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Allen BJ, Frye H, Ramanathan R, Caggiano LR, Tabima DM, Chesler NC, Philip JL. Biomechanical and Mechanobiological Drivers of the Transition From PostCapillary Pulmonary Hypertension to Combined Pre-/PostCapillary Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e028121. [PMID: 36734341 PMCID: PMC9973648 DOI: 10.1161/jaha.122.028121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Combined pre-/postcapillary pulmonary hypertension (Cpc-PH), a complication of left heart failure, is associated with higher mortality rates than isolated postcapillary pulmonary hypertension alone. Currently, knowledge gaps persist on the mechanisms responsible for the progression of isolated postcapillary pulmonary hypertension (Ipc-PH) to Cpc-PH. Here, we review the biomechanical and mechanobiological impact of left heart failure on pulmonary circulation, including mechanotransduction of these pathological forces, which lead to altered biological signaling and detrimental remodeling, driving the progression to Cpc-PH. We focus on pathologically increased cyclic stretch and decreased wall shear stress; mechanotransduction by endothelial cells, smooth muscle cells, and pulmonary arterial fibroblasts; and signaling-stimulated remodeling of the pulmonary veins, capillaries, and arteries that propel the transition from Ipc-PH to Cpc-PH. Identifying biomechanical and mechanobiological mechanisms of Cpc-PH progression may highlight potential pharmacologic avenues to prevent right heart failure and subsequent mortality.
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Affiliation(s)
- Betty J. Allen
- Department of SurgeryUniversity of Wisconsin‐MadisonMadisonWI
| | - Hailey Frye
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWI
| | - Rasika Ramanathan
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWI
| | - Laura R. Caggiano
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringUniversity of CaliforniaIrvineCA
| | - Diana M. Tabima
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWI
| | - Naomi C. Chesler
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWI
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringUniversity of CaliforniaIrvineCA
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2
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Structural and Hemodynamic Changes of the Right Ventricle in PH-HFpEF. Int J Mol Sci 2022; 23:ijms23094554. [PMID: 35562945 PMCID: PMC9103781 DOI: 10.3390/ijms23094554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022] Open
Abstract
One of the most important diagnostic challenges in clinical practice is the distinction between pulmonary hypertension (PH) due to primitive pulmonary arterial hypertension (PAH) and PH due to left heart diseases. Both conditions share some common characteristics and pathophysiological pathways, making the two processes similar in several aspects. Their diagnostic differentiation is based on hemodynamic data on right heart catheterization, cardiac structural modifications, and therapeutic response. More specifically, PH secondary to heart failure with preserved ejection fraction (HFpEF) shares features with type 1 PH (PAH), especially when the combined pre- and post-capillary form (CpcPH) takes place in advanced stages of the disease. Right ventricular (RV) dysfunction is a common consequence related to worse prognosis and lower survival. This condition has recently been identified with a new classification based on clinical signs and progression markers. The role and prevalence of PH and RV dysfunction in HFpEF remain poorly identified, with wide variability in the literature reported from the largest clinical trials. Different parenchymal and vascular alterations affect the two diseases. Capillaries and arteriole vasoconstriction, vascular obliteration, and pulmonary blood fluid redistribution from the basal to the apical district are typical manifestations of type 1 PH. Conversely, PH related to HFpEF is primarily due to an increase of venules/capillaries parietal fibrosis, extracellular matrix deposition, and myocyte hypertrophy with a secondary “arteriolarization” of the vessels. Since the development of structural changes and the therapeutic target substantially differ, a better understanding of pathobiological processes underneath PH-HFpEF, and the identification of potential maladaptive RV mechanisms with an appropriate diagnostic tool, become mandatory in order to distinguish and manage these two similar forms of pulmonary hypertension.
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3
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Abstract
Pulmonary hypertension is common in left heart disease and is related most commonly to passive back transmission of elevated left atrial pressures. Some patients, however, may develop pulmonary vascular remodeling superimposed on their left-sided heart disease. This review provides a contemporary appraisal of existing criteria to diagnose a precapillary component to pulmonary hypertension in left heart disease as well as discusses etiologies, management issues, and future directions.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55906, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55906, USA.
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4
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Pirlamarla P, Rame E, Hoopes C, Rajapreyar I. Pulmonary vasodilator use in continuous-flow left ventricular assist device management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:522. [PMID: 33850919 PMCID: PMC8039680 DOI: 10.21037/atm-20-4710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease is the most common etiology for PH. PH in patients with heart failure with reduced fraction (HFrEF) is associated with reduced functional capacity and increased mortality. PH-HFrEF can be isolated post-capillary or combined pre- and post-capillary PH. Chronic elevation of left-sided filling pressures may lead to reverse remodeling of the pulmonary vasculature with development of precapillary component of PH. Untreated PH in patients with HFrEF results in predominant right heart failure (RHF) with irreversible end-organ dysfunction. Management of PH-HFrEF includes diuretics, vasodilators like angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers or angiotensin-receptor blocker-neprilysin inhibitors, hydralazine and nitrates. There is no role for pulmonary vasodilator use in patients with PH-HFrEF due to increased mortality in clinical trials. In patients with end-stage HFrEF and fixed PH unresponsive to vasodilator challenge, implantation of continuous-flow left ventricular assist device (cfLVAD) results in marked improvement in pulmonary artery pressures within 6 months due to left ventricular (LV) mechanical unloading. The role of pulmonary vasodilators in management of precapillary component of PH after cfLVAD is not well-defined. The purpose of this review is to discuss the pharmacologic management of PH after cfLVAD implantation.
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Affiliation(s)
- Preethi Pirlamarla
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Eduardo Rame
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Charles Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama-Birmingham School of Medicine, Birmingham, AL, USA
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5
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Abstract
Introduction: Pulmonary hypertension (PH) secondary to left-sided heart disease (Group 2 PH) is a frequent complication of heart failure (HF) and is a heterogeneous phenotypic disorder that worsens exercise capacity, increases risk for hospitalization and survival independent of left ventricular ejection fraction (LVEF) or stage of HF. Areas covered: In this review, an update of the current knowledge and some potential challenges about the pathophysiology and treatments of group 2 PH in patients with HF of either preserved or reduced ejection fraction are provided. Also, this review discusses the epidemiology and provides hints for the optimal evaluation and diagnosis of these patients to prevent misclassification of their pulmonary hypertension. Expert opinion: There are many of areas lacking knowledge and understanding in the field of pulmonary hypertension associated to left heart disease (PH-LHD) that should be addressed in the future. Further research should be performed, in terms of pathobiology, and understanding the predisposition (genetic susceptibility and contributing factors) of the different phenotypes of this disorder. More clinical trials targeting new therapeutic options and specific PH therapies are warranted to help this increasing important patient group as the current guidelines recommend to only treat the underlying left-sided heart disease.
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Affiliation(s)
- Ronald Zolty
- a Medical Center College of Medicine , University of Nebraska , Omaha , NE , USA
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6
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Filippetti L, Voilliot D, Bellino M, Citro R, Go YY, Lancellotti P. The Right Heart-Pulmonary Circulation Unit and Left Heart Valve Disease. Heart Fail Clin 2018; 14:431-442. [PMID: 29966640 DOI: 10.1016/j.hfc.2018.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Valvular heart disease (VHD) is frequently accompanied by pulmonary hypertension (PH). In asymptomatic patients, PH is rare, although the exact prevalence is unknown and mainly stems from the severity of the VHD and the presence of diastolic dysfunction. PH can also be depicted during exercise echocardiography. PH either at rest or during exercise is also a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology. Therefore, because PH is a marker of poor prognosis, assessment of PH in VHD is crucial for risk stratification and management of patients with VHD.
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Affiliation(s)
- Laura Filippetti
- Department of Cardiology, University Hospital of Nancy, Lorrain Institute for Heart and Vessels, F-54500 Vandoeuvre-lès-Nancy, France
| | - Damien Voilliot
- Department of Cardiology, University Hospital of Nancy, Lorrain Institute for Heart and Vessels, F-54500 Vandoeuvre-lès-Nancy, France; IADI Laboratory (DIAGNOSIS AND INTERVENTIONAL ADAPTIVE IMAGING), INSERM U947, University of Lorraine, F-54500 Nancy, France
| | - Michele Bellino
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84131 Salerno, Italy
| | - Rodolfo Citro
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84131 Salerno, Italy
| | - Yun Yun Go
- National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, 16960 Singapore, Singapore; GIGA Cardiovascular Sciences, University Hospital Sart Tilman, 4000 Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, University Hospital Sart Tilman, 4000 Liège, Belgium; Heart Valve Clinic, Department of Cardiology, University Hospital Sart Tilman, 4000 Liège, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, VIA C. ROSALBA, 35/37 70124 Bari, Italy.
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7
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van Duin RWB, Stam K, Cai Z, Uitterdijk A, Garcia-Alvarez A, Ibanez B, Danser AHJ, Reiss IKM, Duncker DJ, Merkus D. Transition from post-capillary pulmonary hypertension to combined pre- and post-capillary pulmonary hypertension in swine: a key role for endothelin. J Physiol 2018; 597:1157-1173. [PMID: 29799120 PMCID: PMC6375874 DOI: 10.1113/jp275987] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
Key points Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
Abstract Passive, isolated post‐capillary pulmonary hypertension (IpcPH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH (CpcPH) characterized by chronic pulmonary vascular constriction and remodelling. The mechanisms underlying this ‘activation’ of passive pulmonary hypertension (PH) remain incompletely understood. Here we investigated the role of the vasoconstrictor endothelin‐1 (ET) in the progression from IpcPH to CpcPH in a swine model for post‐capillary PH. Swine underwent pulmonary vein banding (PVB; n = 7) or sham‐surgery (Sham; n = 6) and were chronically instrumented 4 weeks later. Haemodynamics were assessed for 8 weeks, at rest and during exercise, before and after administration of the ET receptor antagonist tezosentan. After sacrifice, the pulmonary vasculature was investigated by histology, RT‐qPCR and myograph experiments. Pulmonary arterial pressure and resistance increased significantly over time. mRNA expression of prepro‐endothelin‐1 and endothelin converting enzyme‐1 in the lung was increased, while ETA expression was unchanged and ETB expression was downregulated. This was associated with increased plasma ET levels from week 10 onward and a more pronounced vasodilatation to in vivo administration of tezosentan at rest and during exercise. Myograph experiments showed decreased endothelium‐dependent vasodilatation to Substance P and increased vasoconstriction to KCl in PVB swine consistent with increased muscularization observed with histology. Moreover, maximal vasoconstriction to ET was increased whereas ET sensitivity was decreased. In conclusion, PVB swine gradually developed PH with structural and functional vascular remodelling. From week 10 onward, the pulmonary ET pathway was upregulated, likely contributing to pre‐capillary activation of the initially isolated post‐capillary PH. Inhibition of the ET pathway could thus potentially provide a pharmacotherapeutic target for early stage post‐capillary PH. Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
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Affiliation(s)
- Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Zongye Cai
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - A H Jan Danser
- Department of Pharmacology, Erasmus MC, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Pediatrics / Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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8
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Lundgren J, Sandqvist A, Hedeland M, Bondesson U, Wikström G, Rådegran G. Alterations in plasma L-arginine and methylarginines in heart failure and after heart transplantation. SCAND CARDIOVASC J 2018; 52:196-204. [PMID: 29648475 DOI: 10.1080/14017431.2018.1459823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Endothelial function, including the nitric oxide (NO)-pathway, has previously been extensively investigated in heart failure (HF). In contrast, studies are lacking on the NO pathway after heart transplantation (HT). We therefore investigated substances in the NO pathway prior to and after HT in relation to hemodynamic parameters. DESIGN 12 patients (median age 50.0 yrs, 2 females), heart transplanted between June 2012 and February 2014, evaluated at our hemodynamic lab, at rest, prior to HT, as well as four weeks and six months after HT were included. All patients had normal left ventricular function post-operatively and none had post-operative pulmonary hypertension or acute cellular rejection requiring therapy at the evaluations. Plasma concentrations of ADMA, SDMA, L-Arginine, L-Ornithine and L-Citrulline were analyzed at each evaluation. RESULTS In comparison to controls, the plasma L-Arginine concentration was low and ADMA high in HF patients, resulting in low L-Arginine/ADMA-ratio pre-HT. Already four weeks after HT L-Arginine was normalized whereas ADMA remained high. Consequently the L-Arginine/ADMA-ratio improved, but did not normalize. The biomarkers remained unchanged at the six-month evaluation and the L-Arginine/ADMA-ratio correlated inversely to pulmonary vascular resistance (PVR) six months post-HT. CONCLUSIONS Plasma L-Arginine concentrations normalize after HT. However, as ADMA is unchanged, the L-Arginine/ADMA-ratio remained low and correlated inversely to PVR. Together these findings suggest that (i) the L-Arginine/ADMA-ratio may be an indicator of pulmonary vascular tone after HT, and that (ii) NO-dependent endothelial function is partly restored after HT. Considering the good postoperative outcome, the biomarker levels may be considered "normal" after HT.
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Affiliation(s)
- Jakob Lundgren
- a Department of Clinical Sciences Lund, Cardiology , Lund University , Lund , Sweden.,b The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Heart and Lung Clinic , Skåne University Hospital , Lund , Sweden
| | - Anna Sandqvist
- c Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology , Umeå University , Umeå , Sweden
| | - Mikael Hedeland
- d Department of Chemistry, Environment and Feed Hygiene , National Veterinary Institute (SVA) , Uppsala , Sweden.,e Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry , Uppsala University , Uppsala , Sweden
| | - Ulf Bondesson
- d Department of Chemistry, Environment and Feed Hygiene , National Veterinary Institute (SVA) , Uppsala , Sweden.,e Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry , Uppsala University , Uppsala , Sweden
| | - Gerhard Wikström
- f Department of Medical Sciences, Cardiology , Uppsala University, Uppsala University Hospital , Uppsala , Sweden
| | - Göran Rådegran
- a Department of Clinical Sciences Lund, Cardiology , Lund University , Lund , Sweden.,b The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Heart and Lung Clinic , Skåne University Hospital , Lund , Sweden
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9
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Abstract
Left heart disease (LHD) represents the most common cause of pulmonary hypertension (PH), and is associated with worse prognosis compared with LHD without PH. In addition, PH due to LHD may prevent patients from receiving heart transplantation, because of risk of perioperative right ventricular failure. Current literature lacks comprehensive descriptions and management strategies of PH due to LHD. In this review, we summarize the literature that is available to highlight the definition, pathogenesis, and prognosis of PH due to LHD. Furthermore, we discuss the use of mechanical circulatory support (MCS) in this population. Finally, we provide recommendations regarding the management and reassessment of PH due to LHD in the specific context of MCS.
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10
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Sahay S, Khirfan G, Tonelli AR. Management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction. Respir Med 2017; 131:94-100. [PMID: 28947049 DOI: 10.1016/j.rmed.2017.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/01/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
Management of pulmonary hypertension (PH) has remained an unmet need in advanced left heart failure with reduced ejection fraction. In fact, patients are frequently denied heart transplant due to untreated pulmonary hypertension. The availability of mechanically circulatory devices and PH therapies has provided a ray of hope. PH specific therapies are currently not FDA approved for patients with left heart failure with reduced ejection fraction. However, clinicians have used these medications in anecdotal manner. With this review, we want to highlight the expanding use of PH specific therapy and mechanical circulatory devices in the management of PH in the setting of advanced heart failure with reduced ejection fraction.
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Affiliation(s)
- Sandeep Sahay
- Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Lung Center, Houston Methodist Hospital, Houston, TX, USA.
| | - Ghaleb Khirfan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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11
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Guazzi M, Naeije R. Pulmonary Hypertension in Heart Failure: Pathophysiology, Pathobiology, and Emerging Clinical Perspectives. J Am Coll Cardiol 2017; 69:1718-1734. [PMID: 28359519 DOI: 10.1016/j.jacc.2017.01.051] [Citation(s) in RCA: 216] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 02/08/2023]
Abstract
Pulmonary hypertension is a common hemodynamic complication of heart failure. Interest in left-sided pulmonary hypertension has increased remarkably in recent years because its development and consequences for the right heart are now seen as mainstay abnormalities that begin in the early stages of the disease and bear unfavorable prognostic insights. However, some knowledge gaps limit our ability to influence this complex condition. Accordingly, attention is now focused on: 1) establishing a definitive consensus for a hemodynamic definition, perhaps incorporating exercise and fluid challenge; 2) implementing the limited data available on the pathobiology of lung capillaries and small arteries; 3) developing standard methods for assessing right ventricular function and, hopefully, its coupling to pulmonary circulation; and 4) searching for effective therapies that may benefit lung vessels and the remodeled right ventricle. The authors review the pathophysiology, pathobiology, and emerging clinical perspectives on pulmonary hypertension across the broad spectrum of heart failure stages.
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Affiliation(s)
- Marco Guazzi
- IRCCS Policlinico San Donato Hospital, University of Milan, Milan, Italy.
| | - Robert Naeije
- Erasme Hospital, Free University of Brussels, Brussels, Belgium
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12
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Martinez C, Bernard A, Dulgheru R, Incarnato P, Oury C, Lancellotti P. Pulmonary Hypertension in Aortic Stenosis and Mitral Regurgitation: Rest and Exercise Echocardiography Significance. Prog Cardiovasc Dis 2016; 59:59-70. [PMID: 27389810 DOI: 10.1016/j.pcad.2016.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 01/21/2023]
Abstract
Valvular heart disease is a common cause of increased mean pulmonary artery pressure (PAP). Aortic stenosis and mitral regurgitation are frequently accompanied by pulmonary hypertension (PH), especially when they are severe and symptomatic. In asymptomatic patients, PH is rare, though the exact prevalence is unknown and mainly stems from the severity of the valvular heart disease and the presence of diastolic dysfunction. Exercise echocardiography has recently gained interest in depicting PH. In these asymptomatic patients, exercise PH is observed in about >40%. Either PH at rest (systolic PAP >50 mmHg) or during exercise (systolic PAP >60 mmHg) is a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology.
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Affiliation(s)
- Christophe Martinez
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Anne Bernard
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium; University of Tours Hospital, Cardiology Department, Tours, France and University François Rabelais, Tours, France
| | - Raluca Dulgheru
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Pierluigi Incarnato
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Cécile Oury
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy.
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13
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Hussain N, Charalampopoulos A, Ramjug S, Condliffe R, Elliot CA, O'Toole L, Swift A, Kiely DG. Pulmonary hypertension in patients with heart failure and preserved ejection fraction: differential diagnosis and management. Pulm Circ 2016; 6:3-14. [PMID: 27162611 PMCID: PMC4860544 DOI: 10.1086/685021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most common cause of pulmonary hypertension (PH) due to left heart disease (LHD) was previously rheumatic mitral valve disease. However, with the disappearance of rheumatic fever and an aging population, nonvalvular LHD is now the most common cause of group 2 PH in the developed world. In this review, we examine the challenge of investigating patients who have PH and heart failure with preserved ejection fraction (HF-pEF), where differentiating between pulmonary arterial hypertension (PAH) and PH-LHD can be difficult, and also discuss the entity of combined precapillary and postcapillary PH. Given the proven efficacy of targeted therapy for the treatment of PAH, there is increasing interest in whether these treatments may benefit selected patients with PH associated with HF-pEF, and we review current trial data.
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Affiliation(s)
- Nehal Hussain
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Sheila Ramjug
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Laurence O'Toole
- Department of Cardiology, Northern General Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Andrew Swift
- Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
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14
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New Diagnostic and Therapeutic Strategies for Pulmonary Hypertension Associated with Left Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:18. [DOI: 10.1007/s11936-016-0438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Lai YC, Tabima DM, Dube JJ, Hughan KS, Vanderpool RR, Goncharov DA, St Croix CM, Garcia-Ocaña A, Goncharova EA, Tofovic SP, Mora AL, Gladwin MT. SIRT3-AMP-Activated Protein Kinase Activation by Nitrite and Metformin Improves Hyperglycemia and Normalizes Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction. Circulation 2016; 133:717-31. [PMID: 26813102 DOI: 10.1161/circulationaha.115.018935] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary hypertension associated with heart failure with preserved ejection fraction (PH-HFpEF) is an increasingly recognized clinical complication of metabolic syndrome. No adequate animal model of PH-HFpEF is available, and no effective therapies have been identified to date. A recent study suggested that dietary nitrate improves insulin resistance in endothelial nitric oxide synthase null mice, and multiple studies have reported that both nitrate and its active metabolite, nitrite, have therapeutic activity in preclinical models of pulmonary hypertension. METHODS AND RESULTS To evaluate the efficacy and mechanism of nitrite in metabolic syndrome associated with PH-HFpEF, we developed a 2-hit PH-HFpEF model in rats with multiple features of metabolic syndrome attributable to double-leptin receptor defect (obese ZSF1) with the combined treatment of vascular endothelial growth factor receptor blocker SU5416. Chronic oral nitrite treatment improved hyperglycemia in obese ZSF1 rats by a process that requires skeletal muscle SIRT3-AMPK-GLUT4 signaling. The glucose-lowering effect of nitrite was abolished in SIRT3-deficient human skeletal muscle cells, and in SIRT3 knockout mice fed a high-fat diet, as well. Skeletal muscle biopsies from humans with metabolic syndrome after 12 weeks of oral sodium nitrite and nitrate treatment (IND#115926) displayed increased activation of SIRT3 and AMP-activated protein kinase. Finally, early treatments with nitrite and metformin at the time of SU5416 injection reduced pulmonary pressures and vascular remodeling in the PH-HFpEF model with robust activation of skeletal muscle SIRT3 and AMP-activated protein kinase. CONCLUSIONS These studies validate a rodent model of metabolic syndrome and PH-HFpEF, suggesting a potential role of nitrite and metformin as a preventative treatment for this disease.
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Affiliation(s)
- Yen-Chun Lai
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Diana M Tabima
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - John J Dube
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Kara S Hughan
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Rebecca R Vanderpool
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Dmitry A Goncharov
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Claudette M St Croix
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Adolfo Garcia-Ocaña
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Elena A Goncharova
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Stevan P Tofovic
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Ana L Mora
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Mark T Gladwin
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.).
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16
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Kulik TJ. Pulmonary hypertension caused by pulmonary venous hypertension. Pulm Circ 2015; 4:581-95. [PMID: 25610595 DOI: 10.1086/678471] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/16/2014] [Indexed: 12/21/2022] Open
Abstract
The effect of pulmonary venous hypertension (PVH) on the pulmonary circulation is extraordinarily variable, ranging from no impact on pulmonary vascular resistance (PVR) to a marked increase. The reasons for this are unknown. Both acutely reversible pulmonary vasoconstriction and pathological remodeling (especially medial hypertrophy and intimal hyperplasia) account for increased PVR when present. The mechanisms involved in vasoconstriction and remodeling are not clearly defined, but increased wall stress, especially in small pulmonary arteries, presumably plays an important role. Myogenic contraction may account for increased vascular tone and also indirectly stimulate remodeling of the vessel wall. Increased wall stress may also directly cause smooth muscle growth, migration, and intimal hyperplasia. Even long-standing and severe pulmonary hypertension (PH) usually abates with elimination of PVH, but PVH-PH is an important clinical problem, especially because PVH due to left ventricular noncompliance lacks definitive therapy. The role of targeted PH therapy in patients with PVH-PH is unclear at this time. Most prospective studies indicate that these medications are not helpful or worse, but there is ample reason to think that a subset of patients with PVH-PH may benefit from phosphodiesterase inhibitors or other agents. A different approach to evaluating possible pharmacologic therapy for PVH-PH may be required to better define its possible utility.
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Affiliation(s)
- Thomas J Kulik
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA; and Department of Cardiology, Division of Cardiac Critical Care, and the Pulmonary Hypertension Program, Boston Children's Hospital, Boston, Massachusetts, USA
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17
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Guazzi M, Phillips SA, Arena R, Lavie CJ. Endothelial dysfunction and lung capillary injury in cardiovascular diseases. Prog Cardiovasc Dis 2014; 57:454-62. [PMID: 25446556 DOI: 10.1016/j.pcad.2014.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Cardiac dysfunction of both systolic and diastolic origins leads to increased left atrial pressure, lung capillary injury and increased resistance to gas transfer. Acutely, pressure-induced trauma disrupts the endothelial and alveolar anatomical configuration and definitively causes an impairment of cellular pathways involved in fluid-flux regulation and gas exchange efficiency, a process well identified as stress failure of the alveolar-capillary membrane. In chronic heart failure (HF), additional stimuli other than pressure may trigger the true remodeling process of capillaries and small arteries characterized by endothelial dysfunction, proliferation of myofibroblasts, fibrosis and extracellular matrix deposition. In parallel there is a loss of alveolar gas diffusion properties due to the increased path from air to blood (thickening of extracellular matrix) and loss of fine molecular mechanism involved in fluid reabsorption and clearance. Deleterious changes in gas transfer not only reflect the underlying lung tissue damage but also portend independent prognostic information and may play a role in the pathogenesis of exercise limitation and ventilatory abnormalities observed in these patients. Few currently approved treatments for chronic HF have the potential to positively affect structural remodeling of the lung capillary network; angiotensin-converting enzyme inhibitors are one of the few currently established options. Recently, more attention has been paid to novel therapies specifically targeting the nitric oxide pathway as a suitable target to improve endothelial function and permeability as well as alveolar gas exchange properties.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, I.R.C.C.S. Policlinico San Donato, University of Milano, San Donato Milanese, Italy.
| | - Shane A Phillips
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA, USA
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18
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Dragu R, Rispler S, Habib M, Sholy H, Hammerman H, Galie N, Aronson D. Pulmonary arterial capacitance in patients with heart failure and reactive pulmonary hypertension. Eur J Heart Fail 2014; 17:74-80. [PMID: 25388783 DOI: 10.1002/ejhf.192] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 09/17/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022] Open
Abstract
AIMS Reactive pulmonary hypertension (PH) is a severe form of PH secondary to left-sided heart failure (HF). Given the structural and functional abnormalities in the pulmonary vasculature that occur in reactive PH, we hypothesized that pulmonary artery capacitance (PAC) may be profoundly affected, with implications for clinical outcome. METHODS AND RESULTS We studied 393 HF patients of whom 124 (32%) were classified as having passive PH and 140 (36%) as having reactive PH, and 91 patients with pulmonary arterial hypertension (PAH). Mean PAC was highest in patients without PH (4.5 ± 2.1 mL/mmHg), followed by the passive PH group (2.8 ± 1.4 mL/mmHg) and was lowest in those with reactive PH (1.8 ± 0.7 mL/mmHg) (P = 0.0001). PAC and pulmonary vascular resistance (PVR) fitted well to a hyperbolic inverse relationship (PAC = 0.25/PVR, R(2) = 0.70), with reactive PH patients dispersed almost predominantly on the flat part of the curve where a reduction in PVR is associated with a small improvement in PAC. Elevated PCWP was associated with a significant lowering of PAC for any PVR (P = 0.036). During a median follow-up of 31 months, both reactive PH [hazard ratio (HR) 2.59, 95% confidence interval (CI) 1.14-4.46, P = 0.02] and reduced PAC (HR 0.72 per 1 mL/mmHg increase, 95% CI 0.59-0.88, P = 0.001) were independent predictors of mortality. CONCLUSIONS The development of reactive PH is associated with a marked reduction in PAC. PAC is a strong independent haemodynamic marker of mortality in HF and may contribute to the increased mortality associated with reactive PH.
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Affiliation(s)
- Robert Dragu
- Department of Cardiology, Rambam Health Care Campus and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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19
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Farrero M, Blanco I, Batlle M, Santiago E, Cardona M, Vidal B, Castel MA, Sitges M, Barbera JA, Perez-Villa F. Pulmonary Hypertension Is Related to Peripheral Endothelial Dysfunction in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2014; 7:791-8. [DOI: 10.1161/circheartfailure.113.000942] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Marta Farrero
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Isabel Blanco
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Montserrat Batlle
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Evelyn Santiago
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Montserrat Cardona
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Barbara Vidal
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - M. Angeles Castel
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Marta Sitges
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Joan Albert Barbera
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
| | - Felix Perez-Villa
- From the Heart Failure and Heart Transplantation Program, Cardiology Department, Hospital Clinic (M.F., E.S., M.C., M.A.C., F.P.-V.), and Pulmonary Medicine Department, Hospital Clinic (I.B., J.A.B.), Barcelona, Spain; Institute of Biomedical Research August Pi i Sunyer (IDIBAPS) (I.B., M.B., J.A.B., F.P.-V.); Cardiac Imaging Section, Cardiology Department, Hospital Clinic (B.V.), Barcelona, Spain; and Biomedical Research Networking Centers on Respiratory Diseases (CIBERES) (I.B., J.A.B.), Madrid,
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20
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Abstract
The origins of the hydralazine/isosorbide dinitrate (H+ISDN) combination therapy are rooted in the first large-scale clinical trial in heart failure: V-HeFT I. Initially utilized for the balanced vasodilatory properties of each drug, we now know there is "more to the story." In fact, the maintenance of the nitroso-redox balance may be the true mechanism of benefit. Since the publication of V-HeFT I 30 years ago, H+ISDN has been the subject of much discussion and debate. Regardless of the many controversies surrounding H+ISDN, one thing is clear: therapy is underutilized and many patients who could benefit never receive the drugs. Ongoing physician and patient education are mandatory to improve the rates of H+ISDN use.
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Affiliation(s)
- Robert T Cole
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Divya Gupta
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Javed Butler
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
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21
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Affiliation(s)
- Harsh Patel
- Cleveland Clinic Foundation, Cleveland, OH (H.P., M.D., M.T., B.G., S.K.)
| | - Milind Desai
- Cleveland Clinic Foundation, Cleveland, OH (H.P., M.D., M.T., B.G., S.K.)
| | - E Murat Tuzcu
- Cleveland Clinic Foundation, Cleveland, OH (H.P., M.D., M.T., B.G., S.K.)
| | - Brian Griffin
- Cleveland Clinic Foundation, Cleveland, OH (H.P., M.D., M.T., B.G., S.K.)
| | - Samir Kapadia
- Cleveland Clinic Foundation, Cleveland, OH (H.P., M.D., M.T., B.G., S.K.)
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22
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Lundgren J, Rådegran G. Pathophysiology and potential treatments of pulmonary hypertension due to systolic left heart failure. Acta Physiol (Oxf) 2014; 211:314-33. [PMID: 24703457 DOI: 10.1111/apha.12295] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/03/2014] [Accepted: 03/28/2014] [Indexed: 12/19/2022]
Abstract
Pulmonary hypertension (PH) due to left heart failure is becoming increasingly prevalent and is associated with poor outcome. The precise pathophysiological mechanisms behind PH due to left heart failure are, however, still unclear. In its early course, PH is caused by increased left ventricular filling pressures, without pulmonary vessel abnormalities. Conventional treatment for heart failure may partly reverse such passive PH by optimizing left ventricular function. However, if increased pulmonary pressures persist, endothelial damage, excessive vasoconstriction and structural changes in the pulmonary vasculature may occur. There is, at present, no recommended medical treatment for this active component of PH due to left heart failure. However, as the vascular changes in PH due to left heart failure may be similar to those in pulmonary arterial hypertension (PAH), a selected group of these patients may benefit from PAH treatment targeting the endothelin, nitric oxide or prostacyclin pathways. Such potent pulmonary vasodilators could, however, be detrimental in patients with left heart failure without pulmonary vascular pathology, as selective pulmonary vasodilatation may lead to further congestion in the pulmonary circuit, resulting in pulmonary oedema. The use of PAH therapies is therefore currently not recommended and would require the selection of suitable patients based on the underlying causes of the disease and careful monitoring of their progress. The present review focuses on the following: (i) the pathophysiology behind PH resulting from systolic left heart failure, and (ii) the current evidence for medical treatment of this condition, especially the role of PAH-targeted therapies in systolic left heart failure.
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Affiliation(s)
- J. Lundgren
- The Haemodynamic Laboratory; The Clinic for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
- Department of Cardiology, Clinical Sciences; Lund University; Lund Sweden
| | - G. Rådegran
- The Haemodynamic Laboratory; The Clinic for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
- Department of Cardiology, Clinical Sciences; Lund University; Lund Sweden
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Gomart S, Damoiseaux C, Jespers P, Makanga M, Labranche N, Pochet S, Michaux C, Berkenboom G, Naeije R, McEntee K, Dewachter L. Pulmonary vasoreactivity in spontaneously hypertensive rats--effects of endothelin-1 and leptin. Respir Res 2014; 15:12. [PMID: 24499246 PMCID: PMC3922960 DOI: 10.1186/1465-9921-15-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/17/2014] [Indexed: 11/29/2022] Open
Abstract
Background Systemic hypertension may be associated with an increased pulmonary vascular resistance, which we hypothesized could be, at least in part, mediated by increased leptin. Methods Vascular reactivity to phenylephrine (1 μmol/L), endothelin-1 (10 nmol/L) and leptin (0.001–100 nmol/L) was evaluated in endothelium-intact and -denuded isolated thoracic aorta and pulmonary arteries from spontaneously hypertensive versus control Wistar rats. Arteries were sampled for pathobiological evaluation and lung tissue for morphometric evaluation. Results In control rats, endothelin-1 induced a higher level of contraction in the pulmonary artery than in the aorta. After phenylephrine or endothelin-1 precontraction, leptin relaxed intact pulmonary artery and aortic rings, while no response was observed in denuded arteries. Spontaneously hypertensive rats presented with increased reactivity to phenylephrine and endothelin-1 in endothelium-intact pulmonary arteries. After endothelin-1 precontraction, endothelium-dependent relaxation to leptin was impaired in pulmonary arteries from hypertensive rats. In both strains of rats, aortic segments were more responsive to leptin than pulmonary artery. In hypertensive rats, pulmonary arteries exhibited increased pulmonary artery medial thickness, associated with increased expressions of preproendothelin-1, endothelin-1 receptors type A and B, inducible nitric oxide synthase and decreased endothelial nitric oxide synthase, together with decreased leptin receptor and increased suppressor of cytokine signaling 3 expressions. Conclusions Altered pulmonary vascular reactivity in hypertension may be related to a loss of endothelial buffering of vasoconstriction and decreased leptin-induced vasodilation in conditions of increased endothelin-1.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Laurence Dewachter
- Laboratory of Physiology, Faculty of Medicine, Université Libre de Bruxelles, Lennik road 808, 1070 Brussels, Belgium.
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Dupont M, Tang WHW. Right ventricular afterload and the role of nitric oxide metabolism in left-sided heart failure. J Card Fail 2013; 19:712-21. [PMID: 24125109 DOI: 10.1016/j.cardfail.2013.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/29/2013] [Accepted: 08/08/2013] [Indexed: 12/17/2022]
Abstract
Awareness has grown in recent years that right ventricular (RV) function is equally important as left ventricular (LV) function in the setting of left-sided heart disease. RV dysfunction can be the consequence of an increased afterload imposed by the failing LV. The concept of "afterload" is physically most correctly described by vascular input impedance. However, for clinical purposes, afterload is most often modeled to consist of 3 components; pulmonary vascular resistance (PVR), pulmonary arterial compliance (PAC), and characteristic impedance. Whereas PVR is historically most described, PAC (which represents the distensibility of the vasculature) has rapidly gained recognition for its prognostic ability in both pulmonary arterial hypertension and left-sided heart disease. Owing to the specific anatomy of the pulmonary circulation, PVR and PAC have an inverse hyperbolic relationship, which position can be shifted by varying wedge pressures. Knowledge of the afterload components helps one to understand how elevated left-sided filling pressures increase pulsatile load on the RV. An increase in resistive load (known as "reactive" or "out-of-proportion" pulmonary hypertension) ultimately complements the increase in pulsatile load. Perturbations in nitric oxide metabolism are thought to be crucial in this evolution and have therefore been sought as a major therapeutic target.
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Affiliation(s)
- Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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25
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Kanwar M, Agarwal R, Barnes M, Coons J, Raina A, Sokos G, Murali S, Benza RL. Role of phosphodiesterase-5 inhibitors in heart failure: emerging data and concepts. Curr Heart Fail Rep 2013; 10:26-35. [PMID: 23114592 DOI: 10.1007/s11897-012-0121-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Novel treatment of congestive heart failure (HF) involves utilizing unique pathways to improve upon contemporary therapies. Increasing the availability of cyclic guanosine monophosphate (cGMP) by inhibition of phosphodiesterase-5 (PDE5) is a relatively new, but promising therapeutic strategy. Preclinical studies suggest a favorable myocardial effect of PDE5 inhibitors by blocking adrenergic, hypertrophic and pro-apoptotic signaling, thereby supporting their use in HF. The clinical benefits of acute and chronic PDE5 inhibition on lung diffusion capacity, exercise performance and ejection fraction in humans are emerging and appear promising. Larger, controlled trials are now on-going to assess the safety, efficacy and tolerability of PDE5 inhibitors on morbidity and mortality in patients with both systolic and diastolic heart failure. If the results of these trials are positive, a new avenue for the treatment of HF will open, which will help curtail the societal effects of this costly and morbid disease.
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Affiliation(s)
- Manreet Kanwar
- Department of Medicine, Division of Cardiovascular Diseases, The Cardiovascular Institute at Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212, USA
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Schmeisser A, Schroetter H, Braun-Dulleaus RC. Management of pulmonary hypertension in left heart disease. Ther Adv Cardiovasc Dis 2013; 7:131-51. [DOI: 10.1177/1753944713477518] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease is classified as group II according to the Dana Point classification, which includes left ventricular systolic and/or diastolic left heart failure, and left-sided valvular disease. PH due to left heart disease is the most common cause and when present, especially with right ventricular dysfunction, is associated with a worse prognosis. Left heart disease with secondary PH is associated with increased left atrial pressure, which causes a passive increase in pulmonary pressure. Passive PH could be superimposed by an active protective, and in some patients by an ‘out of proportion’, elevated precapillary pulmonary vasoconstriction and vascular remodelling which leads to greater or lesser further increase of the pulmonary artery pressure. In this review, epidemiological and pathophysiologic mechanisms for the development of group II PH are summarized. The conflicting data about the haemodynamic and possible parameters to diagnose passive versus reactive and ‘out of proportion’ PH are presented. The different therapeutic concepts, along with novel treatment strategies, are reviewed in detail and critically discussed regarding their effectiveness and safety.
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Affiliation(s)
- Alexander Schmeisser
- Internal Medicine/Cardiology, Angiology and Pneumology, Magdeburg University, Leipziger Str.44, 39120 Magdeburg, Germany
| | - Hagen Schroetter
- Technical University Dresden, Heart Centre Dresden, University Hospital, Department of Internal Medicine and Cardiology, Dresden, Germany
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27
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Georgiopoulou VV, Kalogeropoulos AP, Borlaug BA, Gheorghiade M, Butler J. Left Ventricular Dysfunction With Pulmonary Hypertension. Circ Heart Fail 2013; 6:344-54. [DOI: 10.1161/circheartfailure.112.000095] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vasiliki V. Georgiopoulou
- From the Division of Cardiology, Emory University, Atlanta, GA (V.V.G., A.P.K., J.B.); Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B.); and Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Andreas P. Kalogeropoulos
- From the Division of Cardiology, Emory University, Atlanta, GA (V.V.G., A.P.K., J.B.); Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B.); and Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Barry A. Borlaug
- From the Division of Cardiology, Emory University, Atlanta, GA (V.V.G., A.P.K., J.B.); Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B.); and Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Mihai Gheorghiade
- From the Division of Cardiology, Emory University, Atlanta, GA (V.V.G., A.P.K., J.B.); Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B.); and Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Javed Butler
- From the Division of Cardiology, Emory University, Atlanta, GA (V.V.G., A.P.K., J.B.); Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B.); and Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL (M.G.)
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, Cardiology, I.R.C.C.S., Policlinico San Donato, Department of Medical Sciences, University of Milano, Piazza Malan 1 20097, San Donato Milanese, Milano, Italy.
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Marti CN, Gheorghiade M, Kalogeropoulos AP, Georgiopoulou VV, Quyyumi AA, Butler J. Endothelial dysfunction, arterial stiffness, and heart failure. J Am Coll Cardiol 2012; 60:1455-69. [PMID: 22999723 DOI: 10.1016/j.jacc.2011.11.082] [Citation(s) in RCA: 309] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/26/2011] [Accepted: 11/29/2011] [Indexed: 12/11/2022]
Abstract
Outcomes for heart failure (HF) patients remain suboptimal. No known therapy improves mortality in acute HF and HF with preserved ejection fraction; the most recent HF trial results have been negative or neutral. Improvement in surrogate markers has not necessarily translated into better outcomes. To translate breakthroughs with potential therapies into clinical benefit, a better understanding of the pathophysiology establishing the foundation of benefit is necessary. Vascular function plays a central role in the development and progression of HF. Endothelial function and nitric oxide availability affect myocardial function, systemic and pulmonary hemodynamics, and coronary and renal circulation. Arterial stiffness modulates ventricular loading conditions and diastolic function, key components of HF with preserved ejection. Endothelial function and arterial stiffness may therefore serve as important physiological targets for new HF therapies and facilitate patient selection for improved application of existing agents.
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Affiliation(s)
- Catherine N Marti
- Cardiology Division, Department of Medicine, Emory University, Atlanta, Georgia, USA
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30
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Fang JC, DeMarco T, Givertz MM, Borlaug BA, Lewis GD, Rame JE, Gomberg-Maitland M, Murali S, Frantz RP, McGlothlin D, Horn EM, Benza RL. World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2012; 31:913-33. [DOI: 10.1016/j.healun.2012.06.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 01/08/2023] Open
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Haddad F, Kudelko K, Mercier O, Vrtovec B, Zamanian RT, de Jesus Perez V. Pulmonary hypertension associated with left heart disease: characteristics, emerging concepts, and treatment strategies. Prog Cardiovasc Dis 2011; 54:154-67. [PMID: 21875514 DOI: 10.1016/j.pcad.2011.06.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Left heart disease (LHD) represents the most common causes of pulmonary hypertension (PH). Whether caused by systolic or diastolic dysfunction or valvular heart disease, a hallmark of PH associated with LHD is elevated left atrial pressure. In all cases, the increase in left atrial pressure causes a passive increase in pulmonary pressure. In some patients, a superimposed active component caused by pulmonary arterial vasoconstriction and vascular remodeling may lead to a further increase in pulmonary arterial pressure. When present, PH is associated with a worse prognosis in patients with LHD. In addition to local abnormalities in nitric oxide and endothelin production, gene modifiers such as serotonin polymorphisms may be associated with the pathogenesis of PH in LHD. Optimizing heart failure regimens and corrective valve surgery represent the cornerstone of the treatment of PH in LHD. Recent studies suggest that sildenafil, a phosphodiesterase-5 inhibitor, is a promising agent in the treatment of PH in LHD. Unloading the left ventricle with circulatory support may also reverse severe PH in patients with end-stage heart failure allowing candidacy to heart transplantation.
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Affiliation(s)
- Francois Haddad
- Division of Cardiovascular Medicine, Stanford School of Medicine, CA 94305, USA.
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32
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Cole RT, Kalogeropoulos AP, Georgiopoulou VV, Gheorghiade M, Quyyumi A, Yancy C, Butler J. Hydralazine and isosorbide dinitrate in heart failure: historical perspective, mechanisms, and future directions. Circulation 2011; 123:2414-22. [PMID: 21632515 DOI: 10.1161/circulationaha.110.012781] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kalogeropoulos AP, Vega JD, Smith AL, Georgiopoulou VV. Pulmonary Hypertension and Right Ventricular Function in Advanced Heart Failure. ACTA ACUST UNITED AC 2011; 17:189-98. [DOI: 10.1111/j.1751-7133.2011.00234.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Pulmonary hypertension (PH) with left-sided heart disease is defined, according to the latest Venice classification, as a Group 2 PH, which includes left-sided ventricular or atrial disease, and left-sided valvular diseases. These conditions are all associated with increased left ventricular filling pressure. Although PH with left-sided heart disease is a common entity, and long-term follow-up trials have provided firm recognition that development of left-sided PH carries a poor outcome, available data on incidence, pathophysiology, and therapy are sparse. Mitral stenosis was reported as the most frequent cause of PH several decades ago, but PH with left-sided heart disease is now usually caused by systemic hypertension and ischemic heart disease. In patients with these conditions, PH develops as a consequence of impaired left ventricular relaxation and distensibility. Chronic sustained elevation of cardiogenic blood pressure in pulmonary capillaries leads to a cascade of untoward retrograde anatomical and functional effects that represent specific targets for therapeutic intervention. The pathophysiological and clinical importance of the hemodynamic consequences of left-sided heart disease, starting with lung capillary injury and leading to right ventricular overload and failure, are discussed in this Review, focusing on PH as an evolving contributor to heart failure that may be amenable to novel interventions.
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Affiliation(s)
- Marco Guazzi
- Cardiopulmonary Unit, University of Milan, San Paolo Hospital, Via A. di Rudinì 8, 20142 Milan, Italy.
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35
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Guglin M, Khan H. Pulmonary hypertension in heart failure. J Card Fail 2010; 16:461-74. [PMID: 20610227 DOI: 10.1016/j.cardfail.2010.01.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 01/14/2010] [Accepted: 01/19/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary hypertension occurs in 60% to 80% of patients with heart failure and is associated with high morbidity and mortality. METHODS AND RESULTS Pulmonary artery pressure correlates with increased left ventricular end-diastolic pressure. Therefore, pulmonary hypertension is a common feature of heart failure with preserved as well as reduced systolic function. Pulmonary hypertension is partially reversible with normalization of cardiac filling pressures. Pulmonary vasculature remodeling and vasoconstriction create a second component, which does not reverse immediately, but has been shown to improve with vasoactive drugs and especially with left ventricular assist devices. CONCLUSION Many drugs used for idiopathic pulmonary arterial hypertension are being considered as treatment options for heart failure-related pulmonary hypertension. This is of particular significance in the heart transplant population. Randomized clinical trials with interventions targeting heart failure patients with elevated pulmonary artery pressure would be justified.
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Affiliation(s)
- Maya Guglin
- Department of Cardiology, University of South Florida, Tampa, Florida 33618, USA.
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36
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Shah RV, Semigran MJ. Pulmonary hypertension secondary to left ventricular systolic dysfunction: contemporary diagnosis and management. Curr Heart Fail Rep 2009; 5:226-32. [PMID: 19032918 DOI: 10.1007/s11897-008-0034-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pulmonary hypertension secondary to left ventricular systolic dysfunction is often a poor prognostic marker in chronic heart failure. In this article, we review evidence supporting modern strategies addressing pulmonary hypertension in patients with left ventricular systolic dysfunction, including right-sided heart catheterization with vasoreactivity testing and subsequent parenteral, oral, and inhaled therapy. We delineate a diagnostic approach to secondary pulmonary hypertension and outline evidence-based therapeutic strategies for management in acute and chronic heart failure.
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Affiliation(s)
- Ravi V Shah
- Department of Medicine, Massachusetts General Hospital, Grey Bigelow 8, 55 Fruit Street, Boston, MA 02114, USA
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37
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Control of pulmonary vascular tone during exercise in health and pulmonary hypertension. Pharmacol Ther 2008; 119:242-63. [PMID: 18586325 DOI: 10.1016/j.pharmthera.2008.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 04/29/2008] [Indexed: 11/24/2022]
Abstract
Despite the importance of the pulmonary circulation as a determinant of exercise capacity in health and disease, studies into the regulation of pulmonary vascular tone in the healthy lung during exercise are scarce. This review describes the current knowledge of the role of various endogenous vasoactive mechanisms in the control of pulmonary vascular tone at rest and during exercise. Recent studies demonstrate an important role for endothelial factors (NO and endothelin) and neurohumoral factors (noradrenaline, acetylcholine). Moreover, there is evidence that natriuretic peptides, reactive oxygen species and phosphodiesterase activity can influence resting pulmonary vascular tone, but their role in the control of pulmonary vascular tone during exercise remains to be determined. K-channels are purported end-effectors in control of pulmonary vascular tone. However, K(ATP) channels do not contribute to regulation of pulmonary vascular tone, while the role of K(V) and K(Ca) channels at rest and during exercise remains to be determined. Pulmonary hypertension is associated with alterations in pulmonary vascular function and structure, resulting in blunted pulmonary vasodilatation during exercise and impaired exercise capacity. Although there is a paucity of studies pertaining to the regulation of pulmonary vascular tone during exercise in idiopathic pulmonary hypertension, the few studies that have been performed in models of pulmonary hypertension secondary to left ventricular dysfunction suggest altered control of pulmonary vascular tone during exercise. Since the increased pulmonary vascular tone during exercise limits exercise capacity, future studies are needed to investigate the vasomotor mechanisms that are responsible for the blunted exercise-induced pulmonary vasodilatation in pulmonary hypertension.
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Kaestle SM, Reich CA, Yin N, Habazettl H, Weimann J, Kuebler WM. Nitric oxide-dependent inhibition of alveolar fluid clearance in hydrostatic lung edema. Am J Physiol Lung Cell Mol Physiol 2007; 293:L859-69. [PMID: 17616651 DOI: 10.1152/ajplung.00008.2007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Formation of cardiogenic pulmonary edema in acute left heart failure is traditionally attributed to increased fluid filtration from pulmonary capillaries and subsequent alveolar flooding. Here, we demonstrate that hydrostatic edema formation at moderately elevated vascular pressures is predominantly caused by an inhibition of alveolar fluid reabsorption, which is mediated by endothelial-derived nitric oxide (NO). In isolated rat lungs, we quantified fluid fluxes into and out of the alveolar space and endothelial NO production by a two-compartmental double-indicator dilution technique and in situ fluorescence imaging, respectively. Elevation of hydrostatic pressure induced Ca(2+)-dependent endothelial NO production and caused a net fluid shift into the alveolar space, which was predominantly attributable to impaired fluid reabsorption. Inhibition of NO production or soluble guanylate cyclase reconstituted alveolar fluid reabsorption, whereas fluid clearance was blocked by exogenous NO donors or cGMP analogs. In isolated mouse lungs, hydrostatic edema formation was attenuated by NO synthase inhibition. Similarly, edema formation was decreased in isolated mouse lungs of endothelial NO synthase-deficient mice. Chronic heart failure results in endothelial dysfunction and preservation of alveolar fluid reabsorption. These findings identify impaired alveolar fluid clearance as an important mechanism in the pathogenesis of hydrostatic lung edema. This effect is mediated by endothelial-derived NO acting as an intercompartmental signaling molecule at the alveolo-capillary barrier.
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Affiliation(s)
- Stephanie M Kaestle
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin Arnimallee 22, 14195 Berlin, Germany
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39
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Merkus D, Houweling B, de Beer VJ, Everon Z, Duncker DJ. Alterations in endothelial control of the pulmonary circulation in exercising swine with secondary pulmonary hypertension after myocardial infarction. J Physiol 2007; 580:907-23. [PMID: 17289783 PMCID: PMC2075461 DOI: 10.1113/jphysiol.2006.127118] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Secondary pulmonary hypertension after myocardial infarction (MI) has been associated with endothelial dysfunction and activation of the endothelin (ET) system. Here, we investigated whether an increased ET-mediated pulmonary vasoconstrictor influence contributes to pulmonary hypertension after MI, and whether this increased ET vasoconstriction is caused by impaired nitric oxide (NO) and prostanoid production. For this purpose, chronically instrumented swine with and without MI ran on a treadmill at 0-4 km h(-1). Mixed ET(A)/ET(B) receptor blockade (tezosentan) was performed in the absence and presence of single or combined inhibition of endothelial NO synthase (eNOS, with N(omega)-nitro-l-arginine) and cyclo-oxygenase (COX, with indometacin). In normal swine, mixed ET(A)/ET(B) blockade decreased pulmonary vascular resistance, but only during exercise. In MI swine, an increased ET-mediated vasoconstrictor influence was observed in the pulmonary circulation both at rest and during exercise. Inhibition of COX resulted in pulmonary vasoconstriction at rest in MI, but not in normal swine; this vasoconstriction in MI swine was normalized by ET(A)/ET(B) receptor blockade. Inhibition of eNOS enhanced the vasodilator response to ET(A)/ET(B) blockade, indicating that NO blunts the pulmonary vasoconstrictor influence of ET. However, this vasodilator response was enhanced to a similar degree in MI and normal swine. In summary, swine with a recent MI are characterized by an exaggerated pulmonary vasoconstrictor influence of ET. This increased ET-mediated pulmonary vasoconstrictor influence is not caused by a loss of NO bioavailability, and is blunted by an increased prostanoid-mediated vasodilatation. In conclusion, an increased ET-mediated vasoconstriction, which does not appear to be the result of loss of endothelial vasodilators, contributes to pulmonary hypertension after MI.
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Affiliation(s)
- Daphne Merkus
- Experimental Cardiology, Thoraxcentre, Cardiovascular Research School COEUR, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Piepoli MF, Corrà U, Agostoni PG, Belardinelli R, Cohen-Solal A, Hambrecht R, Vanhees L. Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation. Part I: definition of cardiopulmonary exercise testing parameters for appropriate use in chronic heart failure. ACTA ACUST UNITED AC 2006; 13:150-64. [PMID: 16575267 DOI: 10.1097/01.hjr.0000209812.05573.04] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiopulmonary exercise testing (CPET) provides a global assessment of the integrated response to exercise involving the pulmonary, cardiovascular, haematopoietic, neuropsychological, and skeletal muscle systems. This information cannot be obtained through investigation of the individual organ systems in isolation. The non-invasive, dynamic physiological overview permits the evaluation of both submaximal and peak exercise responses, providing the physician with relevant information for clinical decision making. The use of CPET in management of the chronic heart failure patient is increasing with the understanding that resting pulmonary and cardiac function testing cannot reliably predict exercise performance and functional capacity and that, furthermore, overall health status and prognosis are predicted better by indices of exercise tolerance than by resting measurements. Our aim is to produce a statement which provides recommendations on the interpretation and clinical application of CPET in heart failure, based on contemporary scientific knowledge and technical advances: the focus is on clinical indications, issues of standardization, and interpretative strategies for CPET.
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Abstract
Lung capillary pressure in healthy humans at rest ranges between 6 and 10 mmHg. At maximal effort or in pathophysiological conditions such as left sided heart disease or massive pulmonary vasoconstriction, for example in high-altitude pulmonary disease, capillary pressure may be markedly elevated. Increased capillary pressure directly affects transendothelial fluid dynamics and thus results in the formation of hydrostatic lung edema. Excessive pressure increases may cause capillary stress failure. Recent studies, however, suggest that the microvascular response to lung capillary hypertension is more complex. Pressure, strain and shear stress cause dysfunction of the capillary endothelium characterized by an imbalanced release of vasoactive mediators. Endothelial dysfunction evokes a multicellular response with features of vasoconstriction, inflammation, and vascular leakage, thrombosis, and remodeling. These active cellular reactions contribute to the pathophysiological process and may be specifically targeted by new therapeutic strategies.
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Affiliation(s)
- Wolfgang M Kuebler
- Department of Anesthesiology, Deutsches Herzzentrum, Free University of Berlin, Berlin, Germany.
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42
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Kubánek M, Málek I, Kautzner J, Hegarová M, Wiendl M, Lupínek P, Karasová L, Lánská V. The value of B-type natriuretic peptide and big endothelin-1 for detection of severe pulmonary hypertension in heart transplant candidates. Eur J Heart Fail 2005; 7:1149-55. [PMID: 15916922 DOI: 10.1016/j.ejheart.2004.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2004] [Revised: 10/12/2004] [Accepted: 12/20/2004] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Severe pulmonary hypertension (PH) and increased pulmonary vascular resistance (PVR) are important risk factors that predict early postoperative mortality after orthotopic heart transplantation. The aim of our study was to determine the value of B-type natriuretic peptide (BNP) and big endothelin-1 (big ET1) for prediction of severe PH in heart transplant candidates. METHODS The study population included 43 potential heart transplant candidates (38 males, mean age 52 +/- 7 years). All underwent repeated right-heart catheterizations (2-5 studies) at an interval of 3-4 months, giving a total of 124 examinations, associated with blood sampling for BNP and big ET1 analysis. Severe PH was defined as the mean pulmonary artery pressure (MPAP) > 40 mmHg. RESULTS Significantly high PVR (PVR > 3.0 Wood units and TPG > 15 mmHg) was noted on 12 occasions in 10 patients; always in the presence of severe PH. Low BNP levels (<67 pg/ml) ruled out the presence of severe PH with a 100% sensitivity, however, with a low specificity (34%). An increase in plasma BNP > 30 pg/ml (>40% of initial value) in subjects with a previous MPAP< or =40 mmHg detected development of severe PH with a 100% sensitivity and an 80-88% specificity. As a total of 58% of patients presented repeatedly with MPAP< or =40 mmHg, serial BNP testing could reduce the need for hemodynamic studies in this subgroup down to 12-20%. CONCLUSIONS Serial BNP testing in hemodynamically stable heart transplant candidates with MPAP< or =40 mmHg allows reliable detection of development of severe PH, and may significantly reduce the need for repeated right-heart catheterizations in these patients.
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Affiliation(s)
- Milos Kubánek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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Wagner FD, Buz S, Knosalla C, Hetzer R, Hocher B. Modulation of circulating endothelin-1 and big endothelin by nitric oxide inhalation following left ventricular assist device implantation. Circulation 2003; 108 Suppl 1:II278-84. [PMID: 12970246 DOI: 10.1161/01.cir.0000090630.48893.70] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is an established therapy in the treatment of pulmonary hypertension and right ventricular dysfunction following left ventricular assist device implantation. Since it is known that endothelin-1 contributes to pulmonary hypertension, and nitric oxide modulates endothelin-1 synthesis in vitro, we investigated the effects of iNO on circulating endothelin-1 and big endothelin following left ventricular assist device implantation. METHODS AND RESULTS On weaning from cardiopulmonary bypass, 15 consecutive patients with secondary pulmonary hypertension after implantation of a left ventricular assist device were treated with iNO. Endothelin-1 and big endothelin plasma levels were measured preoperatively, on cardiopulmonary bypass prior to iNO, 12, 24, and 48 hour postoperatively, and 72 hour after cessation of iNO. Endothelin-1 levels were increased preoperatively (1.05+/-0.20 fmol/L), and were highest on cardiopulmonary bypass (1.65+/-0.27 fmol/L). During iNO therapy endothelin-1 and big endothelin decreased significantly (endothelin-1: 12 hour 1.24+/-0.18, 24 hour 0.93+/-0.20, and 48 hour 0.81+/-0.14 fmol/L); they were lowest 72 hour post-iNO (endothelin-1: 0.56+/-0.09 fmol/L). Plasma endothelin-1 concentrations and iNO dose were inversely correlated (r=-0.657, P<0.015). A significant correlation was also found between endothelin-1 versus PA pressures and PVR/SVR ratio, but not with CI and SVR. CONCLUSIONS Since it is known that endothelin-1 mediates pulmonary hypertension, we suggest a 2-fold effect of iNO therapy: firstly, a selective vasodilation of the pulmonary vasculature; and secondly, iNO mediated modulation of endothelin-1.
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Affiliation(s)
- Frank D Wagner
- Deutsches Herzzentrum Berlin, Germany Charité der Humboldt Universität Berlin, Berlin, Germany.
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Abstract
Assessment of the pulmonary circulation and right ventricular function is a cornerstone in the evaluation of the patient as a potential heart transplant recipient. The importance of pulmonary hypertension is linked to outcomes in the posttransplant period. Preoperative pulmonary vascular resistance is an independent risk factor for early death after heart transplantation. Pulmonary hypertension can be classified as reversible, or irreversible if not rapidly responsive to pharmacologic maneuvers. However, in most patients, the major component is likely to reverse with vasodilators, because of the central role played by the endothelium in the control of pulmonary vascular tone. To discriminate between patients with reversible and irreversible pulmonary hypertension, provocative therapies are used, and baseline and the postprovocation hemodynamic parameters are measured. To date, there is no reliable hemodynamic threshold beyond which right ventricular failure is certain to occur, nor are there values below which right ventricular failure is always avoidable. Because of this uncertainty, it becomes clear that only through careful preoperative assessment can this life-threatening condition be recognized preoperatively and, hence, managed in the posttransplant recovery period.
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Affiliation(s)
- Maria Eugenia Natale
- Heart Failure and Transplant Center University Hospitals of Cleveland, OH 44106, USA.
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Hare JM, Nguyen GC, Massaro AF, Drazen JM, Stevenson LW, Colucci WS, Fang JC, Johnson W, Givertz MM, Lucas C. Exhaled nitric oxide: a marker of pulmonary hemodynamics in heart failure. J Am Coll Cardiol 2002; 40:1114-9. [PMID: 12354437 DOI: 10.1016/s0735-1097(02)02117-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to test the hypothesis that patients with decompensated heart failure (HF) lose a compensatory process whereby nitric oxide (NO) maintains pulmonary vascular tone. BACKGROUND Exhaled nitric oxide (eNO) partially reflects vascular endothelial NO release. Levels of eNO are elevated in patients with compensated HF and correlate inversely with pulmonary artery pressures (PAP), reflecting pulmonary vasodilatory activity. METHODS We measured the mean mixed expired NO content of a vital-capacity breath using chemiluminescence in patients with compensated HF (n = 30), decompensated HF (n = 7) and in normal control subjects (n = 90). Pulmonary artery pressures were also measured in patients with HF. The eNO and PAP were determined sequentially during therapy with intravenous vasodilators in patients with decompensated HF (n = 7) and in an additional group of patients with HF (n = 13) before and during administration of milrinone. RESULTS The eNO was higher in patients with HF than in control subjects (9.9 +/- 1.1 ppb vs. 6.2 +/- 0.4 ppb, p = 0.002) and inversely correlated with PAP (r = -0.81, p < 0.00001). In marked contrast, patients with decompensated HF exhibited even higher levels of eNO (20.4 +/- 6.2 ppb) and PAP, but there was a loss of the inverse relationship between these two variables. During therapy (7.3 +/- 6 days) with sodium nitroprusside and diuresis, hemodynamics improved, eNO concentrations fell (11.2 +/- 1.2 ppb vs. before treatment, p < 0.05), and the relationship between eNO and PAP was restored. After milrinone, eNO rose proportionally with decreased PAP (p < 0.05). CONCLUSIONS Elevated eNO may reflect a compensatory circulatory mechanism in HF that is lost in patients with clinically decompensated HF. The eNO may be an easily obtainable and quantifiable measure of the response to therapy in advanced HF.
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Affiliation(s)
- Joshua M Hare
- Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Chen JX, Berry LC, Tanner M, Chang M, Myers RP, Meyrick B. Nitric oxide donors regulate nitric oxide synthase in bovine pulmonary artery endothelium. J Cell Physiol 2001; 186:116-23. [PMID: 11147806 DOI: 10.1002/1097-4652(200101)186:1<116::aid-jcp1005>3.0.co;2-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study examined the notion that exogenous generation of nitric oxide (NO) modulates NOS gene expression and activity. Bovine pulmonary artery endothelial cells (BPAEC) were treated with the NO donors, 1 mM SNAP (S-nitroso-N-acetylpenicillamine), 0.5 mM SNP (sodium nitroprusside) or 0.2 microM NONOate (spermine NONOate) in medium 199 containing 2% FBS. Controls included untreated cells and cells exposed to 1 mM NAP (N-acetyl-D-penicillamine). NOS activity was assessed using a fibroblast-reporter cell assay; intracellular Ca2+ concentrations were assessed by Fura-2 microfluorometry; and NO release was measured by chemiluminescence. Constitutive endothelial (e) and inducible (i) NOS gene and protein expression were examined by northern and western blot analysis, respectively. Two hours exposure to either SNAP or NONOate caused a significant elevation in NO release from the endothelial cells (SNAP = 51.4 +/- 5.9; NONOate = 23.8 +/- 4.2; control = 14.5 +/- 2.8 microM); but A23187 (3 microM)-stimulated NO release was attenuated when compared to controls. Treatment with either SNAP or NONOate for 2 h also resulted in a significant increase in NOS activity in endothelial homogenates (SNAP = 23.6 +/- 2.5; NONOate= 29.8 +/- 7.7; control = 14.5 +/- 2.5fmol cGMP/microg per 10(6) cells). Exposure to SNAP and SNP, but not NONOate, for 1 h caused an increase in intracellular calcium. Between 4 and 8 h, SNAP and NONOate caused a 2- to 3-fold increase in eNOS, but not iNOS, gene (P < 0.05) and protein expression. NAP had little effect on either eNOS gene expression, activity or NO production. Our data indicate that exogenous generation of NO leads to a biphasic response in BPAEC, an early increase in intracellular Ca2+, and increases in NOS activity and NO release followed by increased expression of the eNOS gene, but not the iNOS gene. We conclude that eNOS gene expression and activity are regulated by a positive-feedback regulatory action of exogenous NO.
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Affiliation(s)
- J X Chen
- Center for Lung Research, Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2650, USA
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Moraes DL, Colucci WS, Givertz MM. Secondary pulmonary hypertension in chronic heart failure: the role of the endothelium in pathophysiology and management. Circulation 2000; 102:1718-23. [PMID: 11015353 DOI: 10.1161/01.cir.102.14.1718] [Citation(s) in RCA: 290] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary vascular resistance is frequently elevated in patients with chronic left ventricular failure as a result of dysregulation of vascular smooth muscle tone and structural remodeling. The former is reversible over a period of minutes to days by pharmacological vasodilators, whereas the latter is relatively fixed and may resolve only slowly, over months to years. These abnormalities are due, at least in part, to pulmonary vascular endothelial dysfunction that results in impaired nitric oxide availability and increased endothelin expression. In patients with chronic heart failure, the resulting pulmonary hypertension directly affects right ventricular function and may affect exercise capacity, morbidity, and mortality. New treatment strategies, which include the use of agents that increase nitric oxide availability or oppose the actions of endothelin, may improve the structure and function of the pulmonary vasculature in patients with chronic heart failure.
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MESH Headings
- Antihypertensive Agents/therapeutic use
- Cardiac Output, Low/complications
- Chronic Disease
- Endothelin Receptor Antagonists
- Endothelins/metabolism
- Endothelium, Vascular/pathology
- Endothelium, Vascular/physiology
- Exercise/physiology
- Humans
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/mortality
- Nitric Oxide/metabolism
- Nitric Oxide/therapeutic use
- Vascular Resistance
- Vasodilation
- Ventricular Dysfunction, Left/complications
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- D L Moraes
- Cardiovascular Section, Boston University Medical Center, Boston, MA 02118, USA
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