management, such as the clinical importance of mild or exercise-related pulmonary arterial hypertension, and they identify avenues by which treatment may advance in the future through the use of combination treatment, outcomes assessment, and exploration of alternative pharmacologic strategies.
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Affiliation(s)
- Michael D McGoon
- Pulmonary Hypertension Clinic, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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231
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Abstract
Pulmonary arterial hypertension is a progressive, symptomatic, and ultimately fatal disorder for which substantial advances in treatment have been made during the past decade. Effective management requires timely recognition and accurate diagnosis of the disorder and appropriate selection among therapeutic alternatives. Despite progress in treatment, obstacles remain that impede the achievement of optimal outcomes. The current article provides an overview of the pathobiologic mechanisms of pulmonary arterial hypertension, including genetic substrates and molecular and cellular mechanisms, and describes the clinical manifestations and classification of pulmonary arterial hypertension. The article also reviews established approaches to evaluation and treatment, with emphasis on the appropriate application of calcium channel blockers, prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors. In addition, the authors discuss unresolved issues that may complicate patient management, such as the clinical importance of mild or exercise-related pulmonary arterial hypertension, and they identify avenues by which treatment may advance in the future through the use of combination treatment, outcomes assessment, and exploration of alternative pharmacologic strategies.
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Affiliation(s)
- Michael D McGoon
- Pulmonary Hypertension Clinic, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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232
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Abman SH. Role of Endothelin Receptor Antagonists in the Treatment of Pulmonary Arterial Hypertension. Annu Rev Med 2009; 60:13-23. [DOI: 10.1146/annurev.med.59.110106.212434] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Steven H. Abman
- Pediatric Heart Lung Center, University of Colorado School of Medicine and The Children's Hospital, Aurora, Colorado 80045;
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233
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Yildiz P. Molecular mechanisms of pulmonary hypertension. Clin Chim Acta 2009; 403:9-16. [PMID: 19361468 DOI: 10.1016/j.cca.2009.01.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 01/18/2009] [Accepted: 01/23/2009] [Indexed: 12/11/2022]
Abstract
The pathogenesis of pulmonary arterial hypertension (PAH) is complex, involving multiple modulating genes and environmental factors. Multifactorial impairment of the physiologic balance can lead to vasoconstriction, vascular smooth muscle cell and endothelial cell proliferation/fibrosis, inflammation, remodeling and in-situ thrombosis. These are the likely mechanisms that lead to narrowing of the vessel followed by progressive increase in pulmonary vascular resistance and the clinical manifestations of pulmonary hypertension. Subsequently, major goal of the therapy is to avoid acute pulmonary vasoconstriction, halt the progression of vascular remodeling, and reverse the early vascular remodeling if possible. Recently published data addressing certain molecular mechanisms for pathogenesis of PAH have led to the successful therapeutic interventions. This review will focus on the common and critical molecular pathways including genetic basis of the development of PAH that on the whole may be new targets for therapeutic interventions.
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Affiliation(s)
- Pinar Yildiz
- Department of Pulmonology, Yedikule Chest Disease and Surgery Training and Research Hospital, Zeytinburnu Istanbul, Turkey.
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234
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McGoon MD, Frost AE, Oudiz RJ, Badesch DB, Galie N, Olschewski H, McLaughlin VV, Gerber MJ, Dufton C, Despain DJ, Rubin LJ. Ambrisentan Therapy in Patients With Pulmonary Arterial Hypertension Who Discontinued Bosentan or Sitaxsentan Due to Liver Function Test Abnormalities. Chest 2009; 135:122-129. [DOI: 10.1378/chest.08-1028] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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235
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Diseases of the Pulmonary Vascular System. THE RESPIRATORY TRACT IN PEDIATRIC CRITICAL ILLNESS AND INJURY 2009. [PMCID: PMC7124039 DOI: 10.1007/978-1-84800-925-7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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236
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Kunieda T, Nakanishi N, Matsubara H, Ohe T, Okano Y, Kondo H, Nishimura M, Shirato K, Tanabe N, Homma S, Yoshida S, Inokuma S, Kodama M, Koike T, Hishida H. Effects of Long-Acting Beraprost Sodium (TRK-100STP) in Japanese Patients With Pulmonary Arterial Hypertension. Int Heart J 2009; 50:513-29. [DOI: 10.1536/ihj.50.513] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Takeyoshi Kunieda
- Department of Cardiovascular Medicine, Kaken Hospital, Clinical Medical Research Center, International University of Health and Welfare
| | - Norifumi Nakanishi
- Division of Cardiology, Department of Medicine, National Cardiovascular Center
| | - Hiromi Matsubara
- Division of Cardiology, National Hospital Organization Okayama Medical Center
| | - Tohru Ohe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yoshiaki Okano
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine
| | - Hirobumi Kondo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine
| | - Masaharu Nishimura
- First Department of Medicine, Hokkaido University Graduate School of Medicine
| | - Kunio Shirato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Nobuhiro Tanabe
- Department of Respirology, Chiba University Graduate School of Medicine
| | - Satoshi Homma
- Cardiovascular Division, Institute of Clinical Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba
| | - Shunji Yoshida
- Division of Rheumatology and Infectious Diseases, Department of Internal Medicine, Fujita Health University School of Medicine
| | - Shigeko Inokuma
- Department of Allergy and Immunological Diseases, Tokyo Metropolitan Komagome Hospital
| | - Makoto Kodama
- First Department of Internal Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Takao Koike
- Second Department of Medicine, Hokkaido University Graduate School of Medicine
| | - Hitoshi Hishida
- Division of Cardiology, Department of Internal Medicine, Fujita Health University School of Medicine
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237
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Do.e Z, Fukumoto Y, Takaki A, Tawara S, Ohashi J, Nakano M, Tada T, Saji K, Sugimura K, Fujita H, Hoshikawa Y, Nawata J, Kondo T, Shimokawa H. Evidence for Rho-Kinase Activation in Patients With Pulmonary Arterial Hypertension. Circ J 2009; 73:1731-9. [DOI: 10.1253/circj.cj-09-0135] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Zhulanqiqige Do.e
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yoshihiro Fukumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Aya Takaki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Shunsuke Tawara
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Junko Ohashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Makoto Nakano
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomohiro Tada
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kenya Saji
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kohichiro Sugimura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Hiroshi Fujita
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Tohoku University Graduate School of Medicine
| | - Jun Nawata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Takashi Kondo
- Department of Thoracic Surgery, Tohoku University Graduate School of Medicine
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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238
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Chakinala M. Evaluating Recent Therapeutic Trials in Pulmonary Arterial Hypertension: Raising the Bar for Clinical Investigation. ACTA ACUST UNITED AC 2009. [DOI: 10.21693/1933-088x-8.1.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Murali Chakinala
- Associate Professor of Medicine, Director, Pulmonary Hypertension Center, Co-Director, Hereditary Hemorrhagic Telangiectasia Center, Washington University School of Medicine
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239
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Vizza CD, Letizia C, Petramala L, Badagliacca R, Poscia R, Zepponi E, Crescenzi E, Nona A, Benedetti G, Ferrante F, Sciomer S, Fedele F. Venous endotelin-1 (ET-1) and brain natriuretic peptide (BNP) plasma levels during 6-month bosentan treatment for pulmonary arterial hypertension. ACTA ACUST UNITED AC 2008; 151:48-53. [DOI: 10.1016/j.regpep.2008.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 07/24/2008] [Accepted: 08/05/2008] [Indexed: 10/21/2022]
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240
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Rhodes CJ, Davidson A, Gibbs JSR, Wharton J, Wilkins MR. Therapeutic targets in pulmonary arterial hypertension. Pharmacol Ther 2008; 121:69-88. [PMID: 19010350 DOI: 10.1016/j.pharmthera.2008.10.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 01/02/2023]
Abstract
Pulmonary arterial hypertension is a progressive, fatal disease. Current treatments including prostanoids, endothelin-1 (ET-1) antagonists, and phosphodiesterase (PDE) inhibitors, have sought to address the pulmonary vascular endothelial dysfunction and vasoconstriction associated with the condition. These treatments may slow the progression of the disease but do not afford a cure. Future treatments must target more directly the structural vascular changes that impair blood flow through the pulmonary circulation. Several novel therapeutic targets have been proposed and are under active investigation, including soluble guanylyl cyclase, phosphodiesterases, tetrahydrobiopterin, 5-HT2B receptors, vasoactive intestinal peptide, receptor tyrosine kinases, adrenomedullin, Rho kinase, elastases, endogenous steroids, endothelial progenitor cells, immune cells, bone morphogenetic protein and its receptors, potassium channels, metabolic pathways, and nuclear factor of activated T cells. Tyrosine kinase inhibitors, statins, 5-HT2B receptor antagonists, EPCs and soluble guanylyl cyclase activators are among the most advanced, having produced encouraging results in animal models, and human trials are underway. This review summarises the current research in this area and speculates on their likely success.
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Affiliation(s)
- Christopher J Rhodes
- Department of Experimental Medicine and Toxicology, Imperial College London, and National Pulmonary Hypertension Service, Hammersmith Hospital, United Kingdom
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241
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Rabinovitch M. Pathobiology of pulmonary hypertension. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2008; 2:369-99. [PMID: 18039104 DOI: 10.1146/annurev.pathol.2.010506.092033] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A variety of conditions can lead to the development of pulmonary arterial hypertension (PAH). Current treatments can improve symptoms and reduce the severity of the hemodynamic abnormality, but most patients remain quite limited, and deterioration in their condition necessitates a lung transplant. This review discusses current experimental and clinical studies that investigate the pathobiology of PAH. An emerging theme is the consideration of ways in which one might reverse the advanced occlusive structural changes in the pulmonary circulation causing PAH. The current debate concerning the role of regeneration through stem cells is presented. This review also highlights investigations in a number of laboratories relating the pathobiology of PAH to mutations causing loss of function of bone morphogenetic protein receptor II in patients with familial PAH, as well as sporadic cases.
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Affiliation(s)
- Marlene Rabinovitch
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305, USA.
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242
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Boutet K, Montani D, Jaïs X, Yaïci A, Sitbon O, Simonneau G, Humbert M. Review: Therapeutic advances in pulmonary arterial hypertension. Ther Adv Respir Dis 2008; 2:249-65. [DOI: 10.1177/1753465808094762] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by vasoconstriction, in situ thrombosis, and vascular remodeling of small pulmonary arteries inducing increased pulmonary arterial resistance. Conventional treatment is based on life style modification and nonspecific treatment (warfarine, diuretics, oxygen). Calcium channel blockers are vasodilatators that have been shown to be of great efficacy in a very specific subpopulation of patients with PAH. For the majority of patients, specific PAH therapies are still lacking. Numerous studies evaluating prostacyclin agonists, endothelin-receptor antagonists, and phosphodiesterase type 5 inhibitors are now available to guide therapeutic choices. Despite those important advances there is still no cure for PAH. Fortunately, research is ongoing and many drugs show promises.
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Affiliation(s)
- K. Boutet
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - David Montani
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Xavier Jaïs
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Azzedine Yaïci
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Oliver Sitbon
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Gérald Simonneau
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Marc Humbert
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France, marc.humbert @abc.aphp.fr
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Beghetti M, Hoeper MM, Kiely DG, Carlsen J, Schwierin B, Segal ES, Humbert M. Safety experience with bosentan in 146 children 2-11 years old with pulmonary arterial hypertension: results from the European Postmarketing Surveillance program. Pediatr Res 2008; 64:200-4. [PMID: 18414142 DOI: 10.1203/pdr.0b013e318179954c] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The oral dual endothelin receptor antagonist bosentan has been shown to improve the short- and medium-term course of adult pulmonary arterial hypertension (PAH); however, data from clinical studies in children are limited. This analysis investigated the safety profile of bosentan in pediatric patients in a European, prospective, noninterventional, Internet-based postmarketing surveillance database (Tracleer PMS). Pediatric patients (aged 2-11 y) were compared with patients aged > or =12 y. Over a 30-mo period, 4994 patients, including 146 bosentan-naïve pediatric patients (51.4% males), were captured in the database. Predominant etiologies in children were idiopathic PAH (40.4%) and PAH related to congenital heart disease (45.2%). The majority of children were in New York Heart Association functional class II (28.1%) or III (50.7%), and median exposure to bosentan was 29.1 wk. Elevated aminotransferases were reported in 2.7% of children versus 7.8% of patients > or =12 y. The discontinuation rate was 14.4% in children versus 28.1% in patients > or =12 y. The Tracleer PMS results provide unique information on pediatric PAH in Europe. They also suggest that Tracleer may be better tolerated in children than in adults. This observation confirms the value of monthly monitoring of liver function for the duration of bosentan treatment.
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Affiliation(s)
- Maurice Beghetti
- Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland.
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Benza RL, Barst RJ, Galie N, Frost A, Girgis RE, Highland KB, Strange C, Black CM, Badesch DB, Rubin L, Fleming TR, Naeije R. Sitaxsentan for the treatment of pulmonary arterial hypertension: a 1-year, prospective, open-label observation of outcome and survival. Chest 2008; 134:775-782. [PMID: 18625676 DOI: 10.1378/chest.07-0767] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Despite advances in the management of pulmonary arterial hypertension (PAH), the mortality rate remains excessive. Long-term efficacy evaluations are needed to guide therapeutic management. The purpose of this study is to present 1-year observational data with two endothelin antagonists, sitaxsentan and bosentan, in a prospective, open-label study. METHODS The present study was a prospective, international, multicenter, randomized, open-label extension of the Sitaxsentan To Relieve Impaired Exercise-2 trial. All-cause mortality, time to discontinuation (all causes) from monotherapy, time to discontinuation due to adverse events, time to elevations in and time to discontinuation due to elevated hepatic transaminases, and time to first clinical worsening event were evaluated. Patients initially receiving sitaxsentan at 50 mg were excluded from the main analysis. The distributions of time-to-event variables are estimated using Kaplan-Meier methods, and treatment effects are evaluated using the Cox proportional hazards model. RESULTS Patients treated with sitaxsentan at 100 mg had 96% overall survival and a 34% risk for a clinical worsening event by 1 year. In addition, there was a 6% risk of elevated aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) levels > 3 x upper limit of normal range (ULN) at 1 year and a 15% risk of discontinuation due to adverse events. Patients treated with bosentan had 88% overall survival and a 40% risk of a clinical worsening event by 1 year. In addition, there was a 14% risk for elevated AST and/or ALT levels > 3 x ULN at 1 year and a 30% risk of discontinuation due to adverse events. CONCLUSIONS At 1 year, sitaxsentan therapy appears safe and efficacious for patients with PAH; reductions in mortality and the risk for clinical worsening events provide support for durability of efficacy.
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Affiliation(s)
| | - Robyn J Barst
- Columbia University College of Physicians and Surgeons, New York, NY
| | | | | | - Reda E Girgis
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Kristin B Highland
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Charlie Strange
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | | | - Lewis Rubin
- University of California, San Diego Medical Center, La Jolla, CA
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STRANGE G, KEOGH AM, WILLIAMS TJ, WLODARCZYK J, MCNEIL KD, GABBAY E. Bosentan therapy in patients with pulmonary arterial hypertension: The relationship between improvements in 6 minute walk distance and quality of life. Respirology 2008; 13:674-82. [DOI: 10.1111/j.1440-1843.2008.01326.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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246
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Opitz CF, Ewert R, Kirch W, Pittrow D. Inhibition of endothelin receptors in the treatment of pulmonary arterial hypertension: does selectivity matter? Eur Heart J 2008; 29:1936-48. [PMID: 18562303 PMCID: PMC2515885 DOI: 10.1093/eurheartj/ehn234] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Treatment options for pulmonary arterial hypertension (PAH) have considerably improved in the past few years. Endothelin (ET)-receptor antagonism has been established as a first-line option for the majority of PAH patients. Endothelin-receptor antagonists (ETRAs) comprise sulfonamide and non-sulfonamide agents with different affinities for ET-receptor subtypes (ETA and ETB), and the focus of development has shifted from drugs with less selectivity to those with high selectivity. There is ongoing debate as to whether selective or non-selective ET-receptor antagonism is more beneficial in the treatment of PAH. This paper reviews the current evidence from experimental and clinical studies obtained from a thorough literature search focusing on the three marketed drugs bosentan, sitaxentan, and ambrisentan. A clinically meaningful difference among the three approved ETRAs with respect to their ET-receptor selectivity could not be demonstrated to date. Therefore, in clinical practice, other features are likely to be of greater relevance when considering treatment, such as the potential for serious drug–drug interactions, convenience of dosing schedule, or rates of limiting side effects. These characteristics bear more relation to the chemical or pharmacological properties of the drugs than to receptor selectivity itself.
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Affiliation(s)
- Christian F Opitz
- Department of Internal Medicine, DRK-Kliniken Berlin, Köpenick, Berlin, Germany.
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247
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Ochiai E, Kamei K, Watanabe A, Nagayoshi M, Tada Y, Nagaoka T, Sato K, Sato A, Shibuya K. Inhalation of Stachybotrys chartarum causes pulmonary arterial hypertension in mice. Int J Exp Pathol 2008; 89:201-8. [PMID: 18460072 DOI: 10.1111/j.1365-2613.2008.00585.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Inhalation of Stachybotrys chartarum, a ubiquitous fungus in our living environment, has been suspected as a cause of acute idiopathic pulmonary haemorrhage in infants, but its relation to human diseases is not yet known. The aim of present study was to investigate the effect of repeated intratracheal injection of the fungus into mice, paying special attention to the pulmonary vascular system. Spores of S. chartarum were injected into the trachea of mice from 6 to 18 times over 4-12 weeks, and the lungs were examined by histopathology, morphometrics and haemodynamics. When 1 x 10(4) spores/mouse were injected, histopathological examination showed the development of pulmonary arterial hypertension (PAH). Symmetrical thickening of the intima and media of the pulmonary arterial walls was seen after six injections over 4 weeks. Right ventricular hypertrophy was also evident after 12 injections. PAH was confirmed by the elevation of right ventricular systolic pressure (20.1 +/- 5.7 mmHg in the injected group vs. 12.0 +/- 2.4 mmHg in the control group, P < 0.01). This study showed that the inhalation of S. chartarum caused PAH in mice, suggesting a potential of S. chartarum as a cause of human health problem such as PAH.
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Affiliation(s)
- Eri Ochiai
- Department of Pathogenic Fungi, Medical Mycology Research Center, Chiba University, Chiba, Japan
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Abstract
Significant advances in the treatment of pulmonary arterial hypertension (PAH) have occurred over the last 10 years, starting with the approval of epoprostenol in 1998. Subsequently, multiple additional medications have received approval, including a subcutaneous prostacyclin, an inhaled prostacyclin, and oral medications in 2 separate classes. Over this same period, the classification of pulmonary hypertension has been revised with changes including the substitution of the term idiopathic for primary PAH and an expanded list of conditions felt to be associated with the development of PAH. Long-term follow-up studies have provided better information on prognosis and expected outcomes with treatment, with particularly valuable data on reassessment of prognosis after treatment with epoprostenol. Combination therapy is more frequently being used, and limited data on novel therapies such as stem cell transplantation have been published. The purpose of this review is to describe the current state of evidence for the diagnosis, prognosis, and treatment of the patient with PAH.
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249
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O'Callaghan DS. Emerging treatments for pulmonary arterial hypertension. CLINICAL RESPIRATORY JOURNAL 2008; 2:132-40. [DOI: 10.1111/j.1752-699x.2008.00059.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cacoub P, Amoura Z, Langleben D. La prise en charge thérapeutique de l’hypertension artérielle pulmonaire par les antagonistes des récepteurs de l’endothéline en 2008. Rev Med Interne 2008; 29:283-9. [DOI: 10.1016/j.revmed.2007.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 12/14/2007] [Indexed: 10/22/2022]
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