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Zamanian RT, Weatherald J, Sweatt AJ, Hemnes A, Rashid M, Psotka MA, Bogaard HJ, de Jesus Perez V. Constructing the Framework for Disease Modification in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2024; 209:1189-1195. [PMID: 38471030 PMCID: PMC11146536 DOI: 10.1164/rccm.202401-0089pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/12/2024] [Indexed: 03/14/2024] Open
Affiliation(s)
- Roham T. Zamanian
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
| | - Anna Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Moira Rashid
- Planned Parenthood of Orange and San Bernandino Counties, California
| | - Mitchell A. Psotka
- U.S. Food and Drug Administration, Silver Spring, Maryland
- Inova Schar Heart and Vascular, Falls Church, Virginia; and
| | - Harm J. Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Vinicio de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
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2
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Weatherald J, Sitbon O. POINT: Should the Use of Upfront Triple Combination Therapy Be Standard of Care in Pulmonary Arterial Hypertension? Yes. Chest 2024; 165:492-494. [PMID: 38461011 DOI: 10.1016/j.chest.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine University of Alberta, Edmonton, AB, Canada
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
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Grünig E, Jansa P, Fan F, Hauser JA, Pannaux M, Morganti A, Rofael H, Chin KM. Randomized Trial of Macitentan/Tadalafil Single-Tablet Combination Therapy for Pulmonary Arterial Hypertension. J Am Coll Cardiol 2024; 83:473-484. [PMID: 38267108 DOI: 10.1016/j.jacc.2023.10.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Endothelin receptor antagonist (ERA) and phosphodiesterase 5 inhibitor (PDE5i) combination therapy is recommended for low-/intermediate-risk pulmonary arterial hypertension (PAH) patients. A fixed-dose combination of the ERA macitentan and PDE5i tadalafil (M/T FDC) in a once-daily, single tablet would simplify treatment. OBJECTIVES The multicenter, double-blind, adaptive phase 3 A DUE study investigated the efficacy and safety of M/T FDC vs macitentan 10 mg and vs tadalafil 40 mg monotherapies in PAH patients, including treatment-naïve and prior ERA or PDE5i monotherapy-treated patients. METHODS World Health Organization functional class II-III patients were randomized to M/T FDC, macitentan, or tadalafil depending on their PAH treatment (treatment-naïve, ERA, or PDE5i monotherapy) at baseline. The primary endpoint was change in pulmonary vascular resistance (PVR) at week 16. RESULTS In total, 187 patients were randomized to single-tablet M/T FDC (n = 108), macitentan (n = 35), or tadalafil (n = 44). PVR reduction with M/T FDC was significantly greater vs macitentan (29%; geometric mean ratio 0.71; 95% CL: 0.61-0.82; P < 0.0001) and vs tadalafil (28%; geometric mean ratio 0.72; 95% CL: 0.64-0.80; P < 0.0001). Three patients died in the M/T FDC arm (judged unrelated to treatment). Adverse events (AEs) leading to discontinuation, serious AEs, and those of special interest (anemia, hypotension, and edema) were more frequent with M/T FDC. CONCLUSIONS Macitentan and tadalafil FDC significantly improved PVR vs monotherapies in PAH patients, with a safety and tolerability profile consistent with the individual components. The A DUE study supports M/T FDC as a once-daily, single-tablet combination for initial therapy and escalation to double combination therapy in patients with PAH. (Clinical Study to Compare the Efficacy and Safety of Macitentan and Tadalafil Monotherapies With the Corresponding Fixed-dose Combination Therapy in Subjects With Pulmonary Arterial Hypertension [PAH]) [A DUE]; NCT03904693).
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Affiliation(s)
- Ekkehard Grünig
- Thoraxklinik at Heidelberg University Hospital and Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany
| | - Pavel Jansa
- Charles University and General University Hospital, Prague, Czech Republic
| | - Fenling Fan
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jakob A Hauser
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Clinical Science, Allschwil, Switzerland
| | | | - Adele Morganti
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Statistical Decision Science, Allschwil, Switzerland
| | - Hany Rofael
- Janssen Research and Development, LLC, Clinical Science, Titusville, New Jersey, USA
| | - Kelly M Chin
- UT Southwestern Medical Center, Dallas, Texas, USA.
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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5
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Zhao Q, Chen J, Chen F, Ruan H, Zhang W, Zhou Y, Wang Q, Xu X, Feng K, Guo J, Gong S, Zhang R, Wang L. Evaluating the efficacy and safety of oral triple sequential combination therapy for treating patients with pulmonary arterial hypertension: A multicenter retrospective study. Pulm Circ 2024; 14:e12351. [PMID: 38468630 PMCID: PMC10925724 DOI: 10.1002/pul2.12351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/11/2023] [Accepted: 02/20/2024] [Indexed: 03/13/2024] Open
Abstract
This study aimed to evaluate the effectiveness and safety of an oral sequential triple combination therapy with selexipag after dual combination therapy with endothelin receptor antagonist (ERA) and phosphodiesterase-5 inhibitor (PDE5I)/riociguat in pulmonary arterial hypertension (PAH) patients. A total of 192 PAH patients from 10 centers had received oral sequential selexipag therapy after being on dual-combination therapy with ERA and PDE5i/riociguat for a minimum of 3 months. Clinical data were collected at baseline and after 6 months of treatment. The study analyzed the event-free survival at 6 months and all-cause death over 2 years. At baseline, the distribution of patients among the risk groups was as follows: 22 in the low-risk group, 35 in the intermediate-low-risk group, 91 in the intermediate-high-risk group, and 44 in the high-risk group. After 6 months of treatment, the oral sequential triple combination therapy resulted in reduced NT-proBNP levels (media from 1604 to 678 pg/mL), a decline in the percentage of WHO-FC III/IV (from 79.2% to 60.4%), an increased in the 6MWD (from 325 ± 147 to 378 ± 143 m) and a rise in the percentage of patients with three low-risk criteria (from 5.7% to 13.5%). Among the low-risk group, there was an improvement in the right heart remodeling, marked by a decrease in right atrium area and eccentricity index. The intermediate-low-risk group exhibited significant enhancements in WHO-FC and tricuspid annular plane systolic excursion. For those in the intermediate-high and high-risk groups, there were marked improvements in activity tolerance, as reflected by WHO-FC and 6MWD. The event-free survival rate at 6 months stood at 88%. Over the long-term follow-up, the survival rates at 1 and 2 years were 86.5% and 86.0%, respectively. In conclusion, the oral sequential triple combination therapy enhanced both exercise capacity and cardiac remodeling across PAH patients of different risk stratifications.
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Affiliation(s)
- Qin‐Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary HospitalTongji University School of MedicineShanghaiChina
| | - Jun Chen
- Department of CardiologyXiamen Hospital of Traditional Chinese MedicineFujianChina
| | - Fa‐Dong Chen
- Department of Cardiology, Tongji HospitalTongji University School of MedicineShanghaiChina
| | - Hong‐Yun Ruan
- Department of CardiologyXuzhou Central HospitalXuzhouChina
| | - Wei Zhang
- Department of Rheumatology, Renji HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Yan‐Li Zhou
- Department of CardiologyFirst Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Qi‐Qi Wang
- Department of Cardiology and Atrial Fibrillation Center, The First Affiliated Hospital College of MedicineZhejiang UniversityHangzhouZhejiangChina
| | - Xiao‐Ling Xu
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
| | - Ke‐Fu Feng
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTCUniversity of Science and Technology of ChinaHefeiAnhuiChina
| | - Jian‐Zhou Guo
- Department of Cardiovascular Surgery, Fuwai Hospital Chinese Academy of Medical SciencesGuangdong ProvinceShenzhenChina
| | - Su‐Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary HospitalTongji University School of MedicineShanghaiChina
| | - Rui‐Feng Zhang
- Department of Respiratory MedicineZhongda Hospital of Southeast UniversityNanjingChina
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary HospitalTongji University School of MedicineShanghaiChina
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Farmakis IT, Baroutidou A, Patsiou V, Arvanitaki A, Doundoulakis I, Hobohm L, Zafeiropoulos S, Konstantinides SV, D'Alto M, Badagliacca R, Giannakoulas G. Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients. ERJ Open Res 2024; 10:00706-2023. [PMID: 38259812 PMCID: PMC10801731 DOI: 10.1183/23120541.00706-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.
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Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michele D'Alto
- Department of Cardiology, University “L. Vanvitelli”-Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Weatherald J, Varughese RA, Liu J, Humbert M. Management of Pulmonary Arterial Hypertension. Semin Respir Crit Care Med 2023; 44:746-761. [PMID: 37369218 DOI: 10.1055/s-0043-1770118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.
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Affiliation(s)
- Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rhea A Varughese
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jonathan Liu
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Hôpital Marie Lannelongue, Le Plessis Robinson, INSERM UMR_S 999, France
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Celant LR, Wessels JN, Kianzad A, Marcus JT, Meijboom LJ, Bogaard HJ, de Man FS, Vonk Noordegraaf A. Restoration of right ventricular function in the treatment of pulmonary arterial hypertension. Heart 2023; 109:1844-1850. [PMID: 37527919 DOI: 10.1136/heartjnl-2023-322742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE A 45% threshold of right ventricular ejection fraction (RVEF) is proposed clinically relevant in patients with pulmonary arterial hypertension (PAH). We aim to determine treatment response, long-term right ventricular (RV) functional stability and prognosis of patients with PAH reaching or maintaining the RVEF 45% threshold. METHODS Incident, treatment-naive, adult PAH patients with cardiac magnetic resonance imaging at baseline and first follow-up were included (total N=127) and followed until date of censoring or death/lung transplantation. Patients were categorised into two groups based on 45% RVEF. Baseline predictors, treatment response and prognosis were assessed with logistic regression analyses, two-way analysis of variance and log-rank tests. RESULTS Patients were 50±17 years old, 73% female, of which N=75 reached or maintained the 45% RVEF threshold at follow-up (RVEF≥45%@FU), while N=52 patients did not (RVEF<45%@FU). RV end-diastolic volume and N-terminal pro-B-type natriuretic peptide at baseline were multivariable predictors of an RVEF ≥45% at follow-up. A 40% pulmonary vascular resistance (PVR) reduction resulted in greater improvement in RV function (ΔRVEF 17±11 vs. 5±8; pinteraction<0.001) compared to a PVR reduction <40%, but did not guarantee an RVEF ≥45%. Finally, the 45% RVEF threshold was associated with stable RV function during long-term follow-up and better survival (HR: 1.91 (95% CI: 1.11 to 3.27)). Patients failing to reach or maintain the 45% RVEF threshold at first follow-up mostly stayed below this threshold over the next consecutive visits. CONCLUSION After treatment initiation, 60% of patients with PAH reach or maintain the 45% RVEF threshold, which is associated with a long-term stable RV function and favourable prognosis.
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Affiliation(s)
- Lucas R Celant
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jeroen N Wessels
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Azar Kianzad
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - J Tim Marcus
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
| | - Lilian J Meijboom
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Frances S de Man
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, location Vrije Universiteit, Amsterdam, Netherlands
- Pulmonary Hypertension and Thrombosis, Cardiovascular Sciences, Amsterdam, the Netherlands
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Liu H, Wang Y, Zhang Q, Liu C, Ma Y, Huang P, Ge R, Ma L. Macrophage-derived inflammation promotes pulmonary vascular remodeling in hypoxia-induced pulmonary arterial hypertension mice. Immunol Lett 2023; 263:113-122. [PMID: 37875238 DOI: 10.1016/j.imlet.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 10/26/2023]
Abstract
The role of inflammation in pulmonary hypertension is gradually gaining increasing research attention. However, no previous study has evaluated the characteristics of inflammation during chronic hypoxia-induced pulmonary hypertension. Therefore, the aim of this study was to investigate the characteristics of the inflammatory process involved in hypoxia-induced pulmonary hypertension in mice. The current study evaluated from day 4 to day 28 of hypoxia, the PAAT and PAAT/PET decreased, accompanied by pulmonary vascular remodeling and right ventricular hypertrophy, as well as increased numbers of CD68 macrophages. The expression of the pro-inflammatory factors IL-1β and IL-33 increased, but decreased on day 28. The expression of IL-12 increased from day 4 to day 28, whereas that of the anti-inflammatory factor IL-10 in lung tissue decreased. Furthermore, the expression of the IL-33/ST2 signaling pathway also increased over time under hypoxic conditions. In conclusion, pulmonary artery remodeling in HPH mice worsens progressively in a time-dependent manner, with inflammatory cell infiltration predominating in the early stage and pulmonary vascular remodeling occurring in the later stage.
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Affiliation(s)
- Hong Liu
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China
| | - Yuxiang Wang
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China
| | - Qingqing Zhang
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China; Affiliated Hospital of Qinghai University, Xining, QingHai, China
| | - Chuanchuan Liu
- Affiliated Hospital of Qinghai University, Xining, QingHai, China
| | - Yougang Ma
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China
| | - Pan Huang
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China
| | - Rili Ge
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China
| | - Lan Ma
- Research Center for High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of the Ministry of High Altitude Medicine, Qinghai university, Xining, Qinghai, China; Key Laboratory of Applied Fundamentals of High Altitude Medicine, (Qinghai-Utah Joint Key Laboratory of Plateau Medicine), Qinghai university, Xining, Qinghai, China; Laboratory for High Altitude Medicine of Qinghai Province, Qinghai university, Xining, Qinghai, China.
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10
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Klose H, Harbaum L, Richter MJ, Lichtblau M, Marra AM, Kabitz HJ, Harutyunova S, Milger-Kneidinger K, Lange TJ. [Targeted therapy for pulmonary arterial hypertension in patients without comorbidities]. Pneumologie 2023; 77:890-900. [PMID: 37963478 DOI: 10.1055/a-2145-4711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The 2022 guidelines on pulmonary hypertension from the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) provide therapeutic strategies that account for the variability in the clinical presentation of newly diagnosed patients. We summarize treatment recommendations for pulmonary arterial hypertension (PAH) in patients without significant comorbidities, particularly for idiopathic, hereditary, drug/toxin-induced, or connective tissue disease-associated PAH. In this group of patients, multidimensional assessments for short-term mortality risk guide initial treatment decisions and treatment decisions during follow-up. Upfront dual combination therapy (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) is recommended for low- and intermediate-risk patients, and triple therapy including a parenteral prostacyclin should be considered in high- or intermediate-high-risk patients. If a low or intermediate-low-risk profile cannot be achieved during therapy, sequential add-on therapy escalation with parenteral prostacyclin or a prostacyclin receptor agonist should be considered, and switching from a phosphodiesterase type-5 inhibitor to a guanylate cyclase stimulator may also be considered.
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Affiliation(s)
- Hans Klose
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Lars Harbaum
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, zzt. Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Mona Lichtblau
- Klinik für Pneumologie, Zentrum für Pulmonale Hypertonie, Universitätsspital Zürich, Zürich, Schweiz
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University of Naples, Napoli, Italy
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Aarau, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik an der Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Katrin Milger-Kneidinger
- Medizinische Klinik und Poliklinik V, Ludwig-Maximilians-Universität (LMU) Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Bad Reichenhall, Deutschland
- Fakultät für Medizin, Lehrstuhl für Innere Medizin II, Universität Regensburg, Regensburg, Deutschland
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11
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Papa S, Scoccia G, Serino G, Adamo FI, Jabbour JP, Caputo A, Boromei M, Filomena D, Laviola D, Maggio E, Manzi G, Mihai A, Recchioni T, Sabusco A, Valeri L, Vinciullo S, Vizza CD, Badagliacca R. Impact of Parenteral Prostanoids in Pulmonary Arterial Hypertension: The Relevance of Timing. J Clin Med 2023; 12:6840. [PMID: 37959305 PMCID: PMC10648828 DOI: 10.3390/jcm12216840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Parenteral prostanoids are being recommended in pulmonary arterial hypertension (PAH) treatment, but the prognostic relevance of delayed treatment initiation is still debated. This study assessed the impact of the timing of prostacyclin treatment initiation on reducing PVR and achieving a low-risk profile in PAH patients. The study enrolled 151 patients who started on parenteral prostanoids with different treatment strategies. All patients underwent right heart catheterization, clinical evaluation, and risk assessments at baseline and after 1-year follow-up. Patients with an upfront strategy including parenteral prostanoid plus one oral drug had -5.3 ± 6.2 WU (-50 ± 19%) reduction in PVR, patients with an upfront strategy including parenteral prostanoid plus double oral drug had -12.8 ± 5.9 WU (-68 ± 17%) reduction in PVR, while patients with an add-on strategy including parenteral prostanoid after oral drugs had -3.9 ± 3.5 WU (-23 ± 19%) reduction in PVR. An upfront strategy including parenteral prostanoids was independently associated with an increased likelihood of achieving the greater reduction of PVR compared with an add-on strategy. Additionally, the greater the severity of PH at the time of diagnosis, in terms of PVR and RV reverse remodeling, the higher the probability of treatment failure. An upfront strategy including a parenteral prostanoid is associated with the highest likelihood of achieving a low-risk profile and a greater reduction of PVR compared with parenteral prostanoid as an add-on to oral treatment.
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Affiliation(s)
- Silvia Papa
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Gianmarco Scoccia
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giorgia Serino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Francesca Ileana Adamo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Jean Pierre Jabbour
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Annalisa Caputo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Michela Boromei
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Filomena
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Laviola
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Enrico Maggio
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giovanna Manzi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Mihai
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Tommaso Recchioni
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Sabusco
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy;
| | - Livia Valeri
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Sara Vinciullo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Carmine Dario Vizza
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Roberto Badagliacca
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
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12
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Baszkowski F, Pelczar-Płachta W, Pempera N, Sławek-Szmyt S, Kałużna-Oleksy M, Lesiak M, Bobkowski W. Rapidly Progressive Idiopathic Pulmonary Arterial Hypertension in a Paediatric Patient Treated with Lung Transplantation. Diagnostics (Basel) 2023; 13:3185. [PMID: 37892005 PMCID: PMC10606216 DOI: 10.3390/diagnostics13203185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare heterogeneous disorder in the paediatric population which is mostly associated with congenital heart disease. The management of paediatric idiopathic PAH (IPAH) is difficult due to insufficient comparative data and depends on the results of evidence-based adult studies with several pulmonary vasodilators, as well as the clinical experiences of paediatric experts. Our aim was to present the case of a 9-year-old girl who underwent several methods of treatment, including pharmacotherapy with a significant reaction to treprostinil, as well as bilateral lung transplantation. The patient's treatment was distinguished by the fact that the dose escalation was as rapid as that observed in the adult population. Due to the limited current evidence and knowledge, the initiation of treatment for these patients remains an individual choice. On the grounds of the number of non-specific symptoms, the diagnosis of this patient was a long process and based mainly on the differential diagnosis. The purpose of this paper is to study this example in order to highlight the importance of early symptoms and the quick implementation of intensive treatment. The applied methods may be useful in doubtful diagnosis processes and treatment procedures in the paediatric population.
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Affiliation(s)
- Filip Baszkowski
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 60-572 Poznan, Poland
| | - Weronika Pelczar-Płachta
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 60-572 Poznan, Poland
| | - Nikola Pempera
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 60-572 Poznan, Poland
| | - Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Waldemar Bobkowski
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 60-572 Poznan, Poland
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13
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JG, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Wilson Tang W, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. Circ Heart Fail 2023; 16:e010555. [PMID: 37664964 PMCID: PMC10592283 DOI: 10.1161/circheartfailure.123.010555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RV functional recovery [RVFnRec]). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. METHODS We evaluated 63 incident patients with pulmonary arterial hypertension by right heart catheterization and cardiac magnetic resonance imaging at diagnosis and cardiac magnetic resonance imaging and invasive cardiopulmonary exercise testing following treatment (≈11 months). Sex, age, ethnicity matched healthy control subjects (n=62) with 1-time cardiac magnetic resonance imaging and noninvasive cardiopulmonary exercise testing were recruited from the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) project. We examined therapeutic cardiac magnetic resonance imaging changes relative to the evidence-based peak oxygen consumption (VO2peak)>15 mL/(kg·min) to define RVFnRec by receiver operating curve analysis. Afterload was measured as mean pulmonary artery pressure, resistance, compliance, and elastance. RESULTS A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (area under the curve, 0.87; P=0.0001) and neared upper 95% CI RV end-diastolic volume of controls. This cutoff was met by 22 out of 63 (35%) patients which was reinforced by freedom from clinical worsening, RVFnRec 1 out of 21 (5%) versus no RVFnRec 17 out of 42, 40% (log-rank P=0.006). A therapy-associated increase of 0.8 mL/mm Hg in compliance had the best predictive value of RVFnRec (area under the curve, 0.76; [95% CI, 0.64-0.88]; P=0.001). RVFnRec patients had greater increases in stroke volume, and cardiac output at exercise. CONCLUSIONS RVFnRec defined by RV end-diastolic volume therapeutic decrease of -15 mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise.
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Affiliation(s)
- Franz P. Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Roberto J. Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | | | - Tushar Acharya
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | | | | | - Michael Insel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Saad Kubba
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | - A Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
| | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic
| | | | | | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Erika B. Rosenzweig
- Department of Pediatrics and Medicine, Columbia University, Vegelos College of Physicians and Surgeons
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14
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Price LC, McCabe C, Weatherald J. Reducing the pressure in pulmonary arterial hypertension: sotatercept, haemodynamics and the right ventricle. Eur Respir J 2023; 62:2301513. [PMID: 37696566 DOI: 10.1183/13993003.01513-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
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15
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Tello K, Naeije R, de Man F, Guazzi M. Pathophysiology of the right ventricle in health and disease: an update. Cardiovasc Res 2023; 119:1891-1904. [PMID: 37463510 DOI: 10.1093/cvr/cvad108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Abstract
The contribution of the right ventricle (RV) to cardiac output is negligible in normal resting conditions when pressures in the pulmonary circulation are low. However, the RV becomes relevant in healthy subjects during exercise and definitely so in patients with increased pulmonary artery pressures both at rest and during exercise. The adaptation of RV function to loading rests basically on an increased contractility. This is assessed by RV end-systolic elastance (Ees) to match afterload assessed by arterial elastance (Ea). The system has reserve as the Ees/Ea ratio or its imaging surrogate ejection fraction has to decrease by more than half, before the RV undergoes an increase in dimensions with eventual increase in filling pressures and systemic congestion. RV-arterial uncoupling is accompanied by an increase in diastolic elastance. Measurements of RV systolic function but also of diastolic function predict outcome in any cause pulmonary hypertension and heart failure with or without preserved left ventricular ejection fraction. Pathobiological changes in the overloaded RV include a combination of myocardial fibre hypertrophy, fibrosis and capillary rarefaction, a titin phosphorylation-related displacement of myofibril tension-length relationships to higher pressures, a metabolic shift from mitochondrial free fatty acid oxidation to cytoplasmic glycolysis, toxic lipid accumulation, and activation of apoptotic and inflammatory signalling pathways. Treatment of RV failure rests on the relief of excessive loading.
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Affiliation(s)
- Khodr Tello
- Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Naeije
- Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Frances de Man
- Pulmonary Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marco Guazzi
- Cardiology Division, San Paolo University Hospital, University of Milano, Milano, Italy
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16
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Caputo A, Papa S, Manzi G, Laviola D, Recchioni T, Severino P, Lavalle C, Maestrini V, Mancone M, Badagliacca R, Vizza CD. Medical Management of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. Curr Heart Fail Rep 2023; 20:263-270. [PMID: 37486563 PMCID: PMC10421820 DOI: 10.1007/s11897-023-00612-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to overview the most relevant and recent knowledge regarding medical management in pulmonary arterial hypertension (PAH). RECENT FINDINGS Evidence has shown that PAH patients' quality of life and prognosis depend on the capability of the RV to adapt to increased afterload and to fully recover in response to substantially reduced pulmonary vascular resistance obtained with medical therapy. Data from recent clinical studies show that more aggressive treatment strategies, especially in higher risk categories, determine larger afterload reductions, consequentially increasing the probability of achieving right heart reverse remodeling, therefore improving the patients' survival and quality of life. Remarkable progress has been observed over the past decades in the medical treatment of PAH, related to the development of drugs that target multiple biological pathways, strategies for earlier and more aggressive treatment interventions. New hopes for treatment of patients who are unable to achieve low-risk status have been derived from the phase 2 trial PULSAR and the phase 3 trial STELLAR, which show improvement in the hemodynamic status of patients treated with sotatercept on top of background therapy. Promising results are expected from several ongoing clinical trials targeting new pathways involved in the pathophysiology of PAH.
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Affiliation(s)
- Annalisa Caputo
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy.
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Domenico Laviola
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Tommaso Recchioni
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Severino
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
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17
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Doyle M, Rayarao G, Biederman RWW. The sine transform is the sine qua non of the pulmonary and systemic pressure relationship. Front Cardiovasc Med 2023; 10:1120330. [PMID: 37304951 PMCID: PMC10250723 DOI: 10.3389/fcvm.2023.1120330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.
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Affiliation(s)
- Mark Doyle
- Department Cardiology, Cardiovascular MRI, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, United States
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18
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Jin Q, Chen D, Zhang X, Zhang F, Zhong D, Lin D, Guan L, Pan W, Zhou D, Ge J. Medical Management of Pulmonary Arterial Hypertension: Current Approaches and Investigational Drugs. Pharmaceutics 2023; 15:1579. [PMID: 37376028 DOI: 10.3390/pharmaceutics15061579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a malignant pulmonary vascular syndrome characterized by a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, which eventually leads to right heart failure and even death. Although the exact mechanism of PAH is not fully understood, pulmonary vasoconstriction, vascular remodeling, immune and inflammatory responses, and thrombosis are thought to be involved in the development and progression of PAH. In the era of non-targeted agents, PAH had a very dismal prognosis with a median survival time of only 2.8 years. With the deep understanding of the pathophysiological mechanism of PAH as well as advances in drug research, PAH-specific therapeutic drugs have developed rapidly in the past 30 years, but they primarily focus on the three classical signaling pathways, namely the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. These drugs dramatically improved pulmonary hemodynamics, cardiac function, exercise tolerance, quality of life, and prognosis in PAH patients, but could only reduce pulmonary arterial pressure and right ventricular afterload to a limited extent. Current targeted agents delay the progression of PAH but cannot fundamentally reverse pulmonary vascular remodeling. Through unremitting efforts, new therapeutic drugs such as sotatercept have emerged, injecting new vitality into this field. This review comprehensively summarizes the general treatments for PAH, including inotropes and vasopressors, diuretics, anticoagulants, general vasodilators, and anemia management. Additionally, this review elaborates the pharmacological properties and recent research progress of twelve specific drugs targeting three classical signaling pathways, as well as dual-, sequential triple-, and initial triple-therapy strategies based on the aforementioned targeted agents. More crucially, the search for novel therapeutic targets for PAH has never stopped, with great progress in recent years, and this review outlines the potential PAH therapeutic agents currently in the exploratory stage to provide new directions for the treatment of PAH and improve the long-term prognosis of PAH patients.
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Affiliation(s)
- Qi Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Dandan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai 201508, China
| | - Dongxiang Zhong
- Department of Cardiology, Shanghai East Hospital, Shanghai Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China
| | - Dawei Lin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Lihua Guan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
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Karyofyllis P, Demerouti E, Habibis P, Apostolopoulou S, Tsetika EG, Tsiapras D. Should We Change the Target of Therapy in Pulmonary Hypertension? Life (Basel) 2023; 13:1202. [PMID: 37240847 PMCID: PMC10221333 DOI: 10.3390/life13051202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Despite the evolution of drug therapy in pulmonary arterial hypertension and the more aggressive treatment approach according to the guidelines, patients continue to have unacceptable mortality rates. Furthermore, specific drug therapy alone in chronic thromboembolic pulmonary hypertension also does not seem to have any beneficial impact on survival. As the function of the right ventricle (RV) determines the prognosis of patients with pulmonary hypertension, the treatment strategy should focus on modifying factors involved in RV dysfunction. Although some previous reports demonstrated that the survival of patients with pulmonary hypertension was associated with mPAP, nevertheless, mPAP is still not considered as a target of therapy. There are many examples of effective mPAP lowering with early and aggressive drug therapy in pulmonary arterial hypertension, or with interventions in chronic thromboembolic pulmonary hypertension. This effective mPAP reduction can lead to reverse RV remodeling, and thus, improvement in survival. In this article, the importance of mPAP lowering is stated, as well as why the change of our current strategy and considering mPAP reduction as the target of therapy could make pulmonary hypertension a chronic but not fatal disease.
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Affiliation(s)
| | - Eftychia Demerouti
- Cardiology Department, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Pavlos Habibis
- School of Medicine, University of Thessaly, 41221 Larissa, Greece
| | | | | | - Dimitrios Tsiapras
- Cardiology Department, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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El-Kersh K, Zhao C, Elliott G, Farber HW, Gomberg-Maitland M, Selej M, Garcia-Ferrer J, Benza R. Derivation of a Risk Score (REVEAL-ECHO) Based on Echocardiographic Parameters of Patients With Pulmonary Arterial Hypertension. Chest 2023; 163:1232-1244. [PMID: 36634897 PMCID: PMC10268808 DOI: 10.1016/j.chest.2022.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Multiparametric risk assessment tools determine mortality risk in patients with pulmonary arterial hypertension (PAH) by combining invasive and noninvasive variables so management strategies can be tailored to individuals. RESEARCH QUESTION Can a risk score based on common echocardiographic parameters risk-stratify patients with PAH? STUDY DESIGN AND METHODS A Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) echocardiographic risk score (REVEAL-ECHO) was derived using retrospective echocardiographic data from 2,400 adult patients with PAH enrolled in the REVEAL registry database. A stepwise Cox regression model identified echocardiographic parameters significantly predictive of survival. Values were assigned to each selected parameter based on survival at 12 months' follow-up (Kaplan-Meier estimates). The REVEAL-ECHO risk score was the sum of individual values. Patients were categorized as having low, intermediate, or high risk based on Kaplan-Meier-predicted 12-month survival. RESULTS The risk score included four echocardiographic parameters-right ventricular (RV) chamber enlargement, reduced RV systolic function, tricuspid regurgitation severity, and pericardial effusion-and accounted for PAH etiology. Higher REVEAL-ECHO risk scores signaled lower probability of 12-month survival. Statistically significant separation of mortality risk was observed among the risk strata: intermediate vs low (hazard ratio [HR], 1.43; 95% CI, 1.17-1.75; P = .0004) and high vs low (HR, 2.60; 95% CI, 2.19-3.10; P < .0001). Augmentation of the REVEAL Lite 2 risk calculator with REVEAL-ECHO risk scores achieved separation of REVEAL Lite 2 into four risk groups and identified a subgroup of patients with a low REVEAL Lite 2 risk score who were at higher risk (intermediate-low risk) and a subgroup of patients with an intermediate REVEAL Lite 2 risk score who also were at higher risk (intermediate-high risk). INTERPRETATION A REVEAL-ECHO risk score, derived using four echocardiographic parameters, may discriminate risk further when used as an adjunct to current risk assessment scores. Further validation is required.
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Affiliation(s)
| | - Carol Zhao
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA
| | | | | | | | - Mona Selej
- Actelion Pharmaceuticals US, Inc., Titusville, NJ
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The role of riociguat in combination therapies for pulmonary arterial hypertension. Respir Med 2023; 211:107196. [PMID: 36889521 DOI: 10.1016/j.rmed.2023.107196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/08/2023]
Abstract
Effective clinical decision-making in initial treatment selection and switching or escalations of therapy for pulmonary arterial hypertension (PAH) depends on multiple factors including the patient's risk profile. Data from clinical trials suggest that switching from a phosphodiesterase-5 inhibitor (PDE5i) to the soluble guanylate cyclase stimulator riociguat may provide clinical benefit in patients not reaching treatment goals. In this review, we cover the clinical evidence for riociguat combination regimens for patients with PAH and discuss their evolving role in upfront combination therapy and switching from a PDE5i as an alternative to escalating therapy. Specifically, we review current evidence which suggests or provides a hypothesis for 1) the potential use of riociguat plus endothelin receptor antagonist combinations for upfront combination therapy in patients with PAH at intermediate to high risk of 1-year mortality and 2) the benefits of switching to riociguat from a PDE5i in patients who are not achieving treatment goals with PDE5i-based dual combination therapy and at intermediate risk.
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Idiopathic Pulmonary Arterial Hypertension in Paediatrics Represents Still a Serious Challenge: A Case Series Study. CHILDREN 2023; 10:children10030518. [PMID: 36980076 PMCID: PMC10047811 DOI: 10.3390/children10030518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/28/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023]
Abstract
Introduction: Paediatric pulmonary hypertension (PH) represents a heterogeneous illness that is responsible for high morbidity and mortality if left without treatment. Idiopathic pulmonary arterial hypertension (IPAH) is a subtype of PAH rarely seen in paediatrics. Limited long-term data are available. Methods: Over a period of 20 years, 10 paediatric patients were enrolled at two tertiary centres. Their clinical, echocardiographic, and right heart catheterisation (RHC) features and outcome were evaluated. Results: The mean age at first diagnosis was 5.7 ± 5.7 years. The age at the last follow-up was 12.4 ± 6.1 years. The average follow-up was 6.6 ± 0.8 years. There was a female prevalence of 60% (p < 0.05) in this case series. Regarding the NYHA functional class, 80% of IPAH subjects were in class III or IV. The mean saturation was 91 ± 5%. In this regard, 70% of the patients were on a combination of three drugs, with sildenafil (90%) included. On echocardiography, longitudinal right ventricular contractility (TAPSE) was slightly reduced (13.4 ± 2.6 mm), whilst RVSP was severely elevated (101 ± 19 mmHg). The RHC data showed that mPAP was 61.8 ± 23.1 mmHg (p = 0.0017 with RVSP on echocardiography), mRAP was 10.7 ± 3.8 mmHg, CI was 2.6 ± 1 L·min−1·m−2, PVRi was 16.8 ± 12.6 WU·m2, and SVO2 was 63.6 ± 14.8%. Regarding the outcome, two male IPAH patients (20%) died, and 50% underwent lung transplant or were on transplant assessment or already on the waiting list for lung transplantation. One patient underwent a ductus arteriosus stenting (reverse Potts shunt) and another underwent atrial septostomy and stenting. Conclusions: Notwithstanding the progress in medical therapy, IPAH continues to represent a serious challenge, particularly in the paediatric population, with the need for lung transplantation and significant mortality.
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23
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Pulmonary arterial hypertension in pregnancy. Curr Opin Cardiol 2023; 38:250-256. [PMID: 36811622 PMCID: PMC10090373 DOI: 10.1097/hco.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Although pregnancy in pulmonary arterial hypertension (PAH) is considered high risk and contraindicated, the incidence is rising. It is paramount to understand the pathophysiology and effective management strategies to ensure optimal outcomes for maternal and fetal survival. RECENT FINDINGS In this review, we highlight the outcomes of recent case series of PAH patients in pregnancy, with a focus on proper risk assessment and target goals of PAH therapy. These findings support the notion that the pillars of PAH management, including pulmonary vascular resistance reduction resulting in right heart functional improvement, and widening of the cardiopulmonary reserve, should serve as a blueprint for PAH management in pregnancy. SUMMARY Multidisciplinary and tailored management of PAH in pregnancy, with emphasis on optimizing right heart function prior to delivery, can result in excellent clinical outcomes in a referral pulmonary hypertension center.
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JGN, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Tang WHW, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.15.23285974. [PMID: 36824981 PMCID: PMC9949192 DOI: 10.1101/2023.02.15.23285974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RVFnRec). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. Methods We evaluated 63 incident patients with PAH by right heart catheterization and cardiac MRI (CMR) at diagnosis and CMR and invasive cardiopulmonary exercise (CPET) following treatment (∼11 months). Sex, age, race/ethnicity matched healthy control subjects (n=62) with one-time CMR and non-invasive CPET were recruited from the PVDOMICS project. We examined therapeutic CMR changes relative to the evidence-based peak oxygen consumption (VO2 peak )>15mL/kg/min to define RVFnRec by receiver operating curve analysis. Afterload was measured in the as mean pulmonary artery pressure, resistance, compliance, and elastance. Results A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (AUC 0.87, P=0.0001) and neared upper 95% CI RVEDV of controls. 22/63 (35%) of subjects met this cutoff which was reinforced by freedom from clinical worsening, RVFnRec 1/21 (5%) versus no RVFnRec 17/42, 40%, (log rank P=0.006). A therapy-associated increase of 0.8 mL/mmHg in compliance had the best predictive value of RVFnRec (AUC 0.76, CI 0.64-0.88, P=0.001). RVFnRec subjects had greater increases in stroke volume, and cardiac output at exercise. Conclusions RVFnRec defined by RVEDV therapeutic decrease of -15mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise. Clinical Perspective What is new?: Right ventricular functional recovery (RVFnRec) represents a novel endpoint of therapeutic success in PAH. We define RVFnRec as treatment associated normative RV changes related to function (peak oxygen consumption). Normative RV imaging changes are compared to a well phenotyped age, sex, and race/ethnicity matched healthy control cohort from the PVDOMICS project. Previous studies have focused on RV ejection fraction improvements. However, we show that changes in RVEDV are perhaps more important in that improvements in LV function also occur. Lastly, RVFnRec is best predicted by improvements in pulmonary artery compliance versus pulmonary vascular resistance, a more often cited metric of RV afterload.What are the clinical implications?: RVFnRec represents a potential non-invasive assessment of clinical improvement and therapeutic response. Clinicians with access to cardiac MRI can obtain a limited scan (i.e., ventricular volumes) before and after treatment. Future study should examine echocardiographic correlates of RVFnRec.
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Zhu T, Wu P, Tan Z, Jin Q, Chen Y, Li L, Chen Z, Tang Y, Li J, Fang Z. Differences in right ventricular function and response to targeted therapy between patients with IPAH and PAH-CHD. Front Pharmacol 2023; 14:1124746. [PMID: 36860300 PMCID: PMC9968930 DOI: 10.3389/fphar.2023.1124746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
Background and aims: Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disorder characterized by elevated pulmonary vascular resistance (PVR) and pulmonary arterial pressure (PAP). Right heart failure is a life-threatening complication of PAH and predicts a poor prognosis. PAH associated with congenital heart disease (PAH-CHD) and idiopathic PAH (IPAH) are two prevalent PAH subtypes in China. In this section, we set out to explore baseline right ventricular (RV) function and its response to targeted agents between IPAH and PAH-CHD. Methods and results: Consecutive patients diagnosed with IPAH or PAH-CHD by right heart catheterization (RHC) in the Second Xiangya Hospital from November 2011 to June 2020 were included. All patients received PAH-targeted therapy and the RV function was assessed by echocardiography at baseline and during follow-up. A total of 303 patients (age, 36.23 ± 13.10 years; women, 213 (70.3%); mean PAP [mPAP], 63.54 ± 16.12 mmHg; PVR, 14.74 ± 7.61 WU) with IPAH (n = 121) or PAH-CHD (n = 182) were included in this study. Compared with PAH-CHD, patients with IPAH had worse baseline RV function. As of the latest follow-up, forty-nine patients with IPAH and six patients with PAH-CHD died. Kaplan-Meier analyses showed better survival in PAH-CHD versus IPAH. After PAH-targeted therapy, patients with IPAH had less improvement in 6 MWD, World Health Organization functional class, and RV functional parameters compared with patients with PAH-CHD. Conclusion: Compared with patients with PAH-CHD, patients with IPAH had worse baseline RV function, unfavourable prognosis, and inadequate response to targeted treatment.
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Affiliation(s)
- Tengteng Zhu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Panyun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhen Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Quan Jin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lian Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zewei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yirui Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Alamri AK, Shelburne NJ, Mayeux JD, Brittain E. Pulmonary Hypertension Association's 2022 International Conference Scientific Sessions Overview. Pulm Circ 2023; 13:e12182. [PMID: 36644322 PMCID: PMC9832865 DOI: 10.1002/pul2.12182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The considerable progress made in recent years in the diagnosis, risk stratification, and treatment of pulmonary hypertension was highlighted during the most recent edition of the Pulmonary Hypertension Association Scientific Sessions, which was held in Atlanta, Georgia from June 9 to 11, 2022, with the theme: Vision for the PHuture: The Evolving Science and Management of PH. Content presented over the 3-day conference focused on scientific and management updates since the last sessions were held in 2018 and included didactic talks, debates, and roundtable discussions across a broad spectrum of topics related to pulmonary hypertension. This article aims to summarize the key messages from each of the session talks.
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Affiliation(s)
- Ayedh K. Alamri
- Department of MedicineUniversity of UtahSalt Lake CityUtahUSA,Department of Medicine, College of MedicineNorthern Border UniversityArarSaudi Arabia
| | - Nicholas J. Shelburne
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennalyn D. Mayeux
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Evan Brittain
- Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Bousseau S, Sobrano Fais R, Gu S, Frump A, Lahm T. Pathophysiology and new advances in pulmonary hypertension. BMJ MEDICINE 2023; 2:e000137. [PMID: 37051026 PMCID: PMC10083754 DOI: 10.1136/bmjmed-2022-000137] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.
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Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Rafael Sobrano Fais
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Sue Gu
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiovascular Pulmonary Research Lab, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrea Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 436] [Impact Index Per Article: 436.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Deshwal H, Weinstein T, Salyer R, Thompson J, Cefali F, Fenton R, Bondarsky E, Sulica R. Long-term impact of add-on sequential triple combination therapy in pulmonary arterial hypertension: real world experience. Ther Adv Respir Dis 2023; 17:17534666231199693. [PMID: 37795626 PMCID: PMC10557422 DOI: 10.1177/17534666231199693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/04/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sequential triple combination therapy is recommended for pulmonary arterial hypertension (PAH) patients who are not at therapeutic goal on dual therapy, but long-term data on efficacy and safety is scarce. OBJECTIVE To assess the long-term impact of sequential triple combination therapy in patients with PAH who are not at goal on dual combination therapy. STUDY DESIGN AND METHODS We performed a retrospective observational study in a racially/ethnically diverse cohort of consecutive PAH patients on a stable dual therapy regimen who remained in intermediate- or high-risk category and were subsequently initiated on sequential triple combination therapy. We studied interval change in functional, echocardiographic, and hemodynamic parameters, REVEAL 2.0 risk category and ERS/ESC 2022 simplified four-strata risk category. Multivariate logistic regression analysis was performed to identify independent predictors of successful risk reduction (achievement or maintenance of REVEAL 2.0 low-risk category). Kaplan-Meier survival curves were created to assess the effect of risk reduction on survival. RESULTS Out of 414 PAH patients seen in our program, 55 patients received add-on sequential triple combination regimen and had follow-up hemodynamic data. The mean age was 57 years, with 85% women. The most common etiology of PAH was idiopathic/heritable (41.8%). Most patients were WHO functional class III (76.4%), and 34.5% of patients were in high-risk category (REVEAL 2.0). On a median follow-up of 68 weeks, there was a significant improvement in WHO Functional Class (p < 0.001), six-minute walk distance (35 m) with 61.8% of patients achieving low-risk status by REVEAL 2.0, and a 28% of patients' improvement in pulmonary vascular resistance. Female gender was identified as a strong predictor of successful risk reduction, whereas Hispanic ethnicity estimated right atrial pressure on echocardiogram and pericardial effusion predicted lower probability of risk reduction. Patients who achieved or maintained low-risk status had significantly improved survival. CONCLUSION Add-on sequential triple combination therapy significantly increased functional, echocardiographic, and hemodynamic parameters with improvement in risk category and survival.
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Affiliation(s)
- Himanshu Deshwal
- Pulmonary Hypertension Clinic (Pulmonology), Division of Pulmonary, Sleep, and Critical Care Medicine, West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV 26505, USA
| | - Tatiana Weinstein
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Rachel Salyer
- Department of Medicine, West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, USA
| | - Jesse Thompson
- Department of Medicine, West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, USA
| | - Frank Cefali
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Rebecca Fenton
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Eric Bondarsky
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Roxana Sulica
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
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Benincasa G, Maron BA, Affinito O, D’Alto M, Franzese M, Argiento P, Schiano C, Romeo E, Bontempo P, Golino P, Berrino L, Loscalzo J, Napoli C. Association Between Circulating CD4 + T Cell Methylation Signatures of Network-Oriented SOCS3 Gene and Hemodynamics in Patients Suffering Pulmonary Arterial Hypertension. J Cardiovasc Transl Res 2023; 16:17-30. [PMID: 35960497 PMCID: PMC9944731 DOI: 10.1007/s12265-022-10294-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/19/2022] [Indexed: 02/06/2023]
Abstract
Pathogenic DNA methylation changes may be involved in pulmonary arterial hypertension (PAH) onset and its progression, but there is no data on potential associations with patient-derived hemodynamic parameters. The reduced representation bisulfite sequencing (RRBS) platform identified N = 631 differentially methylated CpG sites which annotated to N = 408 genes (DMGs) in circulating CD4+ T cells isolated from PAH patients vs. healthy controls (CTRLs). A promoter-restricted network analysis established the PAH subnetwork that included 5 hub DMGs (SOCS3, GNAS, ITGAL, NCOR2, NFIC) and 5 non-hub DMGs (NR4A2, GRM2, PGK1, STMN1, LIMS2). The functional analysis revealed that the SOCS3 gene was the most recurrent among the top ten significant pathways enriching the PAH subnetwork, including the growth hormone receptor and the interleukin-6 signaling. Correlation analysis showed that the promoter methylation levels of each network-oriented DMG were associated individually with hemodynamic parameters. In particular, SOCS3 hypomethylation was negatively associated with right atrial pressure (RAP) and positively associated with cardiac index (CI) (|r|≥ 0.6). A significant upregulation of the SOCS3, ITGAL, NFIC, NCOR2, and PGK1 mRNA levels (qRT-PCR) in peripheral blood mononuclear cells from PAH patients vs. CTRLs was found (P ≤ 0.05). By immunoblotting, a significant upregulation of the SOCS3 protein was confirmed in PAH patients vs. CTRLs (P < 0.01). This is the first network-oriented study which integrates circulating CD4+ T cell DNA methylation signatures, hemodynamic parameters, and validation experiments in PAH patients at first diagnosis or early follow-up. Our data suggests that SOCS3 gene might be involved in PAH pathogenesis and serve as potential prognostic biomarker.
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Affiliation(s)
- Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, MB Boston, USA ,Harvard Medical School, Boston, MA USA
| | | | - Michele D’Alto
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | | | - Paola Argiento
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Concetta Schiano
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paola Bontempo
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paolo Golino
- Department of Cardiology, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Liberato Berrino
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, MB Boston, USA
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy ,IRCCS SDN, Naples, Italy
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Rubin LJ, Naeije R. Sotatercept for pulmonary arterial hypertension: something old and something new. Eur Respir J 2023; 61:61/1/2201972. [PMID: 36609525 DOI: 10.1183/13993003.01972-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Lewis J Rubin
- University of California San Diego School of Medicine, San Diego, CA, USA
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Tamura Y, Kumamaru H, Nishimura S, Nakajima Y, Matsubara H, Taniguchi Y, Tsujino I, Shigeta A, Kinugawa K, Kimura K, Tatsumi K. Initial Triple Combination Therapy Including Intravenous Prostaglandin I 2 for the Treatment of Patients with Severe Pulmonary Arterial Hypertension. Int Heart J 2023; 64:684-692. [PMID: 37518350 DOI: 10.1536/ihj.23-047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Upfront combination therapy including intravenous prostaglandin I2 (PGI2-IV) is recognized as the most appropriate treatment for patients with severe pulmonary arterial hypertension (PAH). This retrospective study aimed to determine reasons why this therapy is not used for some patients with severe PAH and describe the hemodynamic and clinical prognoses of patients receiving initial combination treatment with (PGI2-IV+) or without (PGI2-IV-) PGI2-IV.Data for patients with severe PAH (World Health Organization Functional Class III/IV and mean pulmonary arterial pressure [mPAP] ≥ 40 mmHg) were extracted from the Japan Pulmonary Hypertension Registry. Overall, 73 patients were included (PGI2-IV + n = 17; PGI2-IV- n = 56). The PGI2-IV+ cohort was younger than the PGI2-IV- cohort (33.8 ± 10.6 versus 52.6 ± 18.2 years) and had higher mPAP (58.1 ± 12.9 versus 51.8 ± 9.0 mmHg), greater prevalence of idiopathic PAH (88% versus 32%), and less prevalence of connective tissue disease-associated PAH (0% versus 29%). Hemodynamic measures, including mPAP, showed improvement in both cohorts (post-treatment median [interquartile range] 38.5 [17.0-40.0] for the PGI2-IV + cohort and 33.0 [25.0-43.0] mmHg for the PGI2-IV - cohort). Deaths (8/56) and lung transplantation (1/56) occurred only in the PGI2-IV - cohort.These Japanese registry data indicate that older age, lower mPAP, and non-idiopathic PAH may influence clinicians against using upfront combination therapy including PGI2-IV for patients with severe PAH. Early combination therapy including PGI2-IV was associated with improved hemodynamics from baseline, but interpretation is limited by the small sample size.
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Affiliation(s)
- Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
- Japan Pulmonary Hypertension Registry (JAPHR) Network
| | - Hiraku Kumamaru
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo
| | - Shiori Nishimura
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo
| | | | - Hiromi Matsubara
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- National Hospital Organization Okayama Medical Center
| | - Yu Taniguchi
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Ichizo Tsujino
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University
| | - Ayako Shigeta
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Respirology, Graduate School of Medicine, Chiba University
| | - Koichiro Kinugawa
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Second Department of Internal Medicine, University of Toyama
| | - Kazuhiro Kimura
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Koichiro Tatsumi
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Respirology, Graduate School of Medicine, Chiba University
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Benza RL, Langleben D, Hemnes AR, Vonk Noordegraaf A, Rosenkranz S, Thenappan T, Hassoun PM, Preston IR, Ghio S, Badagliacca R, Vizza CD, Lang IM, Meier C, Grünig E. Riociguat and the right ventricle in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2022; 31:31/166/220061. [PMID: 36198418 DOI: 10.1183/16000617.0061-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are progressive diseases that can lead to right heart failure and death. Right ventricular dysfunction, hypertrophy and maladaptive remodelling are consequences of increased right ventricular (RV) afterload in PAH and CTEPH and are indicative of long-term outcomes. Because RV failure is the main cause of morbidity and mortality in PAH and CTEPH, successful treatments should lead to improvements in RV parameters. Riociguat is a soluble guanylate cyclase stimulator approved for the treatment of PAH and inoperable or persistent/recurrent CTEPH after pulmonary endarterectomy. This review examines the current evidence showing the effect of riociguat on the right ventricle, with particular focus on remodelling, function and structural parameters in preclinical models and patients with PAH or CTEPH.
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Affiliation(s)
- Raymond L Benza
- Dept of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Stephan Rosenkranz
- Dept of Cardiology and Cologne Cardiovascular Research Center, Cologne University Heart Center, Cologne, Germany
| | - Thenappan Thenappan
- Cardiovascular Division, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Paul M Hassoun
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Irene M Lang
- Division of Cardiology, Dept of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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D'Alto M, Naeije R. Pulmonary artery pressure-directed therapies in pulmonary arterial hypertension? Vascul Pharmacol 2022; 147:107124. [PMID: 36270620 DOI: 10.1016/j.vph.2022.107124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension is a rare dyspnea-fatigue syndrome defined by an increase in mean pulmonary artery pressure above 20 mmHg combined with an increase in pulmonary vascular resistance higher than 2 Wood units. The condition is of poor prognosis and still incurable in spite of progress achieved in recent decades. The approach is currently optimized by multi-drug combinations titrated on serial risk assessments using recently validated scores. In this issue of Vascular Pharmacology argument is made based on retrospective registry data from three reference centers in favor of initial multi-drug therapies including a parenteral prostanoid dosed to decrease mPAP to normal. This objective was achieved in only a minority of patients, but improved outcome was demonstrated when mPAP can be brought to below 35 mmHg. This data suggest that pulmonary artery pressure-directed multi-drug therapies in PAH may reverse right heart remodeling and limit progression, or even reverse pulmonary vascular disease. However, further studies are needed to validate mPAP as a primary endpoint in PAH drug trials. In the meantime, aggressive initial prescription of parenteral prostanoids combined with one or two oral drugs targeting the pulmonary circulation under careful clinical, imaging and hemodynamic follow-up may be the best therapeutic strategy.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, 80131 Naples, Italy.
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, 1090 Brussels, Belgium
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Muacevic A, Adler JR, Penn BA, Mayeux JD, Ma CL, Clapham KR, Abraham AE, Klanderud D, Sadeh B, Beck EM, Hatton ND, Ryan JJ. Characteristics of Patients With Pulmonary Arterial Hypertension in a Pulmonary Hypertension Association-Accredited Comprehensive Care Center: A Contrast in Features When Compared With US National Registry Data. Cureus 2022; 14:e31764. [PMID: 36569732 PMCID: PMC9772347 DOI: 10.7759/cureus.31764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background Since the initial description in the 1980s, our understanding of the diversity of pulmonary arterial hypertension (PAH) has continued to evolve. In this study, we report the characteristics of patients seen in an academic medical center for PAH from August 2020 through November 2021 and contrast those with nationally reported data from the United States Pulmonary Hypertension Scientific Registry (USPHSR). Study Design Investigators at the University of Utah Pulmonary Hypertension Program prospectively enrolled adult patients diagnosed with WHO Group 1 PAH, who were evaluated between August 2020 and November 2021 in a program-specific registry. Patient exposure and health histories were collected through structured interviews and questionnaires, along with clinical data and medication use. A total of 242 patients were enrolled in the University of Utah Pulmonary Hypertension Registry (UUPHR). Results Of the 242 enrolled patients, the most common etiology was associated PAH (APAH), accounting for 71.1% of the population. The second largest etiology was idiopathic PAH (IPAH) at 26.4%. The remaining patients were distributed between familial PAH (FPAH), pulmonary veno-occlusive disease (PVOD), and others. Of the total population classified as APAH, 39% of cases were noted as secondary to connective tissue disease (CTD) and 33% as toxin-induced. These represented 28% and 24% of the total population, respectively. Conclusions In this US-based accredited academic medical center, the etiology of PAH in our patient population contrasts with national registry data. In the UUPHR, APAH, specifically CTD-PAH and toxin-associated PAH, accounts for the majority of patients with PAH. This contrasts with IPAH, which nationally is the most reported cause of PAH. Differences in our population may reflect the regional variation of the referral site, but it is noteworthy for its contrast with historically reported phenotypes.
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Lescano A, Giacommi G, Botta CE, Soricetti J, Rodriguez M, Vargas Mielles P, Diez F. Real-world evidence of subcutaneous treprostinil use in pulmonary arterial hypertension in Argentina. Ther Adv Respir Dis 2022; 16:17534666221132735. [PMID: 36314498 PMCID: PMC9629562 DOI: 10.1177/17534666221132735] [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: 01/24/2023] Open
Abstract
INTRODUCTION Pulmonary arterial hypertension is a progressive haemodynamic disease with high morbidity and mortality. Of the different treatments available, the prostacyclin analogues are the drugs of choice for high-risk patients, with treprostinil being the most commonly used drug in Argentina. METHODOLOGY The objective of this study is to perform a retrospective evaluation of the efficacy and safety of subcutaneous treprostinil in regular clinical practice in Argentina in 51 patients with pulmonary arterial hypertension after 12 months of follow-up. RESULTS The results showed that treatment with subcutaneous treprostinil is associated with a significant improvement in different clinical efficacy parameters: 65% reduction in advanced functional class (p < 0.0001), 130-m increase in the 6-min walk test (p < 0.0001), 65% reduction in the pro B-type natriuretic peptide value (-531 pg/dL; p < 0.0001), significant reduction of 15.7% in pulmonary vascular resistance [-1.3 wood units (WU); p < 0.0001], improved cardiac index with an increase of 16.7% (+0.4 L/min/m2; p = 0.002), as well as a high survival rate (92%) and a 44% incidence of combined events (mortality, heart failure, syncope and/or lung transplantation), without a significant increase in previously reported adverse events. The risk stratification evaluation according to ESC/ERS guidelines showed a significant decrease in the proportion of patients at high risk after the treatment period (p = 0.004). CONCLUSIONS These real-world results corroborate the efficacy and safety of subcutaneous treprostinil, even at high doses, and open up the possibility of improving its current use in clinical practice as a first-line therapy, especially in high-risk patient profiles.
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Affiliation(s)
| | - Guillermo Giacommi
- Hospital Interzonal de Agudos ‘Dr. Oscar E. Allende’, Mar del Plata, Argentina
| | - Cristian E. Botta
- Department of Heart Failure and Pulmonary Arterial Hypertension, Sanatorio Privado San Gerónimo, Santa Fe, Argentina
| | - Julieta Soricetti
- Hospital General de Agudos Carlos G. Durand, Buenos Aires, Argentina
| | - Manuel Rodriguez
- Cardiology, Area of Heart Failure, Pulmonary Hypertension and Transplantation, Hospital Italiano de Mendoza, Buenos Aires, Argentina
| | | | - Fabián Diez
- Hospital Italiano de Rosario, Rosario, Argentina
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1022] [Impact Index Per Article: 511.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Early echocardiographic evaluation of right ventricular load adaptability after sequential combination treatment in pulmonary arterial hypertension. Herz 2022:10.1007/s00059-022-05139-1. [PMID: 36149453 DOI: 10.1007/s00059-022-05139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Using the tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP) ratio as an index of right ventricular load adaptability, we aimed to evaluate early changes in right heart contractile function of patients with group 1 pulmonary artery hypertension (PAH) after sequential combination PAH-specific therapy. METHODS A total of 49 patients with group 1 PAH and 31 control participants were included in the study. The baseline clinical and echocardiographic data of the control and PAH group were compared. Subsequently, clinical and echocardiographic data of PAH patients before treatment and at 6 months after PAH-specific treatment were analyzed. RESULTS A significant increase in the TAPSE/PASP ratio was found in patients at 6 months of PAH-specific treatment (0.25 ± 0.14; 0.33 ± 0.16, p < 0.001). Right atrial pressure (8 mm Hg [5-10]; 5 mm Hg [3-8], p < 0.001) and PASP (80.8 ± 30.6 mm Hg; 65.9 ± 25.7 mm Hg, p < 0.001) were significantly lower after sequential combination PAH-specific therapy. Negative correlations were found between the TAPSE/PASP ratio and N‑terminal pro-B-type natriuretic peptide (r = -0.524, p < 0.001), tricuspid regurgitation velocity (r = -0.749, p < 0.001), right atrial area (r = -0.298, p = 0.037), and right atrial pressure (r = -0.463, p = 0.001). CONCLUSION In patients with group 1 PAH, echocardiographic evaluation at the early stage of treatment (6 months) shows a significant improvement in the TAPSE/PASP ratio indicating right ventricular load adaptation. Comprehensive studies are needed on the routine use of the TAPSE/PASP ratio in the risk assessment of PAH patients.
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Badagliacca R, Vizza CD, Lang I, Sadushi-Kolici R, Papa S, Manzi G, Filomena D, Ogawa A, Shimokawahara H, Matsubara H. Pulmonary pressure recovery in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension: Determinants and clinical impact. Vascul Pharmacol 2022; 146:107099. [PMID: 36058492 DOI: 10.1016/j.vph.2022.107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Over the past two decades randomized controlled trials of combination treatments for Pulmonary Arterial Hypertension (PAH) have demonstrated improvements of clinical status but only modest reductions in mean pulmonary pressure (mPAP). Recent experiences with upfront combination treatments including parenteral prostacyclins have shown more substantial mPAP reductions, and have provided grounds for reconsiderations of treatment. OBJECTIVES To evaluate the possibility of achieving mPAP <25 mmHg with current treatments, its determinants and the prognostic impact of mPAP reduction. METHODS 267 consecutive idiopathic, hereditary and drug and toxin-induced PAH patients treated with targeted therapies from three expert centers were followed with periodic clinical and hemodynamic assessments for survival detection. RESULTS Fifty-four (20.2%) patients achieved a mPAP <25 mmHg over 58 months (IQR 27-90) of treatment. Determinants of mPAP <25 mmHg were mPAP at diagnosis (HR 0.96, 95C.I. 0.93-0.98, p = 0.002) and an upfront combination strategy (double oral combination: HR 2.3, 95C.I. 1.10-4.76, p = 0.02; one oral plus parenteral prostanoid: HR 3.6, 95C.I. 1.39-9.37, p = 0.008; triple combination employing parenteral prostanoids: HR 12.9, 95C.I. 4.9-33.2, p = 0.0001). Seventy-three patients (27.3%) died. Survival rates were 90%, 79%, 70%, 55%, and 42% at 1, 3, 5, 10, and 15 years, respectively. Mean PAP during follow-up, days from diagnosis to prostanoid initiation and prostanoid maximum dose emerged as independent predictors of survival (Uno-C-index: 0.85). A mPAP ≤35 mmHg during follow-up was identified as the best cutoff value for prediction of survival. CONCLUSIONS Reduction to a mean PAP ≤ 35 mmHg appears to be a meaningful treatment target in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension.
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Affiliation(s)
- Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy.
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Irene Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Aiko Ogawa
- Department of Clinical Science, Okayama Medical Center, Japan
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Prognostic Value of Echocardiographic Variables Prior to and Following Initiation of Parenteral Prostacyclin Therapy. Chest 2022; 162:669-683. [DOI: 10.1016/j.chest.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 12/31/2022] Open
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41
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Benza RL, Gomberg-Maitland M, Farber HW, Vizza CD, Broderick M, Holdstock L, Nelsen AC, Deng C, Rao Y, White RJ. Contemporary Risk Scores Predict Clinical Worsening in Pulmonary Arterial Hypertension - An Analysis of FREEDOM-EV. J Heart Lung Transplant 2022; 41:1572-1580. [DOI: 10.1016/j.healun.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 07/13/2022] [Accepted: 08/09/2022] [Indexed: 10/31/2022] Open
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42
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Vaidya A, Oliveros E, Mulla W, Feinstein D, Hart L, Forfia P. Management of Pulmonary Arterial Hypertension in Pregnancy: Experience from a Nationally Accredited Center. J Cardiovasc Dev Dis 2022; 9:jcdd9060195. [PMID: 35735823 PMCID: PMC9224797 DOI: 10.3390/jcdd9060195] [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: 05/14/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: In pulmonary arterial hypertension (PAH), pregnancy is regarded a contraindication due to high maternal and fetal morbidity and mortality. We report our experience in the management of pregnancies in PAH. (2) Methods: retrospective observational study in a nationally accredited pulmonary hypertension (PH) center from 2013 to 2021. (3) Results: seven pregnancies in six women with PAH, ranging from low to high risk and 21 to 37 years old. Half had known pre-existing PAH before pregnancy. One had a multifetal gestation, and one was pregnant twice under our care. PH medical therapy and serial clinical assessment throughout pregnancy were implemented with focused attention on optimizing right heart function. Delivery was planned by a multidisciplinary team involving PH cardiology, maternal fetal medicine, and obstetric anesthesiology. Patients delivered between 31 and 40 weeks of gestation; five of the seven were via cesarean section. All received regional anesthesia and were monitored in the PH intermediate step-down unit after delivery until discharge. In all cases, delivery was without complications with excellent outcomes for the mother and child. (4) Conclusions: Multidisciplinary and tailored management of PAH in pregnancy, emphasizing optimized right heart function prior to delivery, can result in excellent clinical outcomes in a referral PH center.
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Affiliation(s)
- Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
- Correspondence: ; Tel.: +1-215-707-7636
| | - Estefania Oliveros
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
| | - Wadia Mulla
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Diana Feinstein
- Obstetric Anesthesiology, Department of Anesthesiology, Temple University Hospital, Philadelphia, PA 19197, USA;
| | - Laura Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
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Telehealth: A winning weapon to face the COVID-19 outbreak for patients with pulmonary arterial hypertension. Vascul Pharmacol 2022; 145:107024. [PMID: 35716991 PMCID: PMC9212864 DOI: 10.1016/j.vph.2022.107024] [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: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022]
Abstract
Background COVID-19 pandemic severely affected national health systems, altering the modality and the type of care of patients with acute and chronic diseases. To minimize the risk of exposure to SARS-CoV2 for patients and health professionals, face-to-face visits were cancelled or postponed and the use of telemedicine was strongly encouraged. This reorganization involved especially patients with rare diseases needing periodic comprehensive assessment, such as pulmonary arterial hypertension (PAH). Main body The paper reports a proposal of strategy adopted for patients followed at our PAH center in Rome, where patients management was diversified based on clinical risk according to the European Society of Cardiology/European Respiratory Society PH guidelines-derived score and the REVEAL 2.0 score. A close monitoring and support of these patients were made possible by policy changes reducing barriers to telehealth access and promoting the use of telemedicine. Synchronous/asynchronous modalities and remote monitoring were used to collect and transfer medical data in order to guide physicians in therapeutic-decision making. Conversely, the use of implantable monitors providing hemodynamic information and echocardiography-mobile devices wirelessly connecting was limited by the poor experience existing in this setting. Large surveys and clinical trials are welcome to test the potential benefit of the optimal balance between traditional PAH management and telemedicine opportunities. Conclusion Italy was found unprepared to manage the dramatic effects caused by COVID-19 on healthcare systems. In this emergency situation telemedicine represented a promising tool especially in rare diseases as PAH, but was limited by its scattered availability and legal and ethical issues. Cohesive partnership of health care providers with regional public health officials is needed to prioritize PAH patients for telemedicine by dedicated tools.
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CDCDB: A large and continuously updated drug combination database. Sci Data 2022; 9:263. [PMID: 35654801 PMCID: PMC9163158 DOI: 10.1038/s41597-022-01360-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2022] [Indexed: 12/25/2022] Open
Abstract
In recent years, due to the complementary action of drug combinations over mono-therapy, the multiple-drugs for multiple-targets paradigm has received increased attention to treat bacterial infections and complex diseases. Although new drug combinations screening has benefited from experimental tests like automated high throughput screening, it is limited due to the large number of possible drug combinations. The task of drug combination screening can be streamlined through computational methods and models. Such models require up-to-date databases; however, existing databases are static and consist of the data collected at the time of their creation. This paper introduces the Continuous Drug Combination Database (CDCDB), a continuously updated drug combination database. The CDCDB includes over 40,795 drug combinations, of which 17,107 are unique combinations consisting of more than 4,129 individual drugs, curated from ClinicalTrials.gov, the FDA Orange Book®, and patents. To create CDCDB, we use various methods, including natural language processing techniques, to improve the process of drug combination discovery, ensuring that our database can be used for drug synergy prediction. Website: https://icc.ise.bgu.ac.il/medical_ai/CDCDB/. Measurement(s) | drug combination effect modeling • drug combination effect modeling | Technology Type(s) | Text mining • Clinical Trials Informatics System | Factor Type(s) | Medicine | Sample Characteristic - Organism | Homo sapiens |
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45
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Suzuki S, Asano R, Aoki T, Nakayama S, Ueda J, Tsuji A, Noguchi T, Ogo T. Prognostic impact of follow-up pulmonary vascular resistance in pulmonary arterial hypertension. Open Heart 2022; 9:openhrt-2022-002054. [PMID: 35675988 PMCID: PMC9185661 DOI: 10.1136/openhrt-2022-002054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Pulmonary arterial hypertension (PAH), caused by pulmonary artery remodelling and increased pulmonary vascular resistance (PVR) due to an unknown mechanism, is an intractable disease with a poor prognosis. The recent development of PAH-specific treatment medications may allow for higher PVR reduction than previously achieved. This study aimed to identify the prognostic significance of follow-up PVR levels achieved shortly after the initiation of targeted treatment in patients with idiopathic/heritable pulmonary arterial hypertension (I/H-PAH). Methods We analysed the data of all patients with I/H-PAH admitted to our hospital between 1998 and 2019. We collected data at baseline and during the first invasive haemodynamic evaluation. The primary outcome was death or lung transplantation. Results Of the 133 treatment-naïve patients enrolled in this study, 47 experienced adverse events during a median follow-up period of 6.4 (IQR 3.5–11.5) years. The median time interval to first follow-up from diagnosis was 162 (IQR 117–253) days. Incidence of the primary outcome was significantly lower in patients who achieved low PVR at follow-up. Of risk factors evaluated at follow-up, the multivariate Cox regression analysis revealed PVR as an independent predictor of the primary outcome (HR 1.103, 95% CI 1.029 to 1.183; p=0.006). The results were consistent across risk profiles according to the simplified risk stratification recommended by the European Society of Cardiology and European Respiratory Society guidelines. Conclusion Follow-up PVR was an independent predictor of transplant-free survival in patients with I/H-PAH. Evaluation of haemodynamic status shortly after initiating treatment may help predict long-term prognosis.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sayuri Nakayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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46
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D'Alto M, Badagliacca R. The importance of right ventricular remodelling in pulmonary arterial hypertension. BRITISH HEART JOURNAL 2022; 108:1338-1339. [PMID: 35606110 DOI: 10.1136/heartjnl-2022-321143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Disease, University of Rome La Sapienza, Rome, Italy
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47
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Lan WF, Deng Y, Wei B, Huang K, Dai P, Xie SS, Wu DD. Echocardiographic Evaluation of Initial Ambrisentan Plus Phosphodiesterase Type 5 Inhibitor on Right Ventricular Pulmonary Artery Coupling in Severe Pulmonary Arterial Hypertension Patients. Front Cardiovasc Med 2022; 9:843606. [PMID: 35592406 PMCID: PMC9113403 DOI: 10.3389/fcvm.2022.843606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/11/2022] [Indexed: 01/09/2023] Open
Abstract
Introductionambrisentan and phosphodiesterase type 5 inhibitor (PDE5i) have been approved for treating patients with pulmonary arterial hypertension (PAH). Echocardiographic right ventricular pulmonary artery coupling (RVPAC) has been shown to be a valid non-invasive and alternative measurement method to assess the predicted outcomes in PAH patients. The aim of this study was to study the effect and clinical correlates of initial ambrisentan plus PDE5i combination therapy on RVPAC in patients with severe PAH.Method and ResultsWe retrospectively studied and analyzed comprehensive clinical data, hemodynamics, and echocardiography in 27 patients with severe PAH before and after 6 months of initial combination therapy. Compared with the baseline, significant improvements in RVPAC ratios were observed, including RVFAC/PASP (0.31 ± 0.10 vs. 0.44 ± 0.15%/mmHg, p < 0.001), TAPSE/PASP (0.15 ± 0.05 vs. 0.21 ± 0.06 mm/mmHg, p = 0.001), S’/PASP (0.10 ± 0.03 vs. 0.14 ± 0.05 cm/s∙mmHg, p = 0.001), and RVSV/RVESV (0.79 ± 0.22 vs. 1.02 ± 0.20, p < 0.001). Functional status indices [World Health Organization functional classifications (WHO-FC) and 6 min walk distance (6MWD) and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels] showed significant improvements. Right heart catheterization (RHC) evaluations for hemodynamic measurements between baseline and the 6–12 month follow-up were sPAP (96 ± 22 vs. 86 ± 24 mmHg, p = 0.002), mPAP (64 ± 18 vs. 56 ± 17 mmHg, p < 0.001) and TPVR (17.3 ± 6.7 vs. 12.1 ± 5.4 WU, p = 0.001). Simultaneously, significant associations between RVPAC ratios and NT-proBNP levels and WHO-FC and 6MWD were observed.ConclusionAmbrisentan plus PDE-5i combination therapy resulted in a significant improvement in RVPAC in severe PAH. Importantly, RVPAC parameters correlated with known prognostic markers of PAH.
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Affiliation(s)
- Wei-Fang Lan
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Deng
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Yan Deng,
| | - Bin Wei
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Kai Huang
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ping Dai
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shan-Shan Xie
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Dan-dan Wu
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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48
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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Sun X, Chen R, Yao X, Zheng Z, Wang M, Wang C, Cheng J. Treatment of Pulmonary Hypertension: Is Triple Therapy Necessarily Better than Monotherapy? Am J Respir Crit Care Med 2021; 204:1492-1493. [PMID: 34672866 PMCID: PMC8865714 DOI: 10.1164/rccm.202108-1965le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Xishi Sun
- Affiliated Hospital of Guangdong Medical University Zhanjiang, China.,The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Riken Chen
- The First Affiliated Hospital of Guangzhou Medical University Guangzhou, China.,State Key Laboratory of Respiratory Disease Guangzhou, China.,Guangzhou Institute of Respiratory Disease Guangzhou, China
| | - Xiaoyun Yao
- Central Hospital of Guangdong Nongken Zhanjiang, China
| | - Zhenzhen Zheng
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Manxia Wang
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
| | - Chaoyu Wang
- Taishan Hospital of Traditional Chinese Medicine Jiangmen, China
| | - Junfen Cheng
- The Second Affiliated Hospital of Guangdong Medical University Zhanjiang, China
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50
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Boucly A, Weatherald J, Savale L, Jaïs X, Montani D, Humbert M, Sitbon O. Reply to Jin et al. and to Sun et al.. Am J Respir Crit Care Med 2021; 204:1494-1495. [PMID: 34672868 PMCID: PMC8865711 DOI: 10.1164/rccm.202107-1725le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | | | - Laurent Savale
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Xavier Jaïs
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Marc Humbert
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay Le Kremlin-Bicêtre, France.,AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue Le Plessis-Robinson, France
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