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Lu M, Baima YJ, Ni Z, Yang L, Zhang SS, Zhang YT. Advances in the potential of nebulized inhalation for the treatment of pulmonary arterial hypertension. Curr Probl Cardiol 2024; 49:102752. [PMID: 39059783 DOI: 10.1016/j.cpcardiol.2024.102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 07/11/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
Pulmonary hypertension is a pathophysiologic manifestation of a heterogeneous group of diseases, with the main pathophysiologic mechanisms being persistent pulmonary vasoconstriction and irreversible vascular remodeling. The impact significantly affects the prognosis of patients with pulmonary hypertension. If it is not treated and intervened in time, it may lead to right ventricular failure and further endanger the patient's life. Within the past decade or so, nebulized inhalation therapy is considered to have advantages in the treatment of pulmonary hypertension as a safe, limited, and rapid therapy, for example, inhaled vasodilators (prostate analogs, nitroglycerin, carbon monoxide analogs sildenafil, and nitroprusside), inhaled anti-inflammatory and antiproliferative agents (simvastatin, and selatinib), and inhaled peroxides (levocetirizine) have been recognized as emerging therapeutic approaches in the treatment of pulmonary hypertension as emerging therapeutic approaches. Therefore, this article provides a brief review of recent advances in the potential of nebulized inhaled vasodilators, anti-inflammatory and antiproliferative agents, and anti-peroxides for the treatment of pulmonary hypertension, with the aim of providing different therapeutic options for the treatment of pulmonary hypertension, enhancing the quality of survival, alleviating symptoms, and improving the prognosis of patients with this condition.
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Affiliation(s)
- Miao Lu
- Tibet University Medical College, Lhasa, Tibet Autonomous Region 850000, China; Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Yang-Jin Baima
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Zhu Ni
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Li Yang
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Song-Shan Zhang
- Tibet University Medical College, Lhasa, Tibet Autonomous Region 850000, China; Department of External Medicine, Tibet Autonomous Region People's Hospital, Lhasa, Tibet Autonomous Region 850000, China
| | - Yun-Tao Zhang
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China.
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Maslow A, Joyce MF, Chen TH, Gorgone M, Dinardo J. Hypoxemia After Percutaneous Mitral Valve Replacement: Management. J Cardiothorac Vasc Anesth 2018. [PMID: 29526445 DOI: 10.1053/j.jvca.2018.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
| | - Maurice F Joyce
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Tzong-Huei Chen
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - James Dinardo
- Department of Anesthesiology, Children's Hospital, Boston, MA
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Pentaerythritol Tetranitrate In Vivo Treatment Improves Oxidative Stress and Vascular Dysfunction by Suppression of Endothelin-1 Signaling in Monocrotaline-Induced Pulmonary Hypertension. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:4353462. [PMID: 28337251 PMCID: PMC5350298 DOI: 10.1155/2017/4353462] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Academic Contribution Register] [Received: 11/21/2016] [Accepted: 01/19/2017] [Indexed: 11/18/2022]
Abstract
Objective. Oxidative stress and endothelial dysfunction contribute to pulmonary arterial hypertension (PAH). The role of the nitrovasodilator pentaerythritol tetranitrate (PETN) on endothelial function and oxidative stress in PAH has not yet been defined. Methods and Results. PAH was induced by monocrotaline (MCT, i.v.) in Wistar rats. Low (30 mg/kg; MCT30), middle (40 mg/kg; MCT40), or high (60 mg/kg; MCT60) dose of MCT for 14, 28, and 42 d was used. MCT induced endothelial dysfunction, pulmonary vascular wall thickening, and fibrosis, as well as protein tyrosine nitration. Pulmonary arterial pressure and heart/body and lung/body weight ratio were increased in MCT40 rats (28 d) and reduced by oral PETN (10 mg/kg, 24 d) therapy. Oxidative stress in the vascular wall, in the heart, and in whole blood as well as vascular endothelin-1 signaling was increased in MCT40-treated rats and normalized by PETN therapy, likely by upregulation of heme oxygenase-1 (HO-1). PETN therapy improved endothelium-dependent relaxation in pulmonary arteries and inhibited endothelin-1-induced oxidative burst in whole blood and the expression of adhesion molecule (ICAM-1) in endothelial cells. Conclusion. MCT-induced PAH impairs endothelial function (aorta and pulmonary arteries) and increases oxidative stress whereas PETN markedly attenuates these adverse effects. Thus, PETN therapy improves pulmonary hypertension beyond its known cardiac preload reducing ability.
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Singh R, Choudhury M, Saxena A, Kapoor PM, Juneja R, Kiran U. Inhaled Nitroglycerin Versus Inhaled Milrinone in Children with Congenital Heart Disease Suffering from Pulmonary Artery Hypertension. J Cardiothorac Vasc Anesth 2010; 24:797-801. [DOI: 10.1053/j.jvca.2009.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 08/09/2009] [Indexed: 11/11/2022]
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Abstract
A review of nitrate therapy including a short summary of their physiological effects is presented. Both cardiac and non-cardiac indications are reviewed including esophageal spasm, spasm of bile ducts and urinary tract, Raynaud's disease, pulmonary hypertensive disorders, portal hypertension, bronchial asthma, and effect on arrhythmias.
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Wang H, Tang Y, Zhang YL. Hypoxic pulmonary hypertension (HPH) and iptakalim, a novel ATP-sensitive potassium channel opener targeting smaller arteries in hypertension. ACTA ACUST UNITED AC 2006; 23:293-316. [PMID: 16614730 DOI: 10.1111/j.1527-3466.2005.tb00174.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/29/2022]
Abstract
Hypoxic pulmonary hypertension (HPH) is a serious and potentially devastating chronic disorder of the pulmonary circulation. Attempts to use drugs in the therapy of hypoxic pulmonary hypertension indicated the importance of prevention or reduction of vasoconstriction as well as of the reversal of remodeling within the cardiovascular system. Iptakalim (2,3-dimethyl-N-(1-methylethyl)-2-butylamine), a novel ATP-sensitive potassium channel opener, has the desired effects on hypoxic pulmonary arteries. Iptakalim decreases the elevated mean pressure in pulmonary arteries, and attenuates remodeling in the right ventricle, pulmonary arteries and airways. Moreover, iptakalim has selective antihypertensive effects: it significantly lowers arterial pressure in hypertensive animals, but has little if any effect in normotensive animals. In HPH iptakalim has selective effects on smaller arteries. Long-term iptakalim therapy decreases expression of sulfonylurea receptor 2 and of mRNA of inwardly rectifying potassium channel in smaller arteries of spontaneously hypertensive rats. Iptakalim inhibits the effects of endothelin-1, reduces the intracellular calcium concentration and inhibits the cell cycle in smooth muscle cells of pulmonary arteries. There is no evidence for the development of tolerance to the long-lasting antihypertensive action of iptakalim. At therapeutic doses iptakalim has no effects on the central nervous, respiratory, digestive, or endocrine systems. It has a broad therapeutic range, so that it can be safely used in the therapy of HPH.
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Affiliation(s)
- Hai Wang
- Department of Cardiovascular Pharmacology, Beijing Institute of Pharmacology and Toxicology, 27 Taiping Road, Beijing 100850, Peoples' Republic of China.
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Goyal P, Kiran U, Chauhan S, Juneja R, Choudhary M. Efficacy of nitroglycerin inhalation in reducing pulmonary arterial hypertension in children with congenital heart disease. Br J Anaesth 2006; 97:208-14. [PMID: 16707530 DOI: 10.1093/bja/ael112] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There has been a renewed interest in nitric oxide donor drugs, such as nitroglycerin, delivered by the inhalational route for treatment of pulmonary arterial hypertension (PAH). We investigated the acute effects of inhaled nitroglycerin on pulmonary and systemic haemodynamics in children with PAH associated with congenital heart disease. METHODS Nineteen children with acyanotic congenital heart disease and a left to right shunt with severe PAH, undergoing routine diagnostic cardiac catheterization were included in this study. Systolic, diastolic and mean systemic as well as pulmonary artery pressures, right atrial pressure and pulmonary capillary wedge pressure (PCWP) were recorded and systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI) were calculated at room air, following 100% oxygen as well as after nitroglycerin inhalation in all patients. RESULTS Systolic, diastolic and mean pulmonary artery pressure and PVRI decreased significantly, whereas heart rate, systolic, diastolic and mean systemic arterial pressure, PCWP and SVRI did not change significantly following 100% oxygen or inhalation of nitroglycerin. CONCLUSION Inhaled nitroglycerin significantly decreases systolic, diastolic and mean pulmonary artery pressure as well as PVRI without affecting systemic haemodynamics, and thus can be used as a therapeutic modality for acute reduction of PAH in children with congenital heart disease.
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Affiliation(s)
- P Goyal
- Department of Cardiac Anaesthesiology, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi 110029, India.
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Das T, Basu R, Dixit MD, Shetty DP, Muralidhar K. Pulmonary Hypertensive Crisis following Pediatric Cardiac Surgery. Asian Cardiovasc Thorac Ann 1996. [DOI: 10.1177/021849239600400410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/15/2022]
Abstract
In this clinical study, 146 high risk neonates and infants of less than 5 years of age were monitored to identify and characterize pulmonary hypertensive crises following surgery for congenital heart defects. Monitoring included pulse oximetry and catheter measurements of pulmonary arterial and left atrial pressure. Fifty-one patients had one or more hypertensive crises, from which 11 ultimately died and 40 survived with aggressive vasodilator therapy. Each crisis was associated with a stress event. Crises were difficult to attenuate if not treated rapidly and multiple crises would often follow an initial event. Phenoxybenzamine, oxygen, and nitrates were the most frequently used vasodilators. Postoperative management must be individualized on the basis of the monitored response of the pulmonary circulation.
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Affiliation(s)
| | | | | | - Devi Prasad Shetty
- Department of Cardiac Surgery B.M. Birla Heart Research Centre Calcutta, India
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Pogorzelska H, Korewicki J, Zieliński T, Rajecka A, Biederman A. Prognostic significance of changes in the compliance of the pulmonary venous system after isosorbiddinitrate in patients with mitral stenosis. Int J Cardiol 1995; 49:9-15. [PMID: 7607772 DOI: 10.1016/0167-5273(94)02268-n] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/26/2023]
Abstract
It is agreed that a stiff pulmonary venous bed can cause severe pulmonary hypertension. This condition can also influence the clinical and hemodynamic outcome of mitral valve replacement (MVR). This study has been aimed at assessing whether changes in the pulmonary venous compliance (PVcomp) after application of isosorbiddinitrate (ISDN) can be of prognostic value in patients 6 months after MVR. PVcomp was calculated according to the Hirakawa equation in 34 patients with isolated mitral stenosis (MS) before and after ISDN. In 19 patients (group I) there was an increase of PVcomp by more than 15% (5.3 vs. 8.1 ml/mmHg), while 15 patients (group II) showed no differences in PVcomp after ISDN, despite the significant decrease in PAP and PWP in both groups (measured with the use of Swan-Ganz thermodilution catheters). Six months after MVR a significant decrease in PAP, PWP, PVR and an increase in SVI was observed in both groups during rest. During effort (25 W), significant increases in PAP and PWP were recorded in most of patients from the group II, as opposed to group I. It is concluded that significant increase in PVcomp after ISDN in patients with MS can be a prognostic of good clinical results 6 months after MVR.
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Affiliation(s)
- H Pogorzelska
- 2nd Department of Heart Valve Disease, National Institute of Cardiology
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Haider W, Zwölfer W, Hiesmayr M, Mares P, Keznickl P, Heilinger D, Coraim F, Gabriel A, Grubhofer G, Hrska F. Improved cardiac performance and reduced pulmonary vascular constriction by epinephrine administration via a left atrial catheter in cardiac surgical patients. J Cardiothorac Vasc Anesth 1993; 7:684-7. [PMID: 8305658 DOI: 10.1016/1053-0770(93)90053-n] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/29/2023]
Abstract
Diminished left ventricular contractility and increased right ventricular afterload are issues in cardiac surgery. The usual administration of catecholamines (epinephrine) via the central venous (CV) catheter increases cardiac output, but also may increase pulmonary vascular constriction. Epinephrine was, therefore, administered via the left atrial (LA) catheter or the CV catheter in 8 cardiac surgery patients, each serving as his or her own control. The LA administration of epinephrine has an advantage with its immediate effect on the coronary circulation, while avoiding associated pulmonary vasoconstriction by passing through the systemic capillary bed before reaching the lung. It was found in this study that administration of epinephrine via an LA catheter increased the average cardiac output by 1.05 L/min, which was significantly (P < 0.05) greater than with administration via the CV catheter. With LA administration of epinephrine, systemic arterial pressure (systolic arterial pressure and diastolic arterial pressure) (SAP, DAP) were also elevated to a greater extent than by CV administration. On the other hand, pulmonary arterial pressures (systolic pulmonary arterial pressure and diastolic pulmonary arterial pressure) (SPAP, DPAP) were less elevated than by administration via the CV catheter. This produced increased coronary perfusion and a smaller increase in pulmonary vascular tone by LA administration in contrast to CV administration of epinephrine. It is concluded that epinephrine administration via an LA catheter improved myocardial performance and pulmonary perfusion due to direct entry of the agent into the coronary circulation and partial metabolism while passing through the systemic capillary bed before reaching the lung.
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Affiliation(s)
- W Haider
- Department of Cardiothoracic Anesthesia and Intensive Care, Clinic of Anesthesia, University of Vienna, Austria
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Abstract
Patients with primary pulmonary hypertension occasionally present for surgery. Anaesthesia requires continuous cardiovascular monitoring and maintenance of stable pulmonary and systemic haemodynamics. The management of a patient with severe pulmonary hypertension, undergoing open lung biopsy under a combination of general anaesthesia and thoracic epidural analgesia is reported and the problems of primary pulmonary hypertension are discussed.
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Affiliation(s)
- P Armstrong
- Department of Anaesthesia, Royal Infirmary of Edinburgh
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Halperin JL, Rothlauf EB, Brooks KM, Mindich BP, Ambrose JA. Effect of nitroglycerin during hemodynamic estimation of valve orifice in patients with mitral stenosis. J Am Coll Cardiol 1987; 10:342-8. [PMID: 3110239 DOI: 10.1016/s0735-1097(87)80017-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/04/2023]
Abstract
In patients with mitral stenosis, valve orifice calculations using pulmonary capillary wedge pressure as a substitute for left atrial pressure may overestimate the severity of disease. Previous studies have shown that mitral valve area determined from transseptal left atrial pressure measurements exceeds that area derived from pulmonary wedge pressure measurements. This is probably due to pulmonary venoconstriction, which is reversed by nitroglycerin. Nitroglycerin, 0.4 mg, was administered sublingually to 20 patients with mitral valve disease during preoperative cardiac catheterization using the pulmonary capillary wedge pressure as the proximal hydraulic variable. At the time of a peak hypotensive effect, 3 to 5 minutes after nitroglycerin administration, the mean pulmonary capillary wedge pressure decreased from 23 +/- 2 (mean +/- SEM) to 19 +/- 2 mm Hg (p less than 0.005). The mean diastolic transmitral pressure gradient (12.6 +/- 1.2 mm Hg before and 11.5 +/- 1.0 mm Hg after nitroglycerin; p = NS) and cardiac output (4.0 +/- 0.3 to 4.1 +/- 0.3 liters/min; p = NS) did not change significantly. Nevertheless, the hemodynamic mitral orifice area, calculated using the Gorlin formula, increased from 0.8 +/- 0.1 to 1.1 +/- 0.2 cm2 (p less than 0.05). In 12 patients with isolated mitral stenosis, without regurgitation, the mitral valve orifice area after nitroglycerin was 0.4 +/- 0.2 cm2 larger than it was before drug administration (p less than 0.05). Administration of nitroglycerin during evaluation of mitral stenosis eliminates pulmonary venoconstriction, which raises the pulmonary capillary wedge pressure above the left atrial pressure in some patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Abstract
Anomalous pulmonary venous connection is a congenital defect which may first be diagnosed in the adult who has developed lung disease or pulmonary vascular obstructive disease. Surgical repair may be inadvisable in such a case. To date, little attention has been paid in the literature to medical management. A case is presented in which medical palliation with nitrate therapy was successful.
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Packer M. Mechanisms of nitrate action in patients with severe left ventricular failure: conceptual problems with the theory of venosequestration. Am Heart J 1985; 110:259-64. [PMID: 3925745 DOI: 10.1016/0002-8703(85)90497-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/08/2023]
Abstract
Nitroglycerin and other organic nitrates exert a number of favorable effects on the circulation of patients with severe congestive heart failure, and these effects mediate the short- and long-term hemodynamic and clinical improvement that follows treatment with these drugs. Although these agents are potent dilators of systemic venous capacitance vessels, present evidence indicates that they do not exert their beneficial hemodynamic and clinical effects by decreasing venous return to the heart. Rather, their ability to dilate pulmonary and systemic resistance vessels offsets any decrease in cardiac output that might be expected to occur from a decrease in venous return. Of equal importance, the increase in output of the left side of the heart that results from drug-induced pulmonary and systemic vasodilation prevents any decrease in venous return to the right side of the heart that might be expected to accompany an increase in systemic venous capacitance. The net effect of these two interacting forces is not only to keep cardiac output and venous return constant but also to translocate blood volume from the pulmonary circulation and left ventricle to the systemic vessels. In addition, nitrates also relieve subendocardial ischemia and favorably alter pressure-volume relationships in the left ventricle. These observations support the conclusion that the complex cardiovascular responses to organic nitrates in patients with congestive heart failure cannot be adequately summarized by the single concept of preload reduction.
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