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Escal J, Poenou G, Delavenne X, Bezzeghoud S, Mismetti V, Humbert M, Montani D, Bertoletti L. Tailoring oral anticoagulant treatment in the era of multi-drug therapies for PAH and CTEPH. Blood Rev 2024:101240. [PMID: 39245607 DOI: 10.1016/j.blre.2024.101240] [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: 06/26/2024] [Revised: 08/31/2024] [Accepted: 09/02/2024] [Indexed: 09/10/2024]
Abstract
The use of oral anticoagulants in the management of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) presents distinct therapeutic challenges and benefits. In PAH, the benefits of oral anticoagulation are uncertain, with studies yielding mixed results on their efficacy and safety. Conversely, oral anticoagulants are a cornerstone in the treatment of CTEPH, where their use is consistently recommended to prevent recurrent thromboembolic events. The choice between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) remains a significant clinical question, as each type presents advantages and potential drawbacks. Furthermore, drug-drug interactions (DDIs) with concomitant PAH and CTEPH treatments complicate anticoagulant management, necessitating careful consideration of individual patient regimens. This review examines the current evidence on oral anticoagulant use in PAH and CTEPH and discusses the implications of DDIs within a context of multi-drug treatments, including targeted drugs in PAH.
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Affiliation(s)
- Jean Escal
- INSERM UMR1059, Université Jean Monnet, F-42023 Saint-Etienne, France; Laboratoire de Pharmacologie et Toxicologie, CHU de Saint-Etienne, F-42055 Saint-Etienne, France.
| | - Geraldine Poenou
- INSERM UMR1059, Université Jean Monnet, F-42023 Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, F-42055 Saint-Etienne, France.
| | - Xavier Delavenne
- INSERM UMR1059, Université Jean Monnet, F-42023 Saint-Etienne, France; Laboratoire de Pharmacologie et Toxicologie, CHU de Saint-Etienne, F-42055 Saint-Etienne, France.
| | - Souad Bezzeghoud
- Service de Médecine Vasculaire et Thérapeutique, INSERM CIC-1408, CHU de Saint-Etienne, F-42055 Saint-Etienne, France.
| | - Valentine Mismetti
- INSERM UMR1059, Université Jean Monnet, F-42023 Saint-Etienne, France; Service de Pneumologie, CHU de Saint-Etienne, F-42055 Saint-Etienne, France.
| | - Marc Humbert
- INSERM UMR-S 999, Université Paris-Saclay, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre (APHP), Le Kremlin-Bicêtre, France.
| | - David Montani
- INSERM UMR-S 999, Université Paris-Saclay, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de L'Hypertension Pulmonaire OrphaLung, Hôpital de Bicêtre (APHP), Le Kremlin-Bicêtre, France.
| | - Laurent Bertoletti
- INSERM UMR1059, Université Jean Monnet, F-42023 Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, INSERM CIC-1408, INNOVTE, CHU de Saint-Etienne, F-42055 SaintEtienne, France.
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Jain H, Odat RM, Ahmed M, Jain J, Goyal A, Idrees M, Passey S, Jha J, Shah J, Gole S. Safety and Outcomes with Direct Oral Anticoagulants Versus Vitamin-K Antagonists in Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review, Meta-Analysis, and Meta-Regression. Cardiol Rev 2024:00045415-990000000-00285. [PMID: 38833432 DOI: 10.1097/crd.0000000000000735] [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: 06/06/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by organized thrombi inside the pulmonary vasculature, leading to an increase in pulmonary artery pressure. CTEPH is seen in about 3-4% of patients with acute pulmonary embolism and is associated with poor outcomes. Apart from surgical intervention, lifelong anticoagulation is the mainstay of CTEPH management. Traditionally, CTEPH is managed with vitamin-K antagonists (VKA); however, direct oral anticoagulants (DOACs) are recently gaining popularity. However, the current literature comparing DOACs versus VKAs in CTEPH has inconsistent results. An electronic search of the major bibliographic databases was performed to retrieve studies comparing DOACs versus VKAs in CTEPH patients. For dichotomous outcomes, the odds ratio (ORs) with 95% confidence intervals (CI) were pooled using the DerSimonian and Laird random-effects model to generate forest plots. Statistical significance was considered at P < 0.05. Ten studies were included with 3936 patients (1269 in the DOAC group and 2667 in the VKA group). Treatment with DOAC was associated with no statistically significant difference in the risk of all-cause mortality (OR, 0.78; 95% CI, 0.35-1.71; P < 0.53), venous thromboembolism (OR, 1.19; 95% CI, 0.59-2.40; P = 0.63), major bleeding (OR, 0.68; 95% CI, 0.38-1.22; P = 0.20), and clinically relevant nonmajor bleeding (OR, 1.22; 95% CI, 0.80-1.86; P = 0.37). Our analysis demonstrates that DOACs are noninferior to VKAs in terms of their safety and outcomes profile in CTEPH. Further trials are needed to evaluate more robust evidence and to compare additional outcomes.
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Affiliation(s)
- Hritvik Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Ramez M Odat
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mushood Ahmed
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Jyoti Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Muhammad Idrees
- Department of Internal Medicine, Lahore General Hospital, Lahore, Pakistan
| | - Siddhant Passey
- Department of Internal Medicine, University of Connecticut Health Center, CT
| | - Jagriti Jha
- Department of Pediatrics, University of Connecticut Health Center, CT
| | - Janhvi Shah
- Department of Internal Medicine, St Luke's Hospital, Chesterfield, MO
| | - Shrey Gole
- Department of Immunology and Rheumatology, Stanford University, CA
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Zhang T, Guo L, Liang S, Liu H. Direct Oral Anticoagulants in Chronic Thromboembolic Pulmonary Hypertension: First Meta-Analysis of Prospective Studies. Clin Appl Thromb Hemost 2024; 30:10760296241257931. [PMID: 38778745 PMCID: PMC11113019 DOI: 10.1177/10760296241257931] [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: 03/05/2024] [Revised: 04/28/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
Direct oral anticoagulants (DOACs) are becoming increasingly popular clinically, but their safety and effectiveness profile in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is not well-established. Literature from the PubMed and EMBASE databases was systematically screened up to February 2024 to identify relevant studies on the use of DOACs in CTEPH patients. The bias risk of RCTs was assessed using the Cochrane Risk of Bias Tool 2.0. The quality of observational prospective cohorts was assessed using the Newcastle-Ottawa Scale tool. Data pooled from different studies were analyzed. Results from 4 studies were gathered, including 2 randomized controlled trials and 2 prospective cohorts, with a total of 2038 patients, of which 751 were on DOACs and 1287 were on vitamin K antagonists (VKAs). Similar rates of all-cause mortality (3.33% vs 3.33%, RD = -0.01%, 95% CI [-0.02%, 0.00%], P = .17), VTE recurrence (1.46% vs 2.12%, RD = -0.00%, 95% CI [-0.01%, 0.01%], P = .92) were observed. DOACs were associated with a nonsignificant reduction in bleeding events including major bleeding (2.22% vs 3.71%, RD = -0.01%, 95% CI [-0.04%, 0.01%], P = .30), any bleeding (5.33% vs 9.94%, RD = -0.03%, 95% CI [-0.07%, 0.01%], P = .10), and minor bleeding (4.17% vs 13.3%, RD = -0.06%, 95% CI [-0.23%, 0.10%], P = .45). Data pooled from existing perspective trials suggests the use of DOACs in CTEPH patients as an effective and safe alternative to VKAs.
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Affiliation(s)
- Tang Zhang
- Department of Cardiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Shucheng Liang
- Faculty of Medicine, Macau University of Science and Technology, Taipa, China
| | - Hao Liu
- Department of Cardiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
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Guth S, Wilkens H, Halank M, Held M, Hobohm L, Konstantinides S, Omlor A, Seyfarth HJ, Schäfers HJ, Mayer E, Wiedenroth CB. [Chronic thromboembolic pulmonary hypertension]. Pneumologie 2023; 77:937-946. [PMID: 37963483 DOI: 10.1055/a-2145-4807] [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
Chronic thromboembolic pulmonary disease (CTEPD) is an important late complication of acute pulmonary embolism, in which the thrombi transform into fibrous tissue, become integrated into the vessel wall, and lead to chronic obstructions. CTEPD is differentiated into cases without pulmonary hypertension (PH), characterized by a mean pulmonary arterial pressure up to 20 mmHg and a form with PH. Then, it is still referred to as chronic thromboembolic pulmonary hypertension (CTEPH).When there is suspicion of CTEPH, initial diagnostic tests should include echocardiography and ventilation/perfusion scan to detect perfusion defects. Subsequently, referral to a CTEPH center is recommended, where further imaging diagnostics and right heart catheterization are performed to determine the appropriate treatment.Currently, three treatment modalities are available. The treatment of choice is pulmonary endarterectomy (PEA). For non-operable patients or patients with residual PH after PEA, PH-targeted medical therapy, and the interventional procedure of balloon pulmonary angioplasty (BPA) are available. Increasingly, PEA, BPA, and pharmacological therapy are combined in multimodal concepts.Patients require post-treatment follow-up, preferably at (CTE)PH centers. These centers are required to perform a minimum number of PEA surgeries (50/year) and BPA interventions (100/year).
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Affiliation(s)
- Stefan Guth
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Heinrike Wilkens
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin, Missionsärztliche Klinik Würzburg, Würzburg, Deutschland
| | - Lukas Hobohm
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Albert Omlor
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Hans-Jürgen Seyfarth
- Bereich Pneumologie, Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Eckhard Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
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Purgatorio R, Gambacorta N, Samarelli F, Lopopolo G, de Candia M, Catto M, Nicolotti O, Altomare CD. Assessing the Role of a Malonamide Linker in the Design of Potent Dual Inhibitors of Factor Xa and Cholinesterases. Molecules 2022; 27:molecules27134269. [PMID: 35807514 PMCID: PMC9268553 DOI: 10.3390/molecules27134269] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022] Open
Abstract
The rational discovery of new peptidomimetic inhibitors of the coagulation factor Xa (fXa) could help set more effective therapeutic options (to prevent atrial fibrillation). In this respect, we explored the conformational impact on the enzyme inhibition potency of the malonamide bridge, compared to the glycinamide one, as a linker connecting the P1 benzamidine anchoring moiety to the P4 aryl group of novel selective fXa inhibitors. We carried out structure–activity relationship (SAR) studies aimed at investigating para- or meta-benzamidine as the P1 basic group as well as diversely decorated aryl moieties as P4 fragments. To this end, twenty-three malonamide derivatives were synthesized and tested as inhibitors of fXa and thrombin (thr); the molecular determinants behind potency and selectivity were also studied by employing molecular docking. The malonamide linker, compared to the glycinamide one, does significantly increase anti-fXa potency and selectivity. The meta-benzamidine (P1) derivatives bearing 2′,4′-difluoro-biphenyl as the P4 moiety proved to be highly potent reversible fXa-selective inhibitors, achieving inhibition constants (Ki) in the low nanomolar range. The most active compounds were also tested against cholinesterase (ChE) isoforms (acetyl- or butyrylcholinesterase, AChE, and BChE), and some of them returned single-digit micromolar inhibition potency against AChE and/or BChE, both being drug targets for symptomatic treatment of mild-to-moderate Alzheimer’s disease. Compounds 19h and 22b were selected as selective fXa inhibitors with potential as multimodal neuroprotective agents.
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