251
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Maron BA, Abman SH, Elliott CG, Frantz RP, Hopper RK, Horn EM, Nicolls MR, Shlobin OA, Shah SJ, Kovacs G, Olschewski H, Rosenzweig EB. Pulmonary Arterial Hypertension: Diagnosis, Treatment, and Novel Advances. Am J Respir Crit Care Med 2021; 203:1472-1487. [PMID: 33861689 PMCID: PMC8483220 DOI: 10.1164/rccm.202012-4317so] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The diagnosis and management of pulmonary arterial hypertension (PAH) includes several advances, such as a broader recognition of extrapulmonary vascular organ system involvement, validated point-of-care clinical assessment tools, and focus on the early initiation of multiple pharmacotherapeutics in appropriate patients. Indeed, a principal goal in PAH today is an early diagnosis for prompt initiation of treatment to achieve a minimal symptom burden; optimize the patient's biochemical, hemodynamic, and functional profile; and limit adverse events. To accomplish this end, clinicians must be familiar with novel risk factors and the revised hemodynamic definition for PAH. Fresh insights into the role of developmental biology (i.e., perinatal health) may also be useful for predicting incident PAH in early adulthood. Emergent or underused approaches to PAH management include a novel TGF-β ligand trap pharmacotherapy, remote pulmonary arterial pressure monitoring, next-generation imaging using inert gas-based magnetic resonance and other technologies, right atrial pacing, and pulmonary arterial denervation. These and other PAH state of the art advances are summarized here for the wider pulmonary medicine community.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Steven H Abman
- Section of Pulmonary Medicine, Children's Hospital Colorado and the University of Colorado Anschutz Medical Center, University of Colorado, Aurora, Colorado
| | - C Greg Elliott
- Intermountain Medical Center and the University of Utah, Salt Lake City, Utah
| | - Robert P Frantz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Rachel K Hopper
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Graduate School of Medical Sciences, Cornell University, New York, New York
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System and School of Medicine, Stanford University, Stanford, California
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Horst Olschewski
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Erika B Rosenzweig
- Department of Pediatrics and.,Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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252
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Rosenkranz S. Pulmonale Hypertonie und Rechtsherzinsuffizienz. AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1511-2519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungPulmonale Hypertonie (PH) beschreibt einen hämodynamischen Zustand, der durch eine
Druckerhöhung im kleinen Kreislauf charakterisiert ist und der insbesondere bei älteren
Patienten häufig zu beobachten ist. In Abhängigkeit der Ätiologie differenziert die klinische
Klassifikation der pulmonalen Hypertonie 5 Hauptgruppen. Unabhängig von der zugrunde liegenden
Ursache führt eine PH zu einer chronischen Rechtsherzbelastung und Rechtsherzinsuffizienz.
Aktuelle Studien zeigen, dass bereits eine moderate Erhöhung des pulmonalarteriellen Druckes
sowie des pulmonalvaskulären Widerstands prognoserelevant sind. Im Einzelfall ist die
konsequente differenzialdiagnostische Abklärung einer PH essenziell, da sich die
Behandlungsoptionen je nach zugrunde liegender Ursache grundlegend unterscheiden.
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Affiliation(s)
- Stephan Rosenkranz
- Klinik für Kardiologie, Angiologie, Pneumologie und internistische Intensivmedizin, Universtiätsklinikum Köln, Köln, Deutschland
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253
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Diagnostic and prognostic significance of serum angiopoietin-1 and -2 concentrations in patients with pulmonary hypertension. Sci Rep 2021; 11:15502. [PMID: 34326408 PMCID: PMC8322335 DOI: 10.1038/s41598-021-94907-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/12/2021] [Indexed: 11/09/2022] Open
Abstract
Several biomarkers for detecting pulmonary hypertension (PH) have been reported. However, these biomarkers are deemed insufficient to detect PH in its early stages. We evaluated the utility of serum angiopoietin (ANGP), a glycoprotein related to angiogenesis, as a diagnostic and prognostic biomarker of PH. Patients with PH who underwent right-heart catheterization, were retrospectively studied. Serum concentrations of ANGP-1 and ANGP-2 were measured using an enzyme-linked immunosorbent assay in patients with PH (n = 32), those with idiopathic pulmonary fibrosis (IPF) without PH (as a disease control, n = 75), and age-matched healthy controls (HC, n = 60). Nineteen patients (59.4%) with PH had World Health Organization group 3 PH. Serum ANGP-2 concentration, but not ANGP-1, in patients with PH was significantly higher compared with that in HC (p = 0.025) and in patients with IPF without PH (p = 0.008). Serum ANGP-2 concentration in patients with PH positively and significantly correlated with N-terminal pro-B-type natriuretic peptide (r = 0.769, p < 0.001), right ventricular diameter on echocardiography (r = 0.565, p = 0.035), and mean pulmonary arterial pressure (r = 0.449, p = 0.032) and pulmonary vascular resistance (r = 0.451, p = 0.031) on right-heart catheterization. ANGP-1 and ANGP-2 were expressed on lung vascular endothelial cells, as shown by immunohistochemistry. Patients with PH with higher ANGP-2 concentration (≥ 2.48 ng/mL) had significantly worse survival (p = 0.022). Higher ANGP-2 concentration was a significant worse prognostic factor (hazard ratio = 6.063, p = 0.037), while serum ANGP-1 concentration was not. In conclusion, serum ANGP-2 may be a useful diagnostic and prognostic biomarker in patients with PH, especially in patients with group 3 PH.
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254
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Zeng Y, Li N, Zheng Z, Chen R, Liu W, Cheng J, Zhu J, Zeng M, Peng M, Hong C. Screening of key biomarkers and immune infiltration in Pulmonary Arterial Hypertension via integrated bioinformatics analysis. Bioengineered 2021; 12:2576-2591. [PMID: 34233597 PMCID: PMC8806790 DOI: 10.1080/21655979.2021.1936816] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This study aimed to screen key biomarkers and investigate immune infiltration in pulmonary arterial hypertension (PAH) based on integrated bioinformatics analysis. The Gene Expression Omnibus (GEO) database was used to download three mRNA expression profiles comprising 91 PAH lung specimens and 49 normal lung specimens. Three mRNA expression datasets were combined, and differentially expressed genes (DEGs) were obtained. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses and the protein-protein interaction (PPI) network of DEGs were performed using the STRING and DAVID databases, respectively. The diagnostic value of hub gene expression in PAH was also analyzed. Finally, the infiltration of immune cells in PAH was analyzed using the CIBERSORT algorithm. Total 182 DEGs (117 upregulated and 65 downregulated) were identified, and 15 hub genes were screened. These 15 hub genes were significantly associated with immune system functions such as myeloid leukocyte migration, neutrophil migration, cell chemotaxis, Toll-like receptor signaling pathway, and NF-κB signaling pathway. A 7-gene-based model was constructed and had a better diagnostic value in identifying PAH tissues compared with normal controls. The immune infiltration profiles of the PAH and normal control samples were significantly different. High proportions of resting NK cells, activated mast cells, monocytes, and neutrophils were found in PAH samples, while high proportions of resting T cells CD4 memory and Macrophages M1 cell were found in normal control samples. Functional enrichment of DEGs and immune infiltration analysis between PAH and normal control samples might help to understand the pathogenesis of PAH.
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Affiliation(s)
- Yu Zeng
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Nanhong Li
- Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhenzhen Zheng
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Riken Chen
- China State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wang Liu
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Junfen Cheng
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jinru Zhu
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Mingqing Zeng
- First Clinical School of Medicine, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Min Peng
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Cheng Hong
- China State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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255
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Wu WH, Bonnet S, Shimauchi T, Toro V, Grobs Y, Romanet C, Bourgeois A, Vitry G, Omura J, Tremblay E, Nadeau V, Orcholski M, Breuils-Bonnet S, Martineau S, Ferraro P, Potus F, Paulin R, Provencher S, Boucherat O. Potential for inhibition of checkpoint kinases 1/2 in pulmonary fibrosis and secondary pulmonary hypertension. Thorax 2021; 77:247-258. [PMID: 34226205 DOI: 10.1136/thoraxjnl-2021-217377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterised by exuberant tissue remodelling and associated with high unmet medical needs. Outcomes are even worse when IPF results in secondary pulmonary hypertension (PH). Importantly, exaggerated resistance to cell death, excessive proliferation and enhanced synthetic capacity are key endophenotypes of both fibroblasts and pulmonary artery smooth muscle cells, suggesting shared molecular pathways. Under persistent injury, sustained activation of the DNA damage response (DDR) is integral to the preservation of cells survival and their capacity to proliferate. Checkpoint kinases 1 and 2 (CHK1/2) are key components of the DDR. The objective of this study was to assess the role of CHK1/2 in the development and progression of IPF and IPF+PH. METHODS AND RESULTS Increased expression of DNA damage markers and CHK1/2 were observed in lungs, remodelled pulmonary arteries and isolated fibroblasts from IPF patients and animal models. Blockade of CHK1/2 expression or activity-induced DNA damage overload and reverted the apoptosis-resistant and fibroproliferative phenotype of disease cells. Moreover, inhibition of CHK1/2 was sufficient to interfere with transforming growth factor beta 1-mediated fibroblast activation. Importantly, pharmacological inhibition of CHK1/2 using LY2606368 attenuated fibrosis and pulmonary vascular remodelling leading to improvement in respiratory mechanics and haemodynamic parameters in two animal models mimicking IPF and IPF+PH. CONCLUSION This study identifies CHK1/2 as key regulators of lung fibrosis and provides a proof of principle for CHK1/2 inhibition as a potential novel therapeutic option for IPF and IPF+PH.
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Affiliation(s)
- Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Tongji University School of Medicine, Shanghai, Shanghai, China
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Victoria Toro
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Yann Grobs
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Charlotte Romanet
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Alice Bourgeois
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Geraldine Vitry
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Junichi Omura
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Eve Tremblay
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Valerie Nadeau
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Mark Orcholski
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Sandra Breuils-Bonnet
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Sandra Martineau
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Pasquale Ferraro
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Francois Potus
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Roxane Paulin
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
| | - Olivier Boucherat
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre (IUCPQ), Quebec, Quebec, Canada
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256
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Sugarman J, Weatherald J. Management of Pulmonary Hypertension Due to Chronic Lung Disease. Methodist Debakey Cardiovasc J 2021; 17:124-133. [PMID: 34326932 PMCID: PMC8298116 DOI: 10.14797/zkut3813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 12/03/2022] Open
Abstract
Pulmonary hypertension (PH) is a known complication of chronic parenchymal lung
diseases, including chronic obstructive lung disease, interstitial lung
diseases, and more rare parenchymal lung diseases. Together, these diseases
encompass two of the five clinical classifications of PH: group 3 (chronic lung
disease [CLD] and/or hypoxia) and group 5 (unclear and/or multifactorial
mechanisms). The principal management strategy in PH associated with CLD is
optimization of the underlying lung disease. There has been increasing interest
in therapies that treat pulmonary arterial hypertension (group 1, PAH), and
although some studies have explored the use of these oral PAH-targeted therapies
to treat PH associated with CLD, there is currently no evidence to support their
routine use; in fact, some studies suggest harm. Inhaled therapies that target
the pulmonary vasculature may avoid certain problems observed with oral PAH
therapies. Recent studies suggest a promising role for inhaled PAH therapies in
group 3 PH, but this requires further study. The objective of this article is to
review the current treatment strategies for group 3 and group 5 PH.
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Affiliation(s)
- Jordan Sugarman
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
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257
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Shifting gears: the search for group 3 pulmonary hypertension treatment. Curr Opin Pulm Med 2021; 27:296-302. [PMID: 34175858 DOI: 10.1097/mcp.0000000000000788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Treatment options for Group 3 pulmonary hypertension, characterized as secondary to chronic hypoxia or lung disease, remain an elusive holy grail for physicians and patients alike. Despite increasing identification and investigation into this pulmonary vasculopathy group with the second-highest frequency and highest mortality, there are no therapeutic interventions that offer the significant improvements in morbidity and mortality comparable to those benefiting other pulmonary hypertension groups including pulmonary arterial hypertension. This review examines the data on available and emerging Group 3 pulmonary hypertension treatments. RECENT FINDINGS Pulmonary vasodilators have yielded equivocal results in this patient population, although recent evidence shows modestly improved outcomes with inhaled treprostinil in interstitial lung disease-associated pulmonary hypertension. With pulmonary vasodilators providing limited benefit, emerging data support the right ventricle as a potential treatment target in Group 3 pulmonary hypertension. SUMMARY Group 3 pulmonary hypertension is associated with significant morbidity and mortality. Pulmonary vasodilators offer only limited haemodynamic and exertional benefits, and lung transplantation remains the only cure for this deadly disease. The right ventricle may provide a novel intervention target.
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258
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Nathan SD, Waxman A, Rajagopal S, Case A, Johri S, DuBrock H, De La Zerda DJ, Sahay S, King C, Melendres-Groves L, Smith P, Shen E, Edwards LD, Nelsen A, Tapson VF. Inhaled treprostinil and forced vital capacity in patients with interstitial lung disease and associated pulmonary hypertension: a post-hoc analysis of the INCREASE study. THE LANCET RESPIRATORY MEDICINE 2021; 9:1266-1274. [PMID: 34214475 DOI: 10.1016/s2213-2600(21)00165-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND INCREASE was a randomised, placebo-controlled, phase 3 trial that evaluated inhaled treprostinil in patients with interstitial lung disease (ILD) and associated pulmonary hypertension. Treprostinil improved exercise capacity from baseline to week 16, assessed with the use of a 6-min walk test, compared with placebo. Improvements in forced vital capacity (FVC) were also reported. The aim of this post-hoc analysis was to further characterise the effects of inhaled treprostinil on FVC in the overall study population and in various subgroups of interest. METHODS In this post-hoc analysis, we evaluated FVC changes in the overall study population and in various subgroups defined by cause of disease or baseline clinical parameters. The study population included patients aged 18 years and older who had a diagnosis of ILD based on evidence of diffuse parenchymal lung disease on chest CT done within 6 months before random assignment (not centrally adjudicated). All analyses were done on the intention-to-treat population, defined as individuals who were randomly assigned and received at least one dose of study drug. The INCREASE study is registered with ClinicalTrials.gov, NCT02630316. FINDINGS Between Feb 3, 2017, and Aug 30, 2019, 326 patients were enrolled in the INCREASE trial. Inhaled treprostinil was associated with a placebo-corrected least squares mean improvement in FVC of 28·5 mL (SE 30·1; 95% CI -30·8 to 87·7; p=0·35) at week 8 and 44·4 mL (35·4; -25·2 to 114·0; p=0·21) at week 16, with associated percentage of predicted FVC improvements of 1·8% (0·7; 0·4 to 3·2; p=0·014) and 1·8% (0·8; 0·2 to 3·4; p=0·028). Subgroup analysis of patients with idiopathic interstitial pneumonia showed FVC differences of 46·5 mL (SE 39·9; 95% CI -32·5 to 125·5; p=0·25) at week 8 and 108·2 mL (46·9; 15·3 to 201·1; p=0·023) at week 16. Analysis of patients with idiopathic pulmonary fibrosis showed FVC differences of 84·5 mL (52·7; -20·4 to 189·5; p=0·11) at week 8 and 168·5 mL (64·5; 40·1 to 297·0; p=0·011) at week 16. The most frequent adverse events included cough, headache, dyspnoea, dizziness, nausea, fatigue, and diarrhoea. INTERPRETATION In patients with ILD and associated pulmonary hypertension, inhaled treprostinil was associated with improvements in FVC versus placebo at 16 weeks. This difference was most evident in patients with idiopathic interstitial pneumonia, particularly idiopathic pulmonary fibrosis. Inhaled treprostinil appears to be a promising therapy for idiopathic pulmonary fibrosis that warrants further investigation in a prospective, randomised, placebo-controlled study. FUNDING United Therapeutics Corporation.
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Affiliation(s)
- Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA.
| | - Aaron Waxman
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Amy Case
- Piedmont Healthcare, Austell, GA, USA
| | - Shilpa Johri
- Pulmonary Associates of Richmond, Richmond, VA, USA
| | - Hilary DuBrock
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
| | - David J De La Zerda
- Division of Pulmonary & Critical Care Medicine, University of Miami Health System, Miami, FL, USA
| | - Sandeep Sahay
- Division of Pulmonary, Critical Care and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Christopher King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lana Melendres-Groves
- Pulmonary & Critical Care Division, University of New Mexico, 1 University of New Mexico, DoIM MSC10-5550, Albuquerque, NM, USA
| | - Peter Smith
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Eric Shen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Lisa D Edwards
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Andrew Nelsen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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259
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Harari S, Wells A. Inhaled trepostinil for severe fibrotic interstitial lung disease: grounds for cautious optimism? THE LANCET RESPIRATORY MEDICINE 2021; 9:1209-1211. [PMID: 34214474 DOI: 10.1016/s2213-2600(21)00264-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Sergio Harari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Department of Medical Sciences, Ospedale San Giuseppe, MultiMedica IRCCS, Milan 20123, Italy.
| | - Athol Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
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260
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Pulmonary hypertension in interstitial lung disease: screening, diagnosis and treatment. Curr Opin Pulm Med 2021; 27:396-404. [PMID: 34127619 DOI: 10.1097/mcp.0000000000000790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Pulmonary vascular disease resulting in pulmonary hypertension in the context of interstitial lung disease (PH-ILD) is a common complication that presents many challenges in clinical practice. Despite recent advances, the pathogenetic interplay between parenchymal and vascular disease in ILD is not fully understood. This review provides an overview of the current knowledge and recent advances in the field. RECENT FINDINGS Clinical trials employing the phosphodiesterase-5-inhibitor sildenafil delivered negative results whereas riociguat showed harmful effects in the PH-ILD population. More recently, inhaled treprostinil showed positive effects on the primary endpoint (six-min walk-distance) in the largest prospective randomized placebo-controlled trial to date in this patient population. Additionally, a pilot trial of ambulatory inhaled nitric oxide suggests beneficial effects based on the novel endpoint of actigraphy. SUMMARY In view of these novel developments this review provides an overview of the status quo of screening, diagnosis and management of pulmonary vascular disease and PH in patients with ILD.
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261
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Kandeel M, Yamamoto M, Park BK, Al-Taher A, Watanabe A, Gohda J, Kawaguchi Y, Oh-Hashi K, Kwon HJ, Inoue JI. Discovery of New Potent anti-MERS CoV Fusion Inhibitors. Front Pharmacol 2021; 12:685161. [PMID: 34149429 PMCID: PMC8206564 DOI: 10.3389/fphar.2021.685161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV), capable of zoonotic transmission, has been associated with emerging viral pneumonia in humans. In this study, a set of highly potent peptides were designed to prevent MERS-CoV fusion through competition with heptad repeat domain 2 (HR2) at its HR1 binding site. We designed eleven peptides with stronger estimated HR1 binding affinities than the wild-type peptide to prevent viral fusion with the cell membrane. Eight peptides showed strong inhibition of spike-mediated MERS-CoV cell-cell fusion with IC50 values in the nanomolar range (0.25–2.3 µM). Peptides #4–6 inhibited 95–98.3% of MERS-CoV plaque formation. Notably, peptide four showed strong inhibition of MERS-CoV plaques formation with EC50 = 0.302 µM. All peptides demonstrated safe profiles without cytotoxicity up to a concentration of 10 μM, and this cellular safety, combined with their anti-MERS-CoV antiviral activity, indicate all peptides can be regarded as potential promising antiviral agents.
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Affiliation(s)
- Mahmoud Kandeel
- Department of Biomedical Sciences, College of Veterinary Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.,Department of Pharmacology, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Mizuki Yamamoto
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Byoung Kwon Park
- Department of Microbiology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Abdulla Al-Taher
- Department of Biomedical Sciences, College of Veterinary Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aya Watanabe
- Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Jin Gohda
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Yasushi Kawaguchi
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Division of Molecular Virology, Department of Microbiology and Immunology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kentaro Oh-Hashi
- Department of Chemistry and Biomolecular Science, Faculty of Engineering, Gifu University, Gifu, Japan
| | - Hyung-Joo Kwon
- Department of Microbiology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jun-Ichiro Inoue
- Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan.,Senior Professor Office, The University of Tokyo, Tokyo, Japan
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262
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Lawrie A, Francis SE. Frataxin and endothelial cell senescence in pulmonary hypertension. J Clin Invest 2021; 131:149721. [PMID: 34060487 PMCID: PMC8159686 DOI: 10.1172/jci149721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary hypertension (PH), increased blood pressure within the lungs, is classified into five diagnostic groups based on etiology, with treatment assigned on this basis. Currently, only Group 1 pulmonary arterial hypertension (PAH) and Group 4 chronic thromboembolic PH (CTEPH) have pharmacological treatments available. The role of the endothelial cell in pulmonary hypertension has long been debated, and in this issue of the JCI, Culley et al. present evidence for the reduction in frataxin expression across multiple groups of PH. Reduced frataxin expression led to endothelial cell senescence and associated with the development of PH. Removal of the senescent cells using the senolytic drug Navitoclax in multiple models of PH effectively treated PH, suggesting a new class of treatments that may work beyond Group 1 and Group 4 PH in patients with evidence of pulmonary vascular endothelial senescence.
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263
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Church C, Gin-Sing W, Grady D, Johnson M, Kiely DG, Lordan J, Turner N, Wort SJ, Condliffe R. Establishing expert consensus for the optimal approach to holistic risk-management in pulmonary arterial hypertension: a Delphi process and narrative review. Expert Rev Respir Med 2021; 15:1493-1503. [PMID: 34018901 DOI: 10.1080/17476348.2021.1931129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Pulmonary arterial hypertension (PAH) is associated with significant morbidity and reduced life expectancy. Various medical therapies, together with non-medical therapies such as exercise training, have been shown to improve outcomes for patients. We performed a Delphi consensus process to establish optimal approaches to optimizing patient care.Methods: A steering group of PAH experts formulated 38 statements grouped into 6 themes: burden of PAH, risk-stratification, the role of clinical phenotyping in the management of PAH, assessing clinical response to treatment, maximizing the medical treatment pathway and the role of other management options. An online survey was sent to PAH health-care professionals throughout the UK to assess consensus with these statements. Consensus was defined as high if ≥70% and very high if ≥90% of the respondents agreed with a statement. A narrative review for each theme was then performedResults: Consensus was very high in 27 (71%) statements, high in 7 (18%) statements and was not achieved in 4 (11%) statements.Conclusions: Based on the consensus scores, the steering group derived 13 recommendations which, if implemented, should result in improved holistic care of patients with PAH.
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Affiliation(s)
- Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Wendy Gin-Sing
- Pulmonary Hypertension Service, Hammersmith Hospital, London, United Kingdom
| | - Duncan Grady
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Trust, Cambridge, United Kingdom
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Jim Lordan
- Pulmonary Vascular Unit, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Nadine Turner
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - S John Wort
- Pulmonary Hypertension Service, Royal Brompton Hospital, London, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
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264
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Naranjo M, Hassoun PM. Systemic Sclerosis-Associated Pulmonary Hypertension: Spectrum and Impact. Diagnostics (Basel) 2021; 11:911. [PMID: 34065226 PMCID: PMC8161029 DOI: 10.3390/diagnostics11050911] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a catastrophic complication of one of the most common and devastating autoimmune diseases. Once diagnosed, it becomes the leading cause of mortality among this patient population. Screening modalities and risk assessments have been designed and validated by various organizations and societies in order to identify patients early in their disease course and promptly refer them to expert centers for a hemodynamic assessment and formal diagnosis. Moreover, several large multicenter clinical trials have now included patients with SSc-PAH to assess their response to therapy. Despite an improved understanding of the condition and significant advances in supportive and targeted therapy, outcomes have remained far from optimal. Therefore, rigorous phenotyping and search for novel therapies are desperately needed for this devastating condition.
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Affiliation(s)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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265
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Nasser M, Kolb M, Cottin V. Inhaled Treprostinil in Group 3 Pulmonary Hypertension. N Engl J Med 2021; 384:1871-1872. [PMID: 33979496 DOI: 10.1056/nejmc2103465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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266
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Farmakis IT, Vazakidis P, Doundoulakis I, Arvanitaki A, Zafeiropoulos S, Boutou A, Karvounis H, Giannakoulas G. Haemodynamic effects of PAH-targeted therapies in pulmonary hypertension due to lung disease: A systematic review and meta-analysis. Pulm Pharmacol Ther 2021; 68:102036. [PMID: 33979684 DOI: 10.1016/j.pupt.2021.102036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a negative predictor in patients with lung disease and/or hypoxia (group 3 PH). Current guidelines do not endorse the use of targeted therapies for pulmonary arterial hypertension (PAH) in patients with group 3 PH, due to lack of strong evidence. However, a variety of studies have examined the effect of PAH-targeted therapies in group 3 PH with mixed methods and conflicting results. OBJECTIVE To evaluate the effect of PAH-targeted therapies on haemodynamic parameters as assessed by right heart catheterization in patients with group 3 PH. METHODS Search strategy included PubMed and CENTRAL databases for randomized controlled trials from inception until Jan 30, 2020. We hand searched review articles, clinical trial registries and reference lists of retrieved articles. The primary outcome was the effect of PAH-targeted therapies on haemodynamic parameters [mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), cardiac index (CI) and right atrial pressure (RAP)] in patients with group 3 PH, while secondary outcomes were 6-min walking distance (6MWD), brain natriuretic peptide (BNP) and quality of life (QoL). RESULTS Five studies with a total of 140 patients were included. PAH-targeted therapies improved significantly mPAP [mean difference (MD) -4.02 mmHg, 95% CI -7.95;-0.09], and PVR [standardized mean difference (SMD) -0.29, 95% CI -0.50;-0.07], but not CI (SMD 0.23, 95% CI -0.23; 0.70) or RAP (MD 0.26 mmHg, 95% CI -18.75; 19.27). PAH-targeted therapies significantly increased the 6MWD by 38.5 m (95% CI 17.6; 59.4), while they did not manage to improve QoL (SMD -3.42, 95% CI -14.74; 7.91) or BNP values. There was no effect of oxygenation by the PAH-targeted therapies compared to placebo. CONCLUSION PAH-targeted therapies slightly improved mPAP and PVR in group 3 PH, without affecting CI. Larger RCTs targeted in specific subpopulations are needed to extract more robust conclusions. PROTOCOL REGISTRATION Open Science Framework 10.17605/OSF.IO/56FDW.
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Affiliation(s)
- Ioannis T Farmakis
- Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Polychronis Vazakidis
- Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine and Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, USA
| | - Afroditi Boutou
- Department of Respiratory Medicine, G. Papanikolaou Hospital, Thessaloniki, Greece
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Dwivedi K, Sharkey M, Condliffe R, Uthoff JM, Alabed S, Metherall P, Lu H, Wild JM, Hoffman EA, Swift AJ, Kiely DG. Pulmonary Hypertension in Association with Lung Disease: Quantitative CT and Artificial Intelligence to the Rescue? State-of-the-Art Review. Diagnostics (Basel) 2021; 11:diagnostics11040679. [PMID: 33918838 PMCID: PMC8070579 DOI: 10.3390/diagnostics11040679] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/05/2021] [Accepted: 04/05/2021] [Indexed: 12/24/2022] Open
Abstract
Accurate phenotyping of patients with pulmonary hypertension (PH) is an integral part of informing disease classification, treatment, and prognosis. The impact of lung disease on PH outcomes and response to treatment remains a challenging area with limited progress. Imaging with computed tomography (CT) plays an important role in patients with suspected PH when assessing for parenchymal lung disease, however, current assessments are limited by their semi-qualitative nature. Quantitative chest-CT (QCT) allows numerical quantification of lung parenchymal disease beyond subjective visual assessment. This has facilitated advances in radiological assessment and clinical correlation of a range of lung diseases including emphysema, interstitial lung disease, and coronavirus disease 2019 (COVID-19). Artificial Intelligence approaches have the potential to facilitate rapid quantitative assessments. Benefits of cross-sectional imaging include ease and speed of scan acquisition, repeatability and the potential for novel insights beyond visual assessment alone. Potential clinical benefits include improved phenotyping and prediction of treatment response and survival. Artificial intelligence approaches also have the potential to aid more focused study of pulmonary arterial hypertension (PAH) therapies by identifying more homogeneous subgroups of patients with lung disease. This state-of-the-art review summarizes recent QCT developments and potential applications in patients with PH with a focus on lung disease.
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Affiliation(s)
- Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Correspondence:
| | - Michael Sharkey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Robin Condliffe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Johanna M. Uthoff
- Department of Computer Science, University of Sheffield, Sheffield S1 4DP, UK; (J.M.U.); (H.L.)
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
| | - Peter Metherall
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Haiping Lu
- Department of Computer Science, University of Sheffield, Sheffield S1 4DP, UK; (J.M.U.); (H.L.)
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - Jim M. Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - Eric A. Hoffman
- Advanced Pulmonary Physiomic Imaging Laboratory, University of Iowa, C748 GH, Iowa City, IA 52242, USA;
| | - Andrew J. Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - David G. Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
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268
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Saggar R, Giri PC, Deng C, Johnson D, McCloy MK, Liang L, Shaikh F, Hong J, Channick RN, Shapiro SS, Lynch JP, Belperio JA, Weigt SS, Ramsey AL, Ross DJ, Sayah DM, Shino MY, Derhovanessian A, Sherman AE, Saggar R. Significance of autoimmune disease in severe pulmonary hypertension complicating extensive pulmonary fibrosis: a prospective cohort study. Pulm Circ 2021; 11:20458940211011329. [PMID: 33996029 PMCID: PMC8108092 DOI: 10.1177/20458940211011329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/23/2021] [Indexed: 12/01/2022] Open
Abstract
The association of autoimmune disease (AI) with transplant-free survival in the setting of severe Group 3 pulmonary hypertension and extensive pulmonary fibrosis remains unclear. We report cases of severe pulmonary hypertension (mean pulmonary artery pressure ≥35 mmHg and right ventricular dysfunction) and extensive pulmonary fibrosis after pulmonary arterial hypertension-specific therapy. We used multivariate regression to determine the clinical variables associated with transplant-free survival. Of 286 screened patients, 55 demonstrated severe pulmonary hypertension and extensive pulmonary fibrosis and were treated with parenteral prostacyclin therapy. The (+)AI subgroup (n = 34), when compared to the (-)AI subgroup (n = 21), was more likely to be female (77% versus 19%) and younger (58.7 ± 12.1 versus 66.0 ± 10.7 years), and revealed lower forced vital capacity (absolute) (1.9 ± 0.7 versus 2.9 ± 1.1 L), higher DLCO (% predicted) (31.1 ± 15.2 versus 23.2 ± 8.0), and increased unadjusted transplant-free survival (1 year (84.6 ± 6.3% versus 45 ± 11.1%)), 3 years (71 ± 8.2% versus 28.6 ± 11.9%), and 5 years (47.6 ± 9.6% versus 6.4 ± 8.2%); (p = 0.01)). Transplant-free survival was unchanged after adjusting for age and gender. The pulmonary hemodynamic profiles improved after parenteral prostacyclin therapy, independent of AI status. The baseline variables associated with mortality included age at pulmonary hypertension diagnosis (heart rate (HR) 1.23 (confidence interval (CI) 1.03-1.47); p = 0.02) and presence of AI (HR 0.26 (confidence interval (CI) 0.10-0.70); p < 0.01). Gas exchange was not adversely affected by parenteral prostacyclin therapy. In the setting of severe Group 3 pulmonary hypertension and extensive pulmonary fibrosis treated with pulmonary arterial hypertension-specific therapy, AI is independently associated with increased transplant-free survival. Pulmonary hypertension/pulmonary fibrosis associated with AI should be considered in future clinical trials of pulmonary arterial hypertension-specific therapy in Group 3 pulmonary hypertension.
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Affiliation(s)
| | - Paresh C. Giri
- Division of Pulmonary and Critical Care Medicine, Loma Linda University School of Medicine, Loma Linda, USA
| | | | | | - Mary K. McCloy
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Lloyd Liang
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Faisal Shaikh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Jason Hong
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Richard N. Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Shelley S. Shapiro
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Joseph P. Lynch
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - John A. Belperio
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Samuel S. Weigt
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Allison L. Ramsey
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | | | - David M. Sayah
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Michael Y. Shino
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Ariss Derhovanessian
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Alexander E. Sherman
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Rajan Saggar
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
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Piccari L, Bernardo RJ, Rodríguez-Chiaradía D, Vitulo P, Wort SJ, Sahay S. Pulmonary vasodilator treatment in pulmonary hypertension due to left heart or lung disease: time for a high-definition picture? Pulm Circ 2021; 11:20458940211018074. [PMID: 34104424 PMCID: PMC8165840 DOI: 10.1177/20458940211018074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lucilla Piccari
- Department of Pulmonary Medicine, Hospital del Mar, Barcelona, Spain
| | - Roberto J. Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Diego Rodríguez-Chiaradía
- Department of Pulmonary Medicine, Hospital del Mar, Barcelona, Spain
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain
- University Pompeu Fabra, Barcelona, Spain
| | - Patrizio Vitulo
- Department of Pulmonary Medicine, IRCCS Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
- Italian Pulmonary Hypertension Network, IPHNET, Rome, Italy
| | - S. John Wort
- Department of Pulmonary Medicine, National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Sandeep Sahay
- Weill Cornell Medicine, New York, NY, USA
- Division of Pulmonary Critical Care and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
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270
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Pulmonary hypertension in fibrosing idiopathic interstitial pneumonia: Uncertainties, challenges and opportunities. J Heart Lung Transplant 2021; 40:872-881. [PMID: 33832831 DOI: 10.1016/j.healun.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/14/2021] [Accepted: 03/02/2021] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is a serious complication of chronic fibrosing idiopathic interstitial pneumonia (PH-fIIP) leading to greater morbidity and mortality. The pathophysiologic basis for PH in fIIP is not completely understood, but microvascular rarefaction may play a key role. Severe hypoxemia and reduced diffusion capacity are characteristic. Doppler echocardiography has limited diagnostic utility and right heart catheterization is required to confirm the diagnosis. Lung volumes can be minimally affected, and radiographic findings can be subtle, making the distinction from pulmonary arterial hypertension challenging. Several randomized controlled trials of pulmonary arterial hypertension targeted therapies have recently been completed. Endothelin-receptor antagonists have shown either no benefit or harm. Sildenafil may have some favorable short-term effects but does not appear to impact long-term outcomes. Riociguat treatment increased hospitalizations and mortality. A recent trial of inhaled treprostinil demonstrated improved exercise capacity, but the impact on long-term morbidity and mortality are unknown. Currently, the only viable option for improved survival is lung transplantation. Early referral is imperative to optimize post-transplant outcomes.
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271
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Chapman RW, Corboz MR, Malinin VS, Plaunt AJ, Konicek DM, Li Z, Perkins WR. An overview of the biology of a long-acting inhaled treprostinil prodrug. Pulm Pharmacol Ther 2021; 65:102002. [PMID: 33596473 DOI: 10.1016/j.pupt.2021.102002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 01/01/2023]
Abstract
Treprostinil (TRE) is a prostanoid analog pulmonary vasodilator drug marketed with subcutaneous, intravenous (i.v.), oral, and inhaled routes of administration for the treatment of pulmonary arterial hypertension (PAH). Due to its short half-life, TRE requires either continuous infusion or multiple dosing, which exacerbates its side effects. Therefore, a long-acting prostanoid analog that maintains the positive attributes of TRE but has fewer TRE-related side effects could be of clinical benefit. In this report, we describe the discovery, preclinical development, and biology of the TRE ester prodrug, treprostinil palmitil (TP), which is formulated in a lipid nanoparticle (LNP) for administration as a nebulized inhaled suspension (TPIS). In screening assays focused on the conversion of prodrug to TRE, TP (16 carbon alkyl chain) had the slowest rate of conversion compared with short-alkyl chain TRE prodrugs (i.e., 2-8 carbon alkyl chain). Furthermore, TP is a pure prodrug and possesses no inherent binding to G-protein coupled receptors including prostanoid receptors. Pharmacokinetic studies in rats and dogs demonstrated that TPIS maintained relatively high concentrations of TP in the lungs yet had a low maximum plasma concentrations (Cmax) of both TP and, more importantly, the active product, TRE. Efficacy studies in rats and dogs demonstrated inhibition of pulmonary vasoconstriction induced by exposure to hypoxic air or i.v.-infused U46619 (thromboxane mimetic) over 24 h with TPIS. Cough was not observed with TPIS at an equivalent dose at which TRE caused cough in guinea pigs and dogs, and there was no evidence of desensitization to the inhibition of pulmonary vasoconstriction in rats with repeat inhaled dosing. TPIS was also more efficacious than i.v.-infused TRE in a sugen/hypoxia rat model of PAH to inhibit pulmonary vascular remodeling, an effect likely driven by local activities of TRE within the lungs. TPIS also demonstrated antifibrotic and anti-inflammatory activity in the lungs in rodent models of pulmonary fibrosis and asthma. In a phase 1 study in healthy human participants, TPIS (referred to as INS1009) had a lower plasma TRE Cmax and fewer respiratory-related side effects at equimolar doses compared with inhaled TRE. We have now formulated TP as an aerosol powder for delivery by a dry powder inhaler (referred to as treprostinil palmitil inhalation powder-TPIP), and as an aerosol solution in a fluorohydrocarbon solvent for delivery by a metered dose inhaler. These options may reduce drug administration time and involve less device maintenance compared with delivery by nebulization.
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Affiliation(s)
| | - Michel R Corboz
- Insmed Incorporated, 202/206 North, Bridgewater, NJ, 08807, USA
| | | | - Adam J Plaunt
- Insmed Incorporated, 202/206 North, Bridgewater, NJ, 08807, USA
| | - Donna M Konicek
- Insmed Incorporated, 202/206 North, Bridgewater, NJ, 08807, USA
| | - Zhili Li
- Insmed Incorporated, 202/206 North, Bridgewater, NJ, 08807, USA
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273
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Thomas CA, Lee J, Bernardo RJ, Anderson RJ, Glinskii V, Sung YK, Kudelko K, Hedlin H, Sweatt A, Kawut SM, Raj R, Zamanian RT, de Jesus Perez V. Prescription Patterns for Pulmonary Vasodilators in the Treatment of Pulmonary Hypertension Associated With Chronic Lung Diseases: Insights From a Clinician Survey. Front Med (Lausanne) 2021; 8:764815. [PMID: 34926507 PMCID: PMC8677825 DOI: 10.3389/fmed.2021.764815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Pulmonary hypertension is a complication of chronic lung diseases (PH-CLD) associated with significant morbidity and mortality. Management guidelines for PH-CLD emphasize the treatment of the underlying lung disease, but the role of PH-targeted therapy remains controversial. We hypothesized that treatment approaches for PH-CLD would be variable across physicians depending on the type of CLD and the severity of PH. Methods and Results: Between May and July 2020, we conducted an online survey of PH experts asking for their preferred treatment approach in seven hypothetical cases of PH-CLD of varying severity. We assessed agreement amongst clinicians for initial therapy choice using Fleiss' kappa calculations. Over 90% of respondents agreed that they would treat cases of severe PH in the context of mild lung disease with some form of PH-targeted therapy. For cases of severe PH in the context of severe lung disease, over 70% of respondents agreed to use PH-targeted therapy. For mild PH and mild lung disease cases, <50% of respondents chose to start PH-specific therapy. There was overall poor agreement between respondents in the choice to use mono-, double or triple combination therapy with PH-specific agents in all cases. Conclusion: Although management guidelines discourage the routine use of PH-targeted therapies to treat PH-CLD patients, most physicians choose to treat patients with some form of PH-targeted therapy. The choice of therapy and treatment approach are variable and appear to be influenced by the severity of the PH and the underlying lung disease.
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Affiliation(s)
- Christopher A Thomas
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Justin Lee
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Roberto J Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, Tulsa, OK, United States
| | - Ryan J Anderson
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Vladimir Glinskii
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Yon K Sung
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Kristina Kudelko
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Haley Hedlin
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Andrew Sweatt
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Steven M Kawut
- Pulmonary, Allergy and Critical Care Medicine Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Rishi Raj
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Roham T Zamanian
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
| | - Vinicio de Jesus Perez
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, United States
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