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Gessler T. lloprost delivered via the BREELIB TM nebulizer: a review of the clinical evidence for efficacy and safety. Ther Adv Respir Dis 2019; 13:1753466619835497. [PMID: 30874487 PMCID: PMC6421612 DOI: 10.1177/1753466619835497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Inhaled iloprost is a well-established medication to treat pulmonary arterial hypertension (PAH), a serious and potentially fatal disease of the pulmonary resistance vessels. The therapeutic administration of iloprost requires six to nine inhalations per day, due to the short biological half-life of this prostacyclin analogue. The I-NebTM AADTM, introduced in 2006, is the most commonly used nebulizer for delivering iloprost, requiring at least 6.5 min for an inhaled dose of 5 µg. In order to reduce inhalation time, a portable nebulizer based on modern-device technology was developed. The acute safety and tolerability of rapid iloprost inhalation via the BREELIBTM nebulizer was assessed in a four-part clinical trial. In this review, I describe the rationale and features of the new nebulizer, with particular emphasis on the safety and tolerability profile of iloprost inhalation via BREELIBTM observed in the first clinical studies. Meanwhile, the BREELIBTM nebulizer is approved and available for inhaled iloprost therapy combining significantly reduced inhalation time with good tolerability. This new approach will certainly improve patient convenience and compliance, possibly resulting in broader acceptance and improved efficacy of iloprost aerosol therapy in PAH.
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Affiliation(s)
- Tobias Gessler
- Universities of Giessen and Marburg Lung Centre (UGMLC), German Centre for Lung Research (DZL), Department of Internal Medicine, Justus-Liebig-University Giessen, Klinikstraße 33, D-35392 Giessen, Germany
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Gessler T. Inhalation of repurposed drugs to treat pulmonary hypertension. Adv Drug Deliv Rev 2018; 133:34-44. [PMID: 29886070 DOI: 10.1016/j.addr.2018.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/10/2018] [Accepted: 06/06/2018] [Indexed: 12/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare, but severe and life-threatening disease characterized by vasoconstriction and remodeling of the pulmonary arterioles, leading to progressive increase in pulmonary vascular resistance and ultimately to right-heart failure. In the last two decades, significant progress in treatment of PAH has been made, with currently 12 drugs approved for targeted therapy. Among these, the stable prostacyclin analogues iloprost and treprostinil have been repurposed for inhalation. The paper highlights the development of the two drugs emphasizing the rationale and advantages of the inhalative approach. Despite substantial advances in the specific, mainly vasodilatory PAH therapy, disease progression is mostly inevitable and mortality remains unacceptably high. Thus, introduction of new drugs targeting the cancer-like remodeling of the diseased pulmonary arteries is urgently needed. Inhalation offers pulmonary selectivity and will hopefully pioneer the repurposing of novel highly potent drugs for effective aerosol therapy of PAH.
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Abstract
Pulmonary arterial hypertension (PAH) is a severe condition that markedly reduces exercise capacity and survival in the affected patient population. PAH includes primary pulmonary hypertension (PPH) and pulmonary hypertension associated with collagen vascular diseases, congenital systemic-to-pulmonary shunts, portal hypertension and HIV infection. All these conditions share virtually identical obstructive pathologic changes of the pulmonary microcirculation and probably similar pathobiologic processes. The pathophysiology is characterized by a progressive increase in pulmonary vascular resistance, leading to right ventricular failure and death. Prostacyclin is an endogenous substance that is produced by vascular endothelial cells and induces vasodilatation, inhibition of platelet activity, and antiproliferative effects. A dysregulation of prostacyclin metabolic pathways has been shown in patients with PAH and this represents the rationale for the exogenous therapeutic administration of this substance. The clinical use of prostacyclin in patients with PAH has been made possible by the synthesis of stable analogs that possess different pharmacokinetic properties but share similar pharmacodynamic effects. Experience in humans has been initially collected with epoprostenol, which is a synthetic salt of prostacyclin. Epoprostenol has a short half-life in the circulation and requires continuous administration by the intravenous route by means of infusion pumps and permanent tunnelized catheters. In addition, epoprostenol is unstable at room temperature, and the complex delivery system required is associated with several adverse effects and potentially serious complications. For these reasons, alternatives to intravenous epoprostenol have been sought and this has led to the development of analogs that can be administered subcutaneously (treprostinil), orally (beraprost sodium) or by inhalation (iloprost). Three unblinded clinical trials and several uncontrolled trials have shown that treatment with epoprostenol improved symptoms and exercise capacity in New York Heart Association (NYHA) class III and IV PAH patients and also survival in patients with PPH. Subcutaneous treprostinil improved symptoms, exercise, hemodynamics and clinical events in the largest clinical trial ever performed in PAH, but local infusion site reactions limited efficacy in a proportion of patients. Oral beraprost sodium improved exercise capacity only in patients with PPH and is the only prostacyclin analog that has also been tested in NYHA class II patients. Inhaled iloprost has improved symptoms, exercise capacity and clinical events in patients with PAH and inoperable chronic thromboembolic pulmonary hypertension. The favorable effects of prostanoids observed in all studies coupled with different profiles of adverse events and tolerability for each prostacyclin analog allow the unique opportunity to select the most appropriate compound for the individual patient with PAH.
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Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, University of Bologna, Bologna, Italy.
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The potential for inhaled treprostinil in the treatment of pulmonary arterial hypertension. Ther Adv Respir Dis 2011; 5:195-206. [DOI: 10.1177/1753465810397693] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Inhaled treprostinil is a safe and well-tolerated approved pharmaceutical for the treatment of pulmonary arterial hypertension. In a series of open-label studies and in the pivotal trial with 253 patients, this long-acting prostacyclin analogue demonstrated pronounced pulmonary selectivity of vasodilatory effects, improved physical capacity and excellent tolerability and safety following aerosol administration. For efficient treatment, only four daily inhalations of treprostinil are necessary compared with six to nine in iloprost aerosol therapy. This review describes in detail the development of inhaled treprostinil, starting with intravenous epoprostenol followed by inhaled iloprost and subcutaneous treprostinil, all three representing well-established and widely approved prostanoid therapies for pulmonary hypertension. In order to circumvent the drawbacks of intravenous epoprostenol, stable prostacyclin analogues with similar pharmacological properties have been investigated. In addition, alternative routes of administration have been proposed and evaluated, mainly inhaled and subcutaneous delivery. The concept of inhaled treprostinil was to combine the pulmonary selectivity of an aerosolized vasodilator with the long-acting effects of a stable prostacyclin analogue. Pulmonary arterial hypertension remains, however, a severe, life-threatening disease, in spite of the enormous progress in specific drug therapy over the last decade. Therefore, further improvement of drug therapy will be essential, with clear potential for inhaled treprostinil: a reduction of inhalation frequency and duration would markedly improve quality of life and compliance, and a longer-lasting local prostanoid effect might further enhance the efficacy of inhaled treprostinil. The advantageous pharmacological properties of treprostinil offer the opportunity to establish a convenient metered dose inhaler as a delivery system, to combine inhaled treprostinil with available or future drugs for pulmonary arterial hypertension, or to develop sustained release formulations of treprostinil suitable for inhalation based on liposomes or biodegradable nanoparticles.
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Dickinson MG, Schölvinck EH, Boonstra A, Vonk-Noordegraaf A, Snijder RJ, Berger RM. Low Complication Rates With Totally Implantable Access Port Use in Epoprostenol Treatment of Pulmonary Hypertension. J Heart Lung Transplant 2009; 28:273-9. [DOI: 10.1016/j.healun.2008.11.913] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 09/19/2008] [Accepted: 11/19/2008] [Indexed: 11/15/2022] Open
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Gessler T, Seeger W, Schmehl T. Inhaled Prostanoids in the Therapy of Pulmonary Hypertension. J Aerosol Med Pulm Drug Deliv 2008; 21:1-12. [DOI: 10.1089/jamp.2007.0657] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Tobias Gessler
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Thomas Schmehl
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
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Cheever KH. An overview of pulmonary arterial hypertension: risks, pathogenesis, clinical manifestations, and management. J Cardiovasc Nurs 2005; 20:108-16; quiz 117-8. [PMID: 15855858 DOI: 10.1097/00005082-200503000-00005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article focuses on pulmonary arterial hypertension, including both primary pulmonary hypertension (PPH) and those forms of pulmonary arterial hypertension that are related to other factors, including collagen vascular diseases, congenital shunts, portal hypertension, human immunodeficiency viral infection, and exposure to specific drugs and toxins. Risks for different types of pulmonary arterial hypertension are identified. The common pathogenesis for pulmonary arterial hypertension is discussed, and includes an overview of the role of key vasoactive substances such as nitric oxide, prostacyclin, endothelin, and thromboxane. Typical presenting clinical manifestations, recommendations for screening of patients at risk, and key diagnostic findings are discussed. The mainstay of treatment is identified as pharmacologic, and may include diuretics, digoxin, warfarin, calcium channel antagonists, and prostacyclin analogues such as epoprostenol. Surgical interventions are considered as a last resort, and may include unilateral or bilateral lung transplant or atrial septostomy. Treatment options for patients with pulmonary arterial hypertension hold more hope today than they did a decade ago and are identified so as to guide the advanced practice nurse in recognizing and then facilitating the appropriate management of patients with this rare but disabling disease.
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Affiliation(s)
- Kerry H Cheever
- Chair and Associate Professor, Department of Nursing and Health, DeSales University, Center Valley, PA, USA
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Augoustides JG, Ochroch EA. Pro: Inhaled Prostaglandin as a Pulmonary Vasodilator Instead of Nitric Oxide. J Cardiothorac Vasc Anesth 2005; 19:400-2. [PMID: 16130073 DOI: 10.1053/j.jvca.2005.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John G Augoustides
- Cardiothoracic Section, Hospital of the University of Pennsylvania, PA 19104, USA.
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Affiliation(s)
- John G Augoustides
- Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA
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Abstract
Pulmonary arterial hypertension is a serious progressive condition with a poor prognosis if not identified and treated early. Because the symptoms are nonspecific and the physical findings can be subtle, the disease is often diagnosed in its later stages. Remarkable progress has been made in the field of pulmonary arterial hypertension over the past several decades. The pathology is now better defined, and significant advances have occurred in understanding the pathobiologic mechanisms. Risk factors have been identified, and the genetics have been characterized. Advances in technology allow earlier diagnosis as well as better assessment of disease severity. Therapeutic modalities such as new drugs, e.g., epoprostenol, treprostinil, and bosentan, and surgical/interventional options, e.g., transplantation and atrial septostomy, which were unavailable several decades ago, have had a significant impact on prognosis and outcome. Thus, despite our inability to cure pulmonary arterial hypertension, advances in medical treatments over the past two decades have resulted in significant improvement in outcomes for children with various forms of pulmonary arterial hypertension. This report is a review the current state of the art for pulmonary arterial hypertension in 2004, with an emphasis on childhood pulmonary arterial hypertension and specific recommendations for current practice and future directions.
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Affiliation(s)
- Erika Berman Rosenzweig
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York 10027, USA.
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11
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Olschewski H, Rose F, Schermuly R, Ghofrani HA, Enke B, Olschewski A, Seeger W. Prostacyclin and its analogues in the treatment of pulmonary hypertension. Pharmacol Ther 2004; 102:139-53. [PMID: 15163595 DOI: 10.1016/j.pharmthera.2004.01.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Prostacyclin and its analogues (prostanoids) are potent vasodilators and possess antithrombotic and antiproliferative properties. All of these properties help to antagonize the pathological changes that take place in the small pulmonary arteries of patients with pulmonary hypertension. Indeed, several prostanoids have been shown to be efficacious to treat pulmonary hypertension, while the main mechanism underlying the beneficial effects remains unknown. There are indications of beneficial combination effects of prostaglandins and phosphodiesterase inhibitors and endothelin receptor antagonists. This speaks in favor of combination therapies for pulmonary hypertension in the future. The mode of application of prostanoids used in randomized controlled studies has been quite variable: continuous i.v. infusion of prostacyclin, continuous s.c. infusion of treprostinil, p.o. application of beraprost, and inhaled application of iloprost. In addition, the applied doses were quite different, ranging from 0.25 ng/kg/min for inhaled iloprost to 30-50 ng/kg/min for i.v. prostacyclin. While the principal pharmacological properties of all prostanoids are very similar due to a main action on IP receptors, there are considerable differences in pharmacokinetics and metabolism, with half-lives of 2 min for prostacyclin and about 34 min for treprostinil for i.v. infused drugs and half-lives of about 85 min for s.c. infused treprostinil. In addition, the adverse effects largely depend on the doses used and the mode of application, although there is great variability between subjects. It remains to be determined which patients will profit most from which substance (or combination) and mode of application.
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Abstract
Primary pulmonary hypertension and cor pulmonale represent forms of precapillary pulmonary hypertension due to intrinsic lung disease. In the case of primary pulmonary hypertension, this is due to disease of the pulmonary vasculature while cor pulmonale is related to diseases of the pulmonary vasculature, airways, or interstitium. Patients present with signs and symptoms of right ventricular dysfunction and low cardiac output including dyspnea, chest pain and peripheral edema. Therapy is directed at the underlying disease and may include supplemental oxygen for diseases causing chronic hypoxemia and anticoagulation for thrombotic disease. Vasodilator therapy has variable efficacy for pulmonary vascular disorders. Postacyclin by continuous infusion has been a major advance in the therapy of primary pulmonary hypertension and has prolonged survival and delayed the need for lung transplantation. Bosentan, an endothelin receptor blocking agent is the first oral medication approved for the therapy of pulmonary hypertension.
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Affiliation(s)
- Stuart Lehrman
- Departments of Pulmonary Medicine, General Internal Medicine, and Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York 10595, USA
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Melian EB, Goa KL. Beraprost: a review of its pharmacology and therapeutic efficacy in the treatment of peripheral arterial disease and pulmonary arterial hypertension. Drugs 2002; 62:107-33. [PMID: 11790158 DOI: 10.2165/00003495-200262010-00005] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED Beraprost sodium (beraprost) is a stable, orally active prostacyclin analogue with vasodilatory, antiplatelet and cytoprotective effects. Beraprost acts by binding to prostacyclin membrane receptors ultimately inhibiting the release of Ca2+ from intracellular storage sites. This reduction in the influx of Ca2+ has been postulated to cause relaxation of the smooth muscle cells and vasodilation. Data from a large, randomised, double-blind, multicentre study indicated that beraprost was as efficacious as ticlopidine in the treatment of patients with peripheral arterial disease (Buerger's disease and arteriosclerosis obliterans). Most patients receiving beraprost exhibited reduction of ulcer size, reported improvement of granulation appearance of the tissue and showed improvement of pain at rest and sensation of cold in the extremities. In a large pivotal clinical trial in patients with intermittent claudication, beraprost treatment was associated with statistically significant increases in pain-free and absolute walking distances compared with those in patients receiving placebo. Statistically significant differences in the incidence of critical cardiovascular events among both treatment groups were not observed but patients receiving beraprost were more likely to be satisfied with changes in their quality of life. However, while preliminary unpublished data from a large, phase III, placebo-controlled study in the US suggested a trend toward fewer critical cardiovascular events (no specific data presented), this study did not confirm the positive results from the European phase III trial and statistical significance was not achieved in the study's endpoints relating to exercise. A series of small, noncomparative clinical trials of patients with the rare condition of pulmonary arterial hypertension (PAH) demonstrated that substantial reductions of pulmonary arterial pressure and resistance, increase of cardiac output, and increase of exercise capacity appeared to be associated with beraprost therapy; however, these data are very limited and in most instances are not fully published. Beraprost is a well tolerated agent. Overall, the main adverse events include headache, hot flushes, diarrhoea and nausea. However, patients with PAH showed higher incidence of adverse events than those with peripheral arterial disease. CONCLUSION Beraprost, an orally administered PGI2 analogue, is generally well tolerated and appears to be an effective agent in the treatment of patients with Buerger's disease and arteriosclerosis obliterans. Comparative data from a large randomised trial indicated that the drug appears as effective as ticlopidine in patients with these conditions. In patients with intermittent claudication, significant benefits of beraprost compared with placebo were reported in a randomised clinical trial; however, the use of beraprost in these patients is not supported by recent preliminary unpublished data from a large, phase III, placebo-controlled study. Limited data suggest some efficacy with long-term beraprost treatment of patients with PAH, where options are few and where oral administration of the drug could be a considerable advantage over intravenous prostacyclin (PGI2) therapy. Additional well-designed and, where possible, large trials with active comparators are necessary to define more precisely the place of beraprost in the treatment of patients with PAH, Buerger's disease and arteriosclerosis obliterans.
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Abstract
Primary pulmonary hypertension (PPH) is a rare disorder of the lung vasculature characterised by an increase in pulmonary artery pressure. Although the aetiology of this disease remains unknown, knowledge of the pathophysiology of the disease has advanced considerably. Diagnosis of PPH is largely by exclusion. The clinical symptoms associated with PPH are aspecific and similar to those seen in other cardiovascular and pulmonary diseases. Electrocardiography, echocardiography, pulmonary function tests, and a lung perfusion scan are necessary to exclude secondary forms of pulmonary hypertension and also help to confirm the diagnosis of PPH. A definite diagnosis of PPH is established by right-heart catheterisation which gives a precise measure of the blood pressure in the right side of the heart and the pulmonary artery, right ventricular function and cardiac output. Once a diagnosis of PPH is established, treatment involving drug therapy or surgery is commenced on the basis of the New York Heart Association functional class. Conventional treatment consists of lifetime administration of anticoagulants, oxygen, diuretics, and digoxin. Vasodilator therapy with calcium channel antagonists is indicated in patients who are 'vasoreactive' to acute vasodilator challenge as assessed by right-heart catheterisation. Promising results are obtained by continuous intravenous administration of epoprostenol (prostacyclin). Newer therapies for PPH include prostacyclin analogues, endothelin receptor antagonists, nitric oxide, phosphodiesterase-5 inhibitors, elastase inhibitors, and gene therapy. Surgical treatment consists of atrial septostomy, thromboendarterectomy, and lung or heart-lung transplantation.
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Affiliation(s)
- T L De Backer
- Department of Cardiology, Thoraxcentre, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
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15
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Abstract
Prostacyclin is a substance produced by endothelial cells that induces vasodilation and inhibition of platelet aggregation and of vascular cell migration and proliferation. A dysregulation of the prostacyclin metabolic pathways has been shown in patients with pulmonary arterial hypertension. The clinical use of prostacyclin has been made possible by the synthesis of stable analogues that possesses different pharmacokinetic properties but share similar pharmacodynamic effects. The greatest experience has been collected with intravenous epoprostenol while other compounds like subcutaneous UT-15, inhaled iloprost and oral beraprost are currently in different stages of clinical development. Although favorable results have been reported for each compound, different benefit-to-side effects profiles characterize the various modalities of the administration.
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Affiliation(s)
- N Galié
- Institute of Cardiology, University of Bologna, Bologna, Italy.
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Aguilar RV, Farber HW. Epoprostenol (prostacyclin) therapy in HIV-associated pulmonary hypertension. Am J Respir Crit Care Med 2000; 162:1846-50. [PMID: 11069824 DOI: 10.1164/ajrccm.162.5.2004042] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although HIV-associated pulmonary hypertension and primary pulmonary hypertension (PPH) are clinically and histologically similar, treatment options for the former are limited. Treatment with calcium channel blockers (CCB), proven to be beneficial in a subset of patients with PPH, has been disappointing in HIV-associated pulmonary hypertension and there are no data examining the effects of long-term epoprostenol in this entity. Six patients with severe HIV-associated pulmonary hypertension were treated with continuous intravenous epoprostenol infusions. Acute infusion of epoprostenol resulted in a significant (p < 0.05) decrease in mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) of 16. 4 and 32.7%, respectively, and a significant (p < 0.05) increase in mean cardiac output (CO) of 36.9%. At 1 yr, mean PAP and PVR had decreased by 21.7 and 54.9% (p < 0.05), respectively, and mean CO had increased by 51.4% (p < 0.05) when compared with baseline values. Repeat catheterizations of three patients at 2 yr and one patient at 40 mo demonstrated further improvement or maintenance of hemodynamics. In addition, NYHA functional class improved in all patients. We conclude that epoprostenol infusion is effective in improving hemodynamic and functional status in this cohort of six patients with HIV-associated pulmonary hypertension acutely and long-term.
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Affiliation(s)
- R V Aguilar
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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18
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A Breath of Fresh Air. Am J Nurs 2000. [DOI: 10.1097/00000446-200005000-00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Puigarnau Vallhonrat R, Pons Ódena M, Carballo Ruano E. Prostaciclina nebulizada como tratamiento de la hipertensión pulmonar primaria en una niña de 2 años. An Pediatr (Barc) 2000. [DOI: 10.1016/s1695-4033(00)77482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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Wax D, Garofano R, Barst RJ. Effects of long-term infusion of prostacyclin on exercise performance in patients with primary pulmonary hypertension. Chest 1999; 116:914-20. [PMID: 10531153 DOI: 10.1378/chest.116.4.914] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
STUDY OBJECTIVES To determine whether long-term IV prostacyclin (PGI(2)) use improves exercise capacity in patients with primary pulmonary hypertension (PPH). DESIGN Cycle ergometry and the 6-min walk was used to evaluate the exercise performance of patients with PPH. The patients underwent serial exercise testing after starting continuous IV PGI(2) and were followed up for 19.5 +/- 7.5 months. Peak work, peak oxygen consumption (f1.gif" BORDER="0">O(2)), peak O(2) pulse, and distance walked in 6 min were used to evaluate performance. BACKGROUND PPH is characterized by medial hypertrophy and intimal proliferation of the pulmonary arterioles, leading to elevation of pulmonary artery pressure, right ventricular failure, and death. Palliative treatment consists of vasodilators, anticoagulants, cardiac glycosides, diuretics, and transplantation. PGI(2), a potent vasodilator and inhibitor of platelet aggregation, has been used for long-term treatment when conventional therapy has been unsuccessful. PATIENTS Sixteen patients with PPH (10 women, 6 men; mean age, 24 years). RESULTS At the initiation of PGI(2), peak work (+/- SD) was 35.5 +/- 11% of predicted; peak f1.gif" BORDER="0">O(2), 39 +/- 10.4%; peak O(2) pulse, 5.0 +/- 1.7 mL/min; and distance on the 6-min walk, 428 +/- 78 feet. At 18 to 27 months, peak work increased to 58.8 +/- 23% of predicted (p = 0.001), peak f1.gif" BORDER="0">O(2) increased to 52 +/- 15% of predicted (p = 0. 02), peak O(2) pulse increased to 7.1 +/- 3.0 mL/beat (p = 0.004), and performance on the 6-min walk increased to 526 +/- 62 feet (p = 0.001). There was a positive correlation between peak f1.gif" BORDER="0">O(2) and peak 6-min walk of 0.6 (p < 0.005) and between peak work and peak 6-min walk of 0.6 (p < 0.005). CONCLUSIONS Exercise capacity improved in our patients at up to 27 months of follow-up. Exercise testing is helpful in assessing the functional capacity of patients with PPH and may be useful in guiding therapy. Patients who deteriorate while receiving optimal conventional therapy should be considered for IV PGI(2) therapy.
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Affiliation(s)
- D Wax
- Division of Pediatric Cardiology, Columbia University College of Physicians and Surgeons, New York, NY.
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Findlay JY, Harrison BA, Plevak DJ, Krowka MJ. Inhaled nitric oxide reduces pulmonary artery pressures in portopulmonary hypertension. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:381-7. [PMID: 10477839 DOI: 10.1002/lt.500050515] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pulmonary artery hypertension in association with liver failure (portopulmonary hypertension [PPHTN]) is a significant barrier to liver transplantation because patients with this condition have a very high mortality when transplantation is undertaken. Inhaled nitric oxide (NO), a potent pulmonary vasodilator, reduces pulmonary artery pressure (PAP) in some patients with primary pulmonary hypertension, but its effect in patients with PPHTN is controversial. We investigated the hemodynamic effects of inhaled NO in 6 patients with PPHTN. Five of 6 patients responded to NO inhalation with decreases in PAP and pulmonary vascular resistance of greater than 10%; these decreases were statistically significant at NO concentrations of 10 and 30 ppm. Cardiac output did not significantly change. We conclude that inhalation of NO reduces PAPs in some patients with PPHTN.
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Affiliation(s)
- J Y Findlay
- Department of Anesthesiology, Mayo Foundation, Rochester, MN 55905, USA
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Findlay JY, Plevak DJ, Krowka MJ, Sack EM, Porayko MK. Progressive splenomegaly after epoprostenol therapy in portopulmonary hypertension. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:362-5. [PMID: 10477835 DOI: 10.1002/lt.500050517] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with end-stage liver failure, portal hypertension, and associated pulmonary artery hypertension (portopulmonary hypertension [PPHTN]) have a high mortality when undergoing liver transplantation. Successful transplantation in these patients may depend on efforts to reduce pulmonary artery pressure (PAP). To this end, a number of centers are using a continuous intravenous (IV) infusion of epoprostenol, which has been shown to improve symptoms, extend life span, and reduce PAP in patients with primary pulmonary hypertension. We report four cases in which treatment of patients with PPHTN with continuous IV epoprostenol was followed by the development of progressive splenomegaly, with worsening thrombocytopenia and leukopenia. This finding may limit the usefulness of epoprostenol in PPHTN and influence the timing of transplantation in such patients.
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Affiliation(s)
- J Y Findlay
- Department of Anesthesiology, Mayo Foundation, Rochester, MN 55905, USA
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Abstract
As our understanding of the pathogenesis of PAH evolves, newer strategies for its treatment are being developed and implemented. Based on studies with adult PPH patients, anticoagulation is now regarded as a mainstay of therapy and is associated with prolonged survival. Before the era of vasodilator therapy, which began in the late 1970s, most children with PPH died within 1 year of diagnosis. Now with chronic calcium channel blockade, survival and QOL are improved in children who acutely respond to vasodilator drug testing. In the author's experience, the 5-year survival rate for patients treated with chronic oral calcium channel blockade who respond acutely to vasodilator testing is 97% versus 35% for those who do not respond acutely. Continuous i.v. prostacyclin has also been used successfully, with a 5-year survival rate of 92% in children in whom oral calcium channel blockade failed (although in some patients the prostacyclin therapy was used as a bridge to transplantation) versus 29% in children in whom oral calcium channel blockade also failed and for whom chronic prostacyclin was unavailable. Before the availability of long-term prostacyclin therapy, 30% to 40% of patients with PPH died while waiting for transplantation. Prostacyclin has virtually eliminated this situation. The results of lung transplantation for adult patients with PPH at 3 years are similar to the results of those on continuous i.v. prostacyclin. Ultimately, the best therapy for an individual child depends on the results of longer follow-up studies. Inhaled nitric oxide has also been used to treat PAH in newborns and other forms of acute and chronic PAH. Although less experience exists with long-term inhaled nitric oxide than with long-term prostacyclin, the preliminary results of long-term inhaled nitric oxide are promising and await further study. The "optimal" vasodilator for long-term therapy, (e.g., calcium channel blockade), prostacyclin, nitric oxide, or potential future therapies, such as prostacyclin analogs, endothelin receptor blockers and thromboxane synthase inhibitors or receptor blockers, must be based on a thorough evaluation with acute vasodilator testing and overall risk-benefit considerations for the various therapeutic regimens. Further clarification of the mechanisms of the development and perpetuation of the PAH process will undoubtedly lead to a refinement in treatment strategies for patients with PAH, which not too long ago was often considered untreatable and fatal. By increasing our understanding of the pathogenesis and pathophysiology of primary and secondary PAH disorders, one day we may be able to prevent or cure these diseases as opposed to providing only palliative therapy. Despite this, therapeutic advances have significantly improved the outcome for children with PAH.
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Affiliation(s)
- R J Barst
- Department of Pediatrics, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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24
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Palevsky HI, Gurughagavatula I. Pulmonary hypertension in collagen vascular disease. COMPREHENSIVE THERAPY 1999; 25:133-43. [PMID: 10200902 DOI: 10.1007/bf02889609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension associated with collagen vascular disease often eludes diagnosis, sometimes causing considerable morbidity or even death before being identified. This review details its characteristic clinical features, appropriate diagnostic and treatment approaches, and expected outcomes.
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Affiliation(s)
- H I Palevsky
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Health System, Philadelphia 19104-2699, USA
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25
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Parviz M, Bousamra M, Chammas JH, Birks EK, Presberg KW, Jacobs ER, Nelin LD. Effects of chronic pulmonary overcirculation on pulmonary vasomotor tone. Ann Thorac Surg 1999; 67:522-7. [PMID: 10197682 DOI: 10.1016/s0003-4975(98)01141-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A model of shunt-induced pulmonary hypertension was used to study the effects of pulmonary overcirculation on endothelial nitric oxide synthase (eNOS) and cytochrome P450-4A (cP450-4A) vasodilatory mechanisms and related hemodynamic responses. METHODS An aortopulmonary shunt was constructed in 6-week-old piglets (n = 7, sham-operated controls n = 8). Hemodynamic measurements were made 4 weeks later under serial experimental conditions: baseline (fractional concentration of oxygen, 0.4); inhaled nitric oxide, 25 ppm (INO); hypoxia (fractional concentration of oxygen, 0.14); hypoxia + INO; N(omega)-nitro-L-arginine methylester (L-NAME 30 mg/kg intravenously, competitive NOS inhibitor); and L-NAME + INO. Lung protein levels of eNOS and cP450-4A and NOS activity were compared between groups. RESULTS Shunted animals had a higher baseline pulmonary artery pressure (p < 0.05). L-NAME resulted in a greater increase in pulmonary vascular resistance in shunted animals (150% +/- 26% shunt versus 69% +/- 14% control; p = 0.01). The INO administered during baseline conditions decreased pulmonary vascular resistance only in control animals (p < 0.05). Protein levels of eNOS and NOS activity were similar in both groups; however, cP450-4A protein levels were decreased in the shunted group (p = 0.02). CONCLUSIONS The NO production was preserved in shunted animals but they demonstrated greater vasodilatory dependence on NO, evidenced by an exaggerated increase in pulmonary vascular resistance after NOS inhibition. Loss of the cP450-4A vasodilatory system may be the driving force for NO dependency in the shunted pulmonary circulation.
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Affiliation(s)
- M Parviz
- Department of General Surgery, Cardiovascular Research Center, Medical College of Wisconsin, Milwaukee 53226, USA
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26
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Mueller HS, Chatterjee K, Davis KB, Fifer MA, Franklin C, Greenberg MA, Labovitz AJ, Shah PK, Tuman KJ, Weil MH, Weintraub WS. ACC expert consensus document. Present use of bedside right heart catheterization in patients with cardiac disease. American College of Cardiology. J Am Coll Cardiol 1998; 32:840-64. [PMID: 9741535 DOI: 10.1016/s0735-1097(98)00327-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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Acute lung injury: Experimental data. Acta Anaesthesiol Scand 1997. [DOI: 10.1111/j.1399-6576.1997.tb04886.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Jones RL, Qian Y, Wong HN, Chan H, Yim AP. Prostanoid action on the human pulmonary vascular system. Clin Exp Pharmacol Physiol 1997; 24:969-72. [PMID: 9406667 DOI: 10.1111/j.1440-1681.1997.tb02730.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
1. Four types of prostanoid receptor are present on pulmonary arterial vessels of man. Thromboxane (TP) receptors mediate constriction and are blocked by antagonists such as BAY u-3405, GR 32,191 and EP 169. Prostaglandin (PG) EP3 receptors also mediate constriction, the agonist potency ranking being SC 46,275 > sulprostone > misoprostol > or = PGE2; this action needs to be borne in mind when PGE analogues are used therapeutically. 2. Prostaglandin E2 causes relaxation in a few pulmonary artery preparations: an EP2 receptor may be involved. Prostacyclin, acting through i.p. receptors, consistently produces relaxation and studies are in progress to determine the contribution made by K(+)-channel opening. Agonist potencies of stable prostacyclin analogues and non-prostanoid prostacyclin mimetics, such as BMY 45,778 and the novel diphenylindole CU 23, on human pulmonary artery and platelets are well correlated. Interestingly, the non-prostanoid mimetics show persistent relaxant effects in vitro, which may be related to their high lipophilicities. 3. Prostacyclin and iloprost are being used to treat severe pulmonary hypertension; further study of the pharmacodynamic and pharmacokinetic properties of other i.p. receptor agonists could produce improved therapy.
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Affiliation(s)
- R L Jones
- Department of Pharmacology, Chinese University of Hong Kong, Shatin, Hong Kong SAR
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29
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Abstract
Rare in occurrence, insidious in onset, and relentless in its course, pulmonary hypertension in systemic autoimmune disease remains one of the most challenging entities to diagnose and treat today. The subtlety and nonspecificity of its symptoms and signs, the lack of availability of sensitive, noninvasive, accurate diagnostic tests, the rudimentary understanding we have of its pathogenesis, the multiplicity of findings on histopathologic survey, and the paucity of data from large-scale therapeutic trials in this population all pose many frustrations for patient and physician. Although supportive, symptomatic therapy remains the mainstay of treatment, we continue to await the results of carefully conducted clinical trials investigating antiinflammatory drugs and vasodilators. Careful scrutiny of the histologic lesions seen in pulmonary hypertension has shown striking similarity with the changes of PPH in some patients, and close follow-up of patients diagnosed with PPH has shown that some of them later develop evidence of a specific autoimmune disease like scleroderma. A natural tendency to extrapolate the use of therapeutic modalities of PPH to patients with autoimmune disease-associated pulmonary hypertension then results. We are thus encouraged by the lessons learned from the past about PPH; studies of patients with PPH have identified a subset of them who enjoy a distinct survival advantage with use of vasodilators or transplantation. We remain hopeful that future investigations in the treatment of autoimmune disease-associated pulmonary hypertension will yield similar information, and that we will be able to provide afflicted individuals some long-awaited improvements in quality and duration of life.
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Affiliation(s)
- I Gurubhagavatula
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
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30
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Jones RL, Qian YM, Wise H, Wong HN, Lam WL, Chan HW, Yim AP, Ho JK. Relaxant actions of nonprostanoid prostacyclin mimetics on human pulmonary artery. J Cardiovasc Pharmacol 1997; 29:525-35. [PMID: 9156364 DOI: 10.1097/00005344-199704000-00015] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The specific prostacyclin (IP) receptor agonist cicaprost relaxed human pulmonary artery preparations precontracted with phenylephrine [50% inhibitory concentration (IC50) approximately 0.6 nM], U-46619 (IC50 approximately 0.9 nM), and K+ (approximately 40% maximal relaxation); endothelium removal had little effect on relaxant activity. Ranking of relaxant potencies for prostacyclin and five of its analogs was 17 alpha, 20-dimethyl-delta 6,6a-6a-carba PGI1 (TEI-9063) > or = cicaprost > iloprost > prostacyclin > taprostene > benzodioxane prostacyclin > 15-deoxy-16 alpha-hydroxy-16 beta,20-dimethyl-delta 6,6a-6a-carba PGI1 (TEI-3356). The potency of the isocarbacyclin TEI-3356 may have been under-estimated because of its contractile (EP3 receptor agonist) activity. The potency ranking of four nonprostanoid prostacyclin mimetics was 3-[4-(4,5-diphenyl-2-oxazolyl)-5-oxazolyl]phenoxy] acetic acid (BMY 45778; IC50 approximately 2.5 nM) > > 2-[3-[2-(4, 5-diphenyl-2-oxazolyl)ethyl]phenoxy]acetic acid (BMY 42393) > octimibate > CU 23 (a novel diphenylindole). From IP receptor binding affinities obtained on human platelet membranes, it is suggested that the slightly shallower log concentration-response curves for BMY 45778, BMY 42393, and CU 23 may reflect the near-maximal receptor occupancy required for complete relaxation. A fifth nonprostanoid, CU 602, had much shallower log concentration-response curves than cicaprost against phenylephrine tone but not against U-46619 tone; this may indicate IP receptor partial agonism coupled with TP receptor antagonism. The relaxant actions of the nonprostanoid mimetics were more persistent than those of the prostacyclin analogs on washout of the organ bath; by the inhalation route, this type of compound may be retained within pulmonary tissue and thus afford greater pulmonary/systemic selectivity than currently used pulmonary vasodilators.
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Affiliation(s)
- R L Jones
- Department of Pharmacology, Chinese University of Hong Kong, Shatin, Hong Kong
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31
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Álvares E, Telles E, Celeste Vagueiro M. Aspectos actuais da hipertensão arterial pulmonar: primária e secundária. REVISTA PORTUGUESA DE PNEUMOLOGIA 1997. [DOI: 10.1016/s0873-2159(15)31082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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32
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Saji T, Ozawa Y, Ishikita T, Matsuura H, Matsuo N. Short-term hemodynamic effect of a new oral PGI2 analogue, beraprost, in primary and secondary pulmonary hypertension. Am J Cardiol 1996; 78:244-7. [PMID: 8712155 DOI: 10.1016/s0002-9149(96)90408-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In 4 patients with primary pulmonary hypertension, there was a -24% +/- 20% decrease in pulmonary vascular resistance, a significant increase of cardiac index by +27 +/- 14% in all 4 patients; a -15 +/- 12% decrease in pulmonary artery pressure in 3 patients; and in 3 patients with 12% secondary pulmonary hypertension, there was a -24 +/- 14% decrease in pulmonary vascular resistance. Beraprost appears to be effective as a new pulmonary vasodilative agent.
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Affiliation(s)
- T Saji
- Department of Pediatrics, Toho University, Tokyo, Japan
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33
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Gallerani M, Govoni M, Ricci L, Zanardi F, Percoco G, Toselli T, Trotta F. a 49-year-old woman with dyspnoea, palpitations and syncope. Int J Cardiol 1996; 55:67-78. [PMID: 8839813 DOI: 10.1016/0167-5273(96)02658-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension is rarely described in association with Sjögren's syndrome. The authors report the case of a patient in which pulmonary hypertension was the inaugural clinical manifestation of primary Sjögren's syndrome. Clinical assessment, differential diagnosis, etiopathological implications, and therapeutic approach are discussed.
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Affiliation(s)
- M Gallerani
- Emergency Department, St. Anna Hospital, Ferrara, Italy
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