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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [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: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Lopez-Crisosto C, Arias-Carrasco R, Sepulveda P, Garrido-Olivares L, Maracaja-Coutinho V, Verdejo HE, Castro PF, Lavandero S. Novel molecular insights and public omics data in pulmonary hypertension. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166200. [PMID: 34144090 DOI: 10.1016/j.bbadis.2021.166200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 12/21/2022]
Abstract
Pulmonary hypertension is a rare disease with high morbidity and mortality which mainly affects women of reproductive age. Despite recent advances in understanding the pathogenesis of pulmonary hypertension, the high heterogeneity in the presentation of the disease among different patients makes it difficult to make an accurate diagnosis and to apply this knowledge to effective treatments. Therefore, new studies are required to focus on translational and personalized medicine to overcome the lack of specificity and efficacy of current management. Here, we review the majority of public databases storing 'omics' data of pulmonary hypertension studies, from animal models to human patients. Moreover, we review some of the new molecular mechanisms involved in the pathogenesis of pulmonary hypertension, including non-coding RNAs and the application of 'omics' data to understand this pathology, hoping that these new approaches will provide insights to guide the way to personalized diagnosis and treatment.
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Affiliation(s)
- Camila Lopez-Crisosto
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago 8380492, Chile; Advanced Center for Chronic Diseases (ACCDiS), Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 8380492, Chile
| | - Raul Arias-Carrasco
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago 8380492, Chile
| | - Pablo Sepulveda
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 8380492, Chile; Division of Cardiovascular Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Garrido-Olivares
- Cardiovascular Surgery, Division of Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vinicius Maracaja-Coutinho
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago 8380492, Chile
| | - Hugo E Verdejo
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 8380492, Chile; Division of Cardiovascular Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo F Castro
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 8380492, Chile; Division of Cardiovascular Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Sergio Lavandero
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago 8380492, Chile; Department of Internal Medicine, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA.
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Hemnes A, Rothman AMK, Swift AJ, Zisman LS. Role of biomarkers in evaluation, treatment and clinical studies of pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020957234. [PMID: 33282185 PMCID: PMC7682212 DOI: 10.1177/2045894020957234] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension is a complex disease resulting from the interplay of myriad biological and environmental processes that lead to remodeling of the pulmonary vasculature with consequent pulmonary hypertension. Despite currently available therapies, there remains significant morbidity and mortality in this disease. There is great interest in identifying and applying biomarkers to help diagnose patients with pulmonary arterial hypertension, inform prognosis, guide therapy, and serve as surrogate endpoints. An extensive literature on potential biomarker candidates is available, but barriers to the implementation of biomarkers for clinical use in pulmonary arterial hypertension are substantial. Various omic strategies have been undertaken to identify key pathways regulated in pulmonary arterial hypertension that could serve as biomarkers including genomic, transcriptomic, proteomic, and metabolomic approaches. Other biologically relevant components such as circulating cells, microRNAs, exosomes, and cell-free DNA have recently been gaining attention. Because of the size of the datasets generated by these omic approaches and their complexity, artificial intelligence methods are being increasingly applied to decipher their meaning. There is growing interest in imaging the lung with various modalities to understand and visualize processes in the lung that lead to pulmonary vascular remodeling including high resolution computed tomography, Xenon magnetic resonance imaging, and positron emission tomography. Such imaging modalities have the potential to demonstrate disease modification resulting from therapeutic interventions. Because right ventricular function is a major determinant of prognosis, imaging of the right ventricle with echocardiography or cardiac magnetic resonance imaging plays an important role in the evaluation of patients and may also be useful in clinical studies of pulmonary arterial hypertension.
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Affiliation(s)
- Anna Hemnes
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrew J Swift
- University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
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Lee MH, Bull TM. The role of pulmonary arterial hypertension-targeted therapy in systemic sclerosis. F1000Res 2019; 8:F1000 Faculty Rev-2124. [PMID: 32025283 PMCID: PMC6971837 DOI: 10.12688/f1000research.20313.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension, categorized as group 1 pulmonary hypertension by the World Health Organization classification system, represents a major complication of systemic sclerosis resulting from pulmonary vascular involvement of the disease. The high mortality seen in systemic sclerosis-associated pulmonary arterial hypertension is likely due to the impairment of right ventricular systolic function and the coexistence of other non-group-1 pulmonary hypertension phenotypes that may negatively impact clinical response to pulmonary arterial hypertension-targeted therapy. This review highlights two areas of recent advances regarding the management of systemic sclerosis patients with pulmonary hypertension: the tolerability of pulmonary arterial hypertension-targeted therapy in the presence of mild to moderate interstitial lung disease and the potential clinical significance of the antifibrotic effect of soluble guanylate cyclase stimulators demonstrated in preclinical studies.
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Affiliation(s)
- Michael H Lee
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Colorado, USA
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Colorado, USA
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Zhang L, Chen S, Zeng X, Lin D, Li Y, Gui L, Lin MJ. Revealing the pathogenic changes of PAH based on multiomics characteristics. J Transl Med 2019; 17:231. [PMID: 31331330 PMCID: PMC6647123 DOI: 10.1186/s12967-019-1981-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 07/12/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pulmonary artery hypertension (PAH), which is characterized by an increase in pulmonary circulation blood pressure, is a fatal disease, and its pathogenesis remains unclear. METHODS In this study, RNA sequencing (RNA-seq), tandem mass tags (TMT) and reduced representation bisulfite sequencing (RRBS) were performed to detect the levels of mRNA, protein, and DNA methylation in pulmonary arteries (PAs), respectively. To screen the possible pathways and proteins related to PAH, pathway enrichment analysis and protein-protein interaction (PPI) network analysis were performed. For selected genes, differential expression levels were confirmed at both the transcriptional and translational levels by real-time PCR and Western blot analyses, respectively. RESULTS A total of 362 differentially expressed genes (|Fold-change| > 1.5 and p < 0.05), 811 differentially expressed proteins (|Fold-change| > 1.2 and p < 0.05) and 76,562 differentially methylated regions (1000 bp slide windows, 500 bp overlap, p < 0.05, and |Fold-change| > 1.2) were identified when the PAH group (n = 15) was compared with the control group (n = 15). Through an integrated analysis of the characteristics of the three omic analyses, a multiomics table was constructed. Additionally, pathway enrichment analysis showed that the differentially expressed proteins were significantly enriched in five Kyoto Encyclopedia of Genes and Genomes (KEGG) biological pathways and ten Gene Ontology (GO) terms for the PAH group compared with the control group. Moreover, protein-protein interaction (PPI) networks were constructed to identify hub genes. Finally, according to the genes identified in the PPI and the protein expression fold-change, nine key genes and their associated proteins were verified by real-time PCR and Western blot analyses, including Col4a1, Itga5, Col2a1, Gstt1, Gstm3, Thbd, Mgst2, Kng1 and Fgg. CONCLUSIONS This study conducted multiomic characteristic profiling to identify genes that contribute to the hypoxia-induced PAH model, identifying new avenues for basic PAH research.
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Affiliation(s)
- Li Zhang
- Department of Physiology & Pathophysiology, Fujian Medical University, Fuzhou, China.,The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Shaokun Chen
- Department of Physiology & Pathophysiology, Fujian Medical University, Fuzhou, China.,The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Xixi Zeng
- Department of Physiology & Pathophysiology, Fujian Medical University, Fuzhou, China.,The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Dacen Lin
- Department of Physiology & Pathophysiology, Fujian Medical University, Fuzhou, China.,The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Yumei Li
- The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.,Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Longxin Gui
- The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Mo-Jun Lin
- Department of Physiology & Pathophysiology, Fujian Medical University, Fuzhou, China. .,The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.
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Denton CP, Wells AU, Coghlan JG. Major lung complications of systemic sclerosis. Nat Rev Rheumatol 2018; 14:511-527. [DOI: 10.1038/s41584-018-0062-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
“A biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or of a condition or disease. A biomarker may be used to see how well the body responds to a treatment for a disease or condition. Also called molecular marker or signature molecule” – Biomarker definition, National Institutes of Health, National Cancer Institute, Dictionary of Cancer Terms
Although this definition pertains to the field of cancer and cancer biology, it applies to many disciplines, including the field of pulmonary vascular disease. In the world of pulmonary hypertension (PH), biomarkers hold a special place. In the diagnosis of PH subtype, we are limited by the risk of lung biopsy1 and, further, in patients with pulmonary arterial hypertension (PAH) we are limited by the inability to frequently obtain our strongest predictors of mortality: invasive pulmonary hemodynamic assessment. Thus, biomarkers hold much promise for the field of PH. We are searching for markers of PH subtypes and endophenotypes. We are looking for predictors of mortality in all forms of PH and, critically, we are hoping to find peripheral blood markers that will help us discover which drugs are likely to benefit a particular patient. Although we have made inroads in all 3 areas, there are substantial opportunities for refinement of our current biomarkers and discovery of novel markers to improve the care of PH patients. This review will cover the state of current biomarkers in PH and discuss challenges and future directions.
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Affiliation(s)
- Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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