1
|
Barrios D, Durán D, Rodríguez C, Moisés J, Retegui A, Lobo JL, López R, Chasco L, Jara-Palomares L, Muriel A, Otero-Candelera R, Ruiz-Artacho P, Monreal M, Bikdeli B, Jiménez D. Oxygen Therapy in Patients With Intermediate-Risk Acute Pulmonary Embolism: A Randomized Trial. Chest 2024; 165:673-681. [PMID: 37717936 DOI: 10.1016/j.chest.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND The effect of supplemental oxygen therapy in patients with intermediate-risk pulmonary embolism (PE) who do not have hypoxemia at baseline is uncertain. RESEARCH QUESTION Does supplemental oxygen improve echocardiographic parameters in nonhypoxemic patients with intermediate-risk PE? STUDY DESIGN AND METHODS This pilot trial randomly assigned nonhypoxemic patients with stable PE and echocardiographic right ventricle (RV) enlargement to receive anticoagulation plus supplemental oxygen for the first 48 h vs anticoagulation alone. The primary outcome was normal echocardiographic RV size 48 h after randomization. Secondary efficacy outcomes were the numerical change in the RV to left ventricle (LV) diameter ratio measured 48 h and 7 days after randomization with respect to the baseline ratio measured at inclusion. RESULTS The study was stopped prematurely because of the COVID-19 pandemic after recruiting 70 patients (mean ± SD age, 67.3 ± 16.1 years; 36 female [51.4%]) with primary outcome data. Forty-eight h after randomization, normalization of the RV size occurred in 14 of the 33 patients (42.4%) assigned to oxygen and in eight of the 37 patients (21.6%) assigned to ambient air (P = .08). In the oxygen group, the mean RV to LV ratio was reduced from 1.28 ± 0.28 at baseline to 1.01 ± 0.16 at 48 h (P < .001); in the ambient air group, mean RV to LV ratios were 1.21 ± 0.18 at baseline and 1.08 ± 0.19 at 48 h (P < .01). At 90 days, one major bleeding event and one death (both in the ambient air group) had occurred. INTERPRETATION In analyses limited by a small number of enrollees, compared with ambient air, supplemental oxygen did not significantly increase the proportion of patients with nonhypoxemic intermediate-risk PE whose RV to LV ratio normalized after 48 h of treatment. This pilot trial showed improvement in some ancillary efficacy outcomes and provides support for a definitive clinical outcomes trial. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04003116; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Jorge Moisés
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - José Luis Lobo
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital de Araba, Vitoria, Spain
| | - Raquel López
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Leyre Chasco
- Respiratory Department, Hospital Galdakao-Usansolo, Bilbao, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Remedios Otero-Candelera
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Pedro Ruiz-Artacho
- Department of Internal Medicine, Clínica Universidad de Navarra, Madrid; Interdisciplinar Teragnosis and Radiosomics Research Group, Universidad de Navarra, Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Director of the Chair for Thromboembolic Disorders, Universidad Católica de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| |
Collapse
|
2
|
Yang J, Xu J, Xu S, Fan Z, Zhu C, Wan J, Yang J, Xing X. Oxidative stress in acute pulmonary embolism: emerging roles and therapeutic implications. Thromb J 2024; 22:9. [PMID: 38216919 PMCID: PMC10785361 DOI: 10.1186/s12959-023-00577-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/25/2023] [Indexed: 01/14/2024] Open
Abstract
Oxidative stress is an imbalance between the body's reactive oxygen species and antioxidant defense mechanisms. Oxidative stress is involved in the development of several cardiovascular diseases, such as pulmonary hypertension, atherosclerosis, and diabetes mellitus. A growing number of studies have suggested the potential role of oxidative stress in the pathogenesis of pulmonary embolism. Biomarkers of oxidative stress in pulmonary embolism have also been explored, such as matrix metalloproteinases, asymmetric dimethylarginine, and neutrophil/lymphocyte ratio. Here, we comprehensively summarize some oxidative stress mechanisms and biomarkers in the development of acute pulmonary embolism and summarize related treatments based on antioxidant stress to explore effective treatment strategies for acute pulmonary embolism.
Collapse
Affiliation(s)
- Jingchao Yang
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, 650032, Kunming, China
| | - Jinzhu Xu
- Department of Pulmonary and Critical Care Medicine, Yuxi Municipal Hospital of T.C. M, 653100, Yuxi, China
| | - Shuanglan Xu
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Yunnan University, 650021, Kunming, China
| | - Zeqin Fan
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Yunnan University, 650021, Kunming, China
| | - Chenshao Zhu
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, 650032, Kunming, China
| | - Jianyuan Wan
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, 650032, Kunming, China
| | - Jiao Yang
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Kunming Medical University, 650032, Kunming, China.
| | - Xiqian Xing
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Yunnan University, 650021, Kunming, China.
| |
Collapse
|
3
|
Barbero E, Rodríguez C, Mañas E, Retegui A, García-Ortega A, García-Sánchez A, Cano-Pumarega I, Martinez-Garcia MÁ, Jimenez D. Nocturnal hypoxemia and prognosis in patients with acute symptomatic pulmonary embolism. Int J Cardiol 2023; 389:131148. [PMID: 37423569 DOI: 10.1016/j.ijcard.2023.131148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/13/2023] [Accepted: 07/05/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Nocturnal hypoxemia has been associated with cardiovascular and non-cardiovascular morbidity and mortality. This study aimed to investigate the prognostic value of nocturnal hypoxemia among patients with hemodynamically stable acute symptomatic pulmonary embolism (PE). METHODS We performed an ad hoc secondary analysis of clinical data from a prospective cohort study. Nocturnal hypoxemia was measured by the percent sleep registry with oxygen saturation <90% [TSat90]). Outcomes assessed over the 30-days after the diagnosis of PE included PE-related death, other cardiovascular deaths, clinical deterioration requiring an escalation of treatment, recurrent venous thromboembolism (VTE), acute myocardial infarction [AMI], or stroke. RESULTS Of the 221 hemodynamically stable patients with acute PE from which the TSat90 could be calculated and did not receive supplemental oxygen, the primary outcome occurred in 11 (5.0%; 95% confidence interval [CI], 2.5% to 8.7%) within 30-days after the diagnosis of PE. When categorized by quartiles, TSat90 was not significantly associated with the occurrence of the primary outcome in unadjusted Cox regression analysis (hazard ratio, 0.96; 95% CI, 0.57 to 1.63; P = 0.88), or after adjustment for body mass index (adjusted hazard ratio, 0.97; 95% CI, 0.57 to 1.65; P = 0.92). When examined as a completely continuous variable (between 0 and 100), TSat90 was not associated with a significant increase in the adjusted hazard of 30-day primary outcome rates (hazard ratio, 0.97; 95% CI, 0.86 to 1.10; P = 0.66). CONCLUSIONS In this study, nocturnal hypoxemia did not identify stable patients with acute symptomatic PE at increased risk for adverse cardiovascular events.
Collapse
Affiliation(s)
- Esther Barbero
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Eva Mañas
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | | | - Irene Cano-Pumarega
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Miguel Ángel Martinez-Garcia
- Respiratory Department, Hospital La Fe, Valencia, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Alcala University, IRYCIS, Madrid, Spain.
| |
Collapse
|
4
|
Durán D, Barrios D, Moisés J, Retegui A, Rodríguez C, Lobo JL, López-Reyes R, Chasco L, Jara-Palomares L, Monreal M, Bikdeli B, Jiménez D. The rationale, design, and methods of a trial to evaluate the efficacy and safety of oxygen therapy in patients with intermediate-risk acute pulmonary embolism. Am Heart J 2023; 257:62-68. [PMID: 36436613 DOI: 10.1016/j.ahj.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND In patients with intermediate-risk pulmonary embolism (PE), reversal of hypoxic vasoconstriction could constitute a target for treatment that protects the right ventricular (RV) function until endogenous fibrinolysis occurs. The Air vs oxygen for Intermediate-Risk pulmonary embolism (AIR) trial aims to assess the effect of oxygen therapy in patients with intermediate-risk acute PE who do not have hypoxemia at baseline. METHODS AND ANALYSES AIR is a prospective, multicenter, randomized, open-label, parallel-group, proof-of-concept trial. A total of 90 patients hospitalized with intermediate-risk PE and an oxygen saturation of 90% or higher at baseline will be randomized in a 1:1 fashion to receive supplemental oxygen or ambient air. The primary outcome is a RV/LV diameter ratio equal or less than 1.0 on echocardiography measured 48 hours after the start of treatment. Secondary efficacy outcomes are the numerical change in the ratio of the RV to the LV diameter measured 48 hours and 7 days after the start of treatment, with respect to the baseline ratio measured at randomization. Clinical adverse events will be also collected. RESULTS Enrollment started in July 2019 and is expected to proceed until 2022. Median age of the first 50 patients was 74 years (interquartile range, 61-81), and 50% were female. CONCLUSIONS This multicenter trial will provide information about the value of supplemental oxygen in patients with intermediate-risk acute PE who do not have hypoxemia at baseline. The results will contribute to research that may assist patients with intermediate-risk PE in the future.
Collapse
Affiliation(s)
- Diego Durán
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Jorge Moisés
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - José L Lobo
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital de Araba, Vitoria, Spain
| | - Raquel López-Reyes
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Leyre Chasco
- Respiratory Department, Hospital Galdakao-Usansolo, Bilbao, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Católica de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
| |
Collapse
|
5
|
Karpov AA, Vaulina DD, Smirnov SS, Moiseeva OM, Galagudza MM. Rodent models of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Heliyon 2022; 8:e09014. [PMID: 35295664 PMCID: PMC8919224 DOI: 10.1016/j.heliyon.2022.e09014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/06/2021] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
Pulmonary embolism (PE) is the third most prevalent cardiovascular disease. It is associated with high in-hospital mortality and the development of acute and chronic complications. New approaches aimed at improving the prognosis of patients with PE are largely dependent on reliable animal models. Mice, rats, hamsters, and rabbits, are currently most commonly used for PE modeling because of their ethical acceptability and economic feasibility. This article provides an overview of the main approaches to PE modeling, and the advantages and disadvantages of each method. Special attention is paid to experimental endpoints, including morphological, functional, and molecular endpoints. All approaches to PE modeling can be broadly divided into three main groups: 1) induction of thromboembolism, either by thrombus formation in vivo or by injection of in vitro prepared blood clots; 2) introduction of particles of non-thrombotic origin; and 3) surgical procedures. The choice of a specific model and animal species is determined based on the objectives of the study. Rodent models of chronic thromboembolic pulmonary hypertension (CTEPH), which is the most devastating complication of PE, are also described. CTEPH models are especially challenging because of insufficient knowledge about the pathogenesis and high fibrinolytic activity of rodent plasma. The CTEPH model should demonstrate a persistent increase in pulmonary artery pressure and stable reduction of the vascular bed due to recurrent embolism. Based on the analysis of available evidence, one might conclude that currently, there is no single optimal method for modeling PE and CTEPH.
Collapse
|
6
|
Ruan Z, Li D, Hu Y, Qiu Z, Chen X. The Association Between Mean Corpuscular Hemoglobin Concentration and Prognosis in Patients with Acute Pulmonary Embolism: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2022; 28:10760296221103867. [PMID: 35642292 PMCID: PMC9163730 DOI: 10.1177/10760296221103867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Introduction Acute pulmonary embolism (APE) is a typical cardiovascular emergency worldwide. Mean hemoglobin concentration (MCHC) is a standard indicator of anemia. Studies on the association between MCHC and APE are scarce. We aimed to investigate the relationship between MCHC and APE. Methods Clinical data were extracted from the Medical Information Bank for Intensive Care (MIMIC)-III. Adult (≥18 years) patients with APE admitted for the first time were included in this study. An analysis was conducted to evaluate the association between MCHC and the prognosis of patients by the Cox regression analysis, generalized additives models and Kaplan–Meier survival curves. The primary outcome was 30-day mortality, and the secondary outcomes were 1-year and 3-year mortality. Results A total of 813 patients who met the selection criteria were enrolled, of whom 130 (16.0%) died within 30 days of admission. Univariate Cox regression indicated that MCHC was significantly associated with mortality (30-day: HR = 0.74, 95% CI = 0.66–0.82, P < 0.001; 1-year: HR = 0.80, 95% CI = 0.74–0.86, P < 0.001; 3-year: HR = 0.82, 95% CI = 0.77–0.88, P < 0.001). MCHC remains stable after adjusting multiple models. Kaplan-Meier survival curves showed that patients with lower MCHC had a poorer 30-day prognosis. Conclusions Lower MCHC is an independent risk factor for increased mortality in patients with APE. As an inexpensive biomarker, MCHC should receive more attention.
Collapse
Affiliation(s)
- Zhishen Ruan
- The First Clinical College, 74738Shandong Chinese Medical University, Ji Nan, People's Republic of China
| | - Dan Li
- The First Clinical College, 74738Shandong Chinese Medical University, Ji Nan, People's Republic of China
| | - Yuanlong Hu
- The First Clinical College, 74738Shandong Chinese Medical University, Ji Nan, People's Republic of China
| | - Zhanjun Qiu
- Department of Pulmonary and Critical Care Medicine, 159393The First Affiliated Hospital of Shandong Chinese Medical University, Ji Nan, People's Republic of China
| | - Xianhai Chen
- Department of Pulmonary and Critical Care Medicine, 159393The First Affiliated Hospital of Shandong Chinese Medical University, Ji Nan, People's Republic of China
| |
Collapse
|
7
|
Andersen A, van der Feen DE, Andersen S, Schultz JG, Hansmann G, Bogaard HJ. Animal models of right heart failure. Cardiovasc Diagn Ther 2020; 10:1561-1579. [PMID: 33224774 PMCID: PMC7666958 DOI: 10.21037/cdt-20-400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Right heart failure may be the ultimate cause of death in patients with acute or chronic pulmonary hypertension (PH). As PH is often secondary to other cardiovascular diseases, the treatment goal is to target the underlying disease. We do however know, that right heart failure is an independent risk factor, and therefore, treatments that improve right heart function may improve morbidity and mortality in patients with PH. There are no therapies that directly target and support the failing right heart and translation from therapies that improve left heart failure have been unsuccessful, with the exception of mineralocorticoid receptor antagonists. To understand the underlying pathophysiology of right heart failure and to aid in the development of new treatments we need solid animal models that mimic the pathophysiology of human disease. There are several available animal models of acute and chronic PH. They range from flow induced to pressure overload induced right heart failure and have been introduced in both small and large animals. When initiating new pre-clinical or basic research studies it is key to choose the right animal model to ensure successful translation to the clinical setting. Selecting the right animal model for the right study is hence important, but may be difficult due to the plethora of different models and local availability. In this review we provide an overview of the available animal models of acute and chronic right heart failure and discuss the strengths and limitations of the different models.
Collapse
Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Diederik E. van der Feen
- Center for Congenital Heart Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Stine Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm Jan Bogaard
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Schultz J, Andersen A, Gade IL, Kjaergaard B, Nielsen-Kudsk JE. Riociguat, sildenafil and inhaled nitric oxide reduces pulmonary vascular resistance and improves right ventricular function in a porcine model of acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 9:293-301. [PMID: 31025569 DOI: 10.1177/2048872619840772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pulmonary vasodilators as add-on to current treatment strategies in acute pulmonary embolism may improve right ventricular unloading and hence improve patient outcome. We aimed to investigate whether stimulation of the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway with riociguat, sildenafil or inhaled NO causes pulmonary vasodilation and improves right ventricular function in a porcine model of acute intermediate risk pulmonary embolism. METHODS Two large autologous blood clots were administered to the pulmonary circulation of 28 pigs (60 kg). Animals were randomized to four increasing, clinically equivalent doses of riociguat (n=6), sildenafil (n=6), inhaled NO (n=6) or vehicle (n=6). Sham animals (n=4) did not receive pulmonary embolism or treatment. Haemodynamic responses were evaluated at baseline, after pulmonary embolism and after each dose using invasive pressure measurements, transoesophageal echocardiography, respiratory parameters and blood analysis. RESULTS Pulmonary embolism caused a three-fold increase in pulmonary vascular resistance compared with baseline (pulmonary embolism: 352±29 vs. baseline: 107±6 dynes, p<0.0001). All treatments lowered pulmonary vascular resistance compared with vehicle (riociguat: -158±35, sildenafil: -224±35, inhaled NO: -156±35 dynes, p<0.0001). Sildenafil, but neither inhaled NO nor riociguat, caused a decrease in systemic vascular resistance (sildenafil 678±41 vs. vehicle 1081±93 dynes, p=0.02) and increased cardiac output (sildenafil 8.8±0.8 vs. vehicle: 5.9±0.2 L/min, p<0.001). Systemic blood pressure was unaltered in all treatment groups. CONCLUSION Stimulation of the NO-sGC-cGMP pathway by riociguat, sildenafil and inhaled NO reduces pulmonary vascular resistance in a porcine model of acute pulmonary embolism without lowering systemic blood pressure.
Collapse
Affiliation(s)
- Jacob Schultz
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Inger Lise Gade
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark
- Department of Haematology, Aalborg University Hospital, Denmark
| | | | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| |
Collapse
|
9
|
Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism - a systematic review. Pulm Circ 2020; 10:2045894019899775. [PMID: 32180938 PMCID: PMC7057411 DOI: 10.1177/2045894019899775] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/18/2019] [Indexed: 01/17/2023] Open
Abstract
Acute pulmonary embolism is the third most common cause of cardiovascular death. Pulmonary embolism increases right ventricular afterload, which causes right ventricular failure, circulatory collapse and death. Most treatments focus on removal of the mechanical obstruction caused by the embolism, but pulmonary vasoconstriction is a significant contributor to the increased right ventricular afterload and is often left untreated. Pulmonary thromboembolism causes mechanical obstruction of the pulmonary vasculature coupled with a complex interaction between humoral factors from the activated platelets, endothelial effects, reflexes and hypoxia to cause pulmonary vasoconstriction that worsens right ventricular afterload. Vasoconstrictors include serotonin, thromboxane, prostaglandins and endothelins, counterbalanced by vasodilators such as nitric oxide and prostacyclins. Exogenous administration of pulmonary vasodilators in acute pulmonary embolism seems attractive but all come with a risk of systemic vasodilation or worsening of pulmonary ventilation-perfusion mismatch. In animal models of acute pulmonary embolism, modulators of the nitric oxide-cyclic guanosine monophosphate-protein kinase G pathway, endothelin pathway and prostaglandin pathway have been investigated. But only a small number of clinical case reports and prospective clinical trials exist. The aim of this review is to give an overview of the causes of pulmonary embolism-induced pulmonary vasoconstriction and of experimental and human investigations of pulmonary vasodilation in acute pulmonary embolism.
Collapse
Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
10
|
Inhaled nitric oxide to control platelet hyper-reactivity in patients with acute submassive pulmonary embolism. Nitric Oxide 2020; 96:20-28. [PMID: 31940502 DOI: 10.1016/j.niox.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND We test if inhaled nitric oxide (NO) attenuates platelet functional and metabolic hyper-reactivity in subjects with submassive pulmonary embolism (PE). METHODS Participants with PE were randomized to either 50 ppm NO + O2 or O2 only for 24 h with blood sampling at enrollment and after treatment; results were compared with healthy controls. Platelet metabolic activity was assessed by oxygen consumption (basal and uncoupled) and reactivity was assessed with agonist-stimulated thromboelastography (TEG) and fluorometric measurement of agonist-stimulated cytosolic [Ca++] without and with pharmacological soluble guanylate (sGC) modulation. RESULTS Participants (N = 38 per group) were well-matched at enrollment for PE severity, comorbidities as well as TEG parameters and platelet O2 consumption. NO treatment doubled the mean plasma [NO3-] (P < 0.001) indicating successful delivery, but placebo treatment produced no change. After 24 h, neither TEG nor O2 consumption parameters differed significantly between treatment groups. Platelet cytosolic [Ca++] was elevated with PE versus controls, and was decreased by treatment with cinaciguat (an sGC activator), but not riociguat (an sGC stimulator). Stimulated platelet lysate sGC activity was increased with PE compared with controls. CONCLUSIONS In patients with acute submassive PE, despite evidence of adequate drug delivery, inhaled NO had no major effect on platelet O2 consumption or agonist-stimulated parameters on TEG. Pharmacological activation, but not stimulation, of sGC effectively decreased platelet cytosolic [Ca++], and platelet sGC activity was increased with PE, confirming the viability of sGC as a therapeutic target.
Collapse
|
11
|
Endogenously released adenosine causes pulmonary vasodilation during the acute phase of pulmonary embolization in dogs. IJC HEART & VASCULATURE 2019; 24:100396. [PMID: 31334333 PMCID: PMC6620623 DOI: 10.1016/j.ijcha.2019.100396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/25/2019] [Accepted: 06/24/2019] [Indexed: 11/22/2022]
Abstract
Background Endogenous adenosine levels increase under stress in various organs. Exogenously administered adenosine is a well-known pulmonary vasodilator. However, the physiology and therapeutic potential of endogenous adenosine during alteration in pulmonary hemodynamics such as pulmonary embolism is not elucidated. We hypothesized that the adenosine level increases following an acute elevation of pulmonary resistance, resulting in pulmonary vasodilation. Methods We induced acute pulmonary embolization by injecting plastic beads in anesthetized dogs. Plasma adenosine levels, defined as the product of plasma adenosine concentration and simultaneous cardiac output, were assessed from blood samples from the superior vena cava, main pulmonary artery (MPA), and ascending aorta 1 and 10 min following injection. Hemodynamics were assessed with (n = 3) and without (n = 8) administration of the adenosine receptor blocker, 8-(p-sulfophenyl)theophylline (8SPT). Results Mean pulmonary arterial pressure (PAP) increased from 11 ± 1 mmHg, peaking at 28 ± 4 mmHg at 52 ± 13 s after injection. During this period, total pulmonary resistance (TPR) elevated from 11 ± 1 to 33 ± 6 Wood unit. Plasma adenosine levels increased in the MPA from 14.5 ± 2 to 38.8 ± 7 nmol/min 1 min after injection. TPR showed greater elevation under 8SPT treatment, to 96 ± 12 Wood unit at PAP peak. Conclusions Endogenously released adenosine after acute pulmonary embolization is one of the initial pulmonary vasodilators. The immediate surge in plasma adenosine levels in the MPA could lead to a hypothesis that adenosine is released by the right heart in response to pressure overload. Adenosine levels increased after experimental acute pulmonary embolization. Plasma adenosine levels immediately rose in the main pulmonary artery. Adenosine is one of the initial pulmonary vasodilators after embolization. Released adenosine could originate from the right heart following pressure overload.
Collapse
|
12
|
Inhaled Nitric Oxide as an Adjunct to Thrombolytic Therapy in a Patient with Submassive Pulmonary Embolism and Severe Hypoxemia. Case Rep Crit Care 2019; 2019:5184702. [PMID: 31032122 PMCID: PMC6458947 DOI: 10.1155/2019/5184702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/14/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator with limited indications in adults. We present a patient with hypoxemia and right ventricular dysfunction due to submassive acute pulmonary emboli where iNO was used as a bridge to thrombolysis. Case A 29-year-old male was admitted to the intensive care unit (ICU) for alcohol intoxication complicated with aspiration pneumonia and acute respiratory failure requiring mechanical ventilation. His medical history included morbid obesity (BMI 43) and alcohol dependence syndrome. Nine days after admission, he developed severe acute hypoxia and tachycardia with arterial oxygen tension (PaO2) of 52 mmHg requiring a positive end-expiratory pressure (PEEP) of 14 cmH2O and fraction of inspired oxygen (FiO2) of 1. Chest computed tomography (CT) revealed a large embolus in the right main pulmonary artery and transthoracic echocardiogram (TTE) reported new right ventricular dilatation with decreased right ventricular function. Due to the severe hypoxemia, he was started on iNO via the breathing circuit of the ventilator at a concentration of 20 parts per million (ppm) with steady improvement in oxygenation after 1 hour with a PaO2 of 81 mmHg on the same ventilator setting. The patient was given thrombolysis with alteplase and the iNO was slowly tapered off during the subsequent four days with concomitant successful tapering of PEEP to 8 cmH2O and FiO2 of 0.45. Conclusion Inhaled NO has been used to improve ventilation-perfusion matching and also to reduce pulmonary vascular resistance (PVR). Its effects on PVR may be useful in the setting of acute pulmonary emboli where vascular obstruction and vasoconstriction contribute to increased pulmonary arterial pressure and PVR which can present as acute right heart failure. We suggest that iNO, if available, could be considered in those patients with acute pulmonary emboli associated with significant hypoxemia as an adjunctive therapy or bridge to thrombolysis or thrombectomy.
Collapse
|
13
|
Inhaled nitric oxide to treat intermediate risk pulmonary embolism: A multicenter randomized controlled trial. Nitric Oxide 2019; 84:60-68. [PMID: 30633959 DOI: 10.1016/j.niox.2019.01.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/21/2018] [Accepted: 01/06/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To test the hypothesis that adjunctive inhaled NO would improve RV function and viability in acute PE. METHODS This was a randomized, placebo-controlled, double blind trial conducted at four academic hospitals. Eligible patients had acute PE without systemic arterial hypotension but had RV dysfunction and a treatment plan of standard anticoagulation. Subjects received either oxygen plus 50 parts per million nitrogen (placebo) or oxygen plus 50 ppm NO for 24 h. The primary composite endpoint required a normal RV on echocardiography and a plasma troponin T concentration <14 pg/mL. The secondary endpoint required a blood brain natriuretic peptide concentration <90 pg/mL and a Borg dyspnea score ≤ 2. The sample size of N = 76 tested if 30% more patients treated with NO would achieve the primary endpoint with 80% power and alpha = 5%. RESULTS We randomized 78 patients and after two withdrawals, 38 were treated per protocol in each group. Patients were well matched for baseline conditions. At 24 h, 5/38 (13%) of patients treated with placebo and 9/38 (24%) of patients treated with NO reached the primary endpoint (P = 0.375). The secondary endpoint was reached in 34% with placebo and 13% of the NO (P = 0.11). In a pre-planned post-hoc analysis, we examined how many patients with RV hypokinesis or dilation at enrollment resolved these abnormalities; 29% more patients treated with NO resolved both abnormalities at 24 h (P = 0.010, Cochrane's Q test). CONCLUSIONS In patients with severe submassive PE, inhaled nitric oxide failed to increase the proportion of patients with a normal troponin and echocardiogram but increased the probability of eliminating RV hypokinesis and dilation on echocardiography. CLINICAL TRIAL REGISTRATION NCT01939301.
Collapse
|
14
|
Discovery and development of sGC stimulators for the treatment of pulmonary hypertension and rare diseases. Nitric Oxide 2018; 77:88-95. [PMID: 29738821 DOI: 10.1016/j.niox.2018.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/26/2022]
Abstract
The NO/sGC/cGMP signaling cascade plays a pivotal role in regulation of cardiovascular, cardiopulmonary and cardiorenal diseases and impairment of this cascade results in severe pathologies. Therefore, pharmacological interventions, targeting this pathway are promising strategies for treating a variety of diseases. Nitrates, supplementing NO and, PDE5 inhibitors preventing cGMP degradation, are used for angina pectoris treatment and the treatment of pulmonary arterial hypertension (PAH), respectively. More recently, a new class of drugs which directly stimulate the sGC enzyme and trigger NO-independent cGMP production was introduced and termed sGC stimulators. In 2013, the first sGC stimulator, riociguat, was approved for the treatment of PAH and chronic thromboembolic pulmonary hypertension (CTEPH). Since cGMP targets multiple intracellular downstream targets, sGC stimulators have shown - beyond the well characterized vasodilatation - anti-fibrotic, anti-inflammatory and anti-proliferative effects. These additional modes of action might extend the therapeutic potential of this drug class substantially. This review summarizes the NO/sGC/cGMP signaling cascades, the discovery and the mode of action of sGC stimulators. Furthermore, the preclinical evidence and development of riociguat for the treatment of PAH and CTEPH is reviewed. Finally, a summary of the antifibrotic effects of sGC stimulators, especially the most recent finding for skin fibrosis are included which may indicate efficacy in fibrotic diseases like Systemic Sclerosis (SSc).
Collapse
|
15
|
Kline JA, Hall CL, Jones AE, Puskarich MA, Mastouri RA, Lahm T. Randomized trial of inhaled nitric oxide to treat acute pulmonary embolism: The iNOPE trial. Am Heart J 2017; 186:100-110. [PMID: 28454823 PMCID: PMC5412723 DOI: 10.1016/j.ahj.2017.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/21/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The study hypothesis is that administration of inhaled nitric oxide (NO) plus oxygen to subjects with submassive pulmonary embolism (PE) will improve right ventricular (RV) systolic function and reduce RV strain and necrosis, while improving patient dyspnea, more than treatment with oxygen alone. METHODS This article describes the rationale and protocol for a registered (NCT01939301), nearly completed phase II, 3-center, randomized, double-blind, controlled trial. Eligible patients have pulmonary imaging-proven acute PE. Subjects must be normotensive, and have RV dysfunction on echocardiography or elevated troponin or brain natriuretic peptide and no fibrinolytics. Subjects receive NO plus oxygen or placebo for 24 hours (±3 hours) with blood sampling before and after treatment, and mandatory echocardiography and high-sensitivity troponin posttreatment to assess the composite primary end point. The sample size of N=78 was predicated on 30% more NO-treated patients having a normal high-sensitivity troponin (<14 pg/mL) and a normal RV on echocardiography at 24 hours with α=.05 and β=.20. Safety was ensured by continuous spectrophotometric monitoring of percentage of methemoglobinemia and a predefined protocol to respond to emergent changes in condition. Blinding was ensured by identical tanks, software, and physical shielding of the device display and query of the clinical care team to assess blinding efficacy. RESULTS We have enrolled 78 patients over a 31-month period. No patient has been withdrawn as a result of a safety concern, and no patient has had a serious adverse event related to NO. CONCLUSIONS We present methods and a protocol for the first double-blinded, randomized trial of inhaled NO to treat PE.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Indiana University School of Medicine, Department of Emergency Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Bldg, 3rd Floor Emergency Medicine Office, Indianapolis, IN.
| | - Cassandra L Hall
- Indiana University School of Medicine, Department of Emergency Medicine, 1701 N Senate Blvd, AG001, Indianapolis, IN.
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS.
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS.
| | - Ronald A Mastouri
- Indiana University School of Medicine, Department of Medicine, Division of Cardiology, Indianapolis, IN.
| | - Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Walther Hall, Room C400, 980 W Walnut St, Indianapolis, IN.
| |
Collapse
|
16
|
Lai X, Kline JA, Wang M. Development, validation, and comparison of four methods to simultaneously quantify l-arginine, citrulline, and ornithine in human plasma using hydrophilic interaction liquid chromatography and electrospray tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 1005:47-55. [PMID: 26513134 DOI: 10.1016/j.jchromb.2015.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/11/2015] [Accepted: 10/03/2015] [Indexed: 10/22/2022]
Abstract
To understand the role of l-arginine depletion in impaired nitric oxide synthesis in disease, it is important to simultaneously quantify arginine, citrulline, and ornithine in the plasma. Because the three amino acids are endogenous analytes, true blank matrix for them is not available. It is necessary and valuable to compare the performance of different approaches due to lack of regulatory clarity for validation. A two-step sample preparation method using methanol as protein precipitation reagent was developed in this study is used for sample preparation. Because true blank matrix for endogenous analytes is not available, water as blank matrix, 1% BSA in PBS as blank matrix, surrogate analyte, and background subtraction were designed to establish successful quantification methods. Four methods to simultaneously quantify arginine, citrulline, and ornithine in human plasma using hydrophilic interaction liquid chromatography and electrospray tandem mass spectrometry were developed, validated, and compared. The developed two-step sample preparation method using methanol as protein precipitation reagent in this study needs less time and provides higher recovery comparing with other approaches. Three of the four methods, water as blank matrix, 1% BSA in PBS as blank matrix, and surrogate analyte, have been successful in fulfilling all the criteria, while background subtraction has failed. Results of the measured concentrations in 97 human plasma samples using the three methods show that the difference between any two methods or among the three methods presents 100% of samples with less than 20% for all the three amino acids and majority of them are under 10%. The developed two-step sample preparation method using methanol as protein precipitation reagent is simple and convenient. Three of the four methods are fully validated and the validation is successful. The BSA functioned effectively as a blank matrix for these three amino acids, considering cost, data quality, matrix similarity, and practicality.
Collapse
Affiliation(s)
- Xianyin Lai
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Cellular & Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Jeffrey A Kline
- Department of Cellular & Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Mu Wang
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| |
Collapse
|
17
|
Jabs A, Oelze M, Mikhed Y, Stamm P, Kröller-Schön S, Welschof P, Jansen T, Hausding M, Kopp M, Steven S, Schulz E, Stasch JP, Münzel T, Daiber A. Effect of soluble guanylyl cyclase activator and stimulator therapy on nitroglycerin-induced nitrate tolerance in rats. Vascul Pharmacol 2015; 71:181-91. [DOI: 10.1016/j.vph.2015.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/20/2015] [Accepted: 03/25/2015] [Indexed: 01/06/2023]
|
18
|
Watts JA, Gellar MA, Fulkerson MBK, Kline JA. A soluble guanylate cyclase stimulator, BAY 41-8543, preserves right ventricular function in experimental pulmonary embolism. Pulm Pharmacol Ther 2012; 26:205-11. [PMID: 23142020 DOI: 10.1016/j.pupt.2012.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/20/2012] [Accepted: 10/26/2012] [Indexed: 11/24/2022]
Abstract
Pulmonary embolism (PE) increases pulmonary vascular resistance, causing right ventricular (RV) dysfunction, and poor clinical outcome. Present studies test if the soluble guanylate cyclase stimulator BAY 41-8543 reduces pulmonary vascular resistance and protects RV function. Experimental PE was induced in anesthetized, male Sprague-Dawley rats by infusing 25 μm polystyrene microspheres (1.95 million/100 g body wt, right jugular vein) producing moderate PE. Pulmonary artery vascular resistance, estimated as RVPSP/CO, increased 3-fold after 5 h of PE. Treatment with BAY 41-8543 (50 μg/kg, I.V.; given at the time of PE induction) normalized this index by reducing RVPSP and markedly increasing CO, via preservation of heart rate and stroke volume. Ex vivo RV heart function showed minimal changes at 5 h of PE, but decreased significantly after 18 h of PE, including peak systolic pressure (PSP, Control 39 ± 1 mmHg vs. 19 ± 3 PE), +dP/dt (1192 ± 93 mmHg/s vs. 444 ± 64) and -dP/dt (-576 ± 60 mmHg/s vs. -278 ± 40). BAY 41-8543 significantly improved all three indices of RV heart function (PSP 35 ± 3.5, +dP/dt 1129 ± 100, -dP/dt -568 ± 87). Experimental PE produced increased PVR and RV dysfunction, which were ameliorated by treatment with BAY 41-8543. Thus, there is vasodilator reserve in this model of experimental PE that can be exploited to reduce the stress upon the heart and preserve RV contractile function.
Collapse
Affiliation(s)
- John A Watts
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
| | | | | | | |
Collapse
|
19
|
Is there a role for soluble guanylate cyclase stimulators in acute pulmonary embolism?*. Crit Care Med 2011; 39:2773-4. [DOI: 10.1097/ccm.0b013e31822b3a34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|