Pulmonary hypertension in heart failure

Chinese patent medicine Tongxinluo: A review on chemical constituents, pharmacological activities, quality control, and clinical applications

BACKGROUND

Cardiovascular and cerebrovascular disease (CCVD) is the leading cause of morbidity and mortality worldwide, imposing a significant economic burden on individuals and societies. For the past few years, Traditional Chinese Medicine (TCM) has attracted much attention due to its advantages such as fewer side effects in the treatment of CCVD. TXL has shown great promise in the treatment of CCVD.

PURPOSE

This paper aims to provide a comprehensive introduction to TXL, covering its chemical constituents, quality control, pharmacological properties, adverse reactions, and clinical applications through an extensive search of relevant electronic databases while discussing its current challenges and provides opinions for future study.

METHODS

The following electronic databases were searched up to 2023: "TXL", "CCVD", "Chemical constituents", "Quality control" and "Pharmacological properties" were entered as keywords in PubMed, Web of Science, Google Scholar and China National Knowledge Infrastructure Database and WANFANG DATA databases. The PRISMA guidelines were followed in this review process.

RESULTS

Studies have confirmed that TXL is effective in treating patients with CCVD and has fewer adverse effects. The aim of this review is to explore TXL anti-CCVD effects in relation to oxidative stress, lipid metabolism and enhanced cardiac function. This review also provides additional information on safety issues.

CONCLUSION

TXL plays a key role in the treatment of CCVD by regulating various pathways such as lipid metabolism, oxidative stress and inflammation. However, further clinical trials and animal experiments are needed to provide more evidence and recommendations for its clinical application. This article provides an overview of TXL research to inform and inspire future studies.

Noninvasive evaluation of pulmonary artery stiffness in heart failure patients via cardiovascular magnetic resonance

Heart failure (HF) presents manifestations in both cardiac and vascular abnormalities. Pulmonary hypertension (PH) is prevalent in up 50% of HF patients. While pulmonary arterial hypertension (PAH) is closely associated with pulmonary artery (PA) stiffness, the association of HF caused, post-capillary PH and PA stiffness is unknown. We aimed to assess and compare PA stiffness and blood flow hemodynamics noninvasively across HF entities and control subjects without HF using CMR. We analyzed data of a prospectively conducted study with 74 adults, including 55 patients with HF across the spectrum (20 HF with preserved ejection fraction [HFpEF], 18 HF with mildly-reduced ejection fraction [HFmrEF] and 17 HF with reduced ejection fraction [HFrEF]) as well as 19 control subjects without HF. PA stiffness was defined as reduced vascular compliance, indicated primarily by the relative area change (RAC), altered flow hemodynamics were detected by increased flow velocities, mainly by pulse wave velocity (PWV). Correlations between the variables were explored using correlation and linear regression analysis. PA stiffness was significantly increased in HF patients compared to controls (RAC 30.92 ± 8.47 vs. 50.08 ± 9.08%, p < 0.001). PA blood flow parameters were significantly altered in HF patients (PWV 3.03 ± 0.53 vs. 2.11 ± 0.48, p < 0.001). These results were consistent in all three HF groups (HFrEF, HFmrEF and HFpEF) compared to the control group. Furthermore, PA stiffness was associated with higher NT-proBNP levels and a reduced functional status. PA stiffness can be assessed non-invasively by CMR. PA stiffness is increased in HFrEF, HFmrEF and HFpEF patients when compared to control subjects.Trial registration The study was registered at the German Clinical Trials Register (DRKS, registration number: DRKS00015615).

Importance of heart failure duration for development of pulmonary hypertension in advanced heart failure

BACKGROUND AND OBJECTIVES

Pulmonary vascular resistance (PVR) is critical when evaluating candidacy for advanced heart failure (HF) therapies, but risk factors for elevated PVR are not well studied. We hypothesized that HF duration would be associated with elevated PVR.

METHODS

Danish single-center registry of consecutive in- and outpatients undergoing right heart catheterization as part of advanced HF work up. The relation between HF duration and PVR was estimated by regression analysis. Finally, the relation between PVR and long-term mortality was assessed by Cox proportional hazards regression and Kaplan-Meier analyses.

RESULTS

A total of 549 patients (77% men, median age 54 (43-61) years, median HF duration 1.6 years (0.1-7.1)) were included. Univariate linear regression displayed an association between longer HF duration and increasing PVR (p = 0.014). PVR > 3 WU was present in 92 patients (17%) who were older (median p < 0.001) and had longer HF duration (p = 0.03). HF duration (per 1 year increase) did not predict PVR > 3 WU after adjustment for covariables (OR 1.00; p = 0.99). During a mean follow-up time of 4.5 years, there were 240 (44%) deaths. Increasing PVR was associated with elevated all-cause mortality risk (adjusted HR 1.24; p < 0.001). PVR > 3 WU was associated with higher mortality (adjusted HR 1.49; p = 0.027).

CONCLUSION

Longer duration of HF was associated with higher PVR in patients with advanced HF, but this association disappeared in multivariate analyses. Longer HF duration per se likely does not cause elevated PVR and should not discourage evaluation for heart transplantation.

The role of tolvaptan in pulmonary hypertension: A retrospective study

Pulmonary hypertension (PH) is a severe form of pulmonary vascular disease that can lead to right heart failure (RHF). Nearly 2-thirds of patients with PH die within 5 years. Studies suggest that a new diuretic medication, called tolvaptan (TLV), can be used to treat PH. However, there is still insufficient evidence to confirm its effectiveness. Therefore, we investigated the role of TLV in patients with PH. This retrospective study included 73 patients with PH hospitalized in Shanghai Pulmonary Hospital between November 2019 and March 2022. All patients received 7.5 to 15.0 mg of TLV for 3 to 21 days starting at admission, in addition to targeted drugs and traditional diuretic therapy. The outcomes included the blood pressure, urine and water intake volumes, electrolyte concentrations, and renal, liver, and cardiac function indexes before and after TLV treatment. In addition, we assessed the clinical symptoms and adverse reactions during the treatment. After TLV treatment, the water intake and urine volumes significantly increased, and body weight, diastolic blood pressure (DBP) and mean arterial pressure significantly decreased. Total bilirubin, direct bilirubin, N-terminal pro-brain natriuretic peptide, and serum uric acid (UA) levels after TLV treatment were significantly lower than before treatment. After TLV treatment, dyspnea significantly improved in 71 of 73 patients, and lower limb edema disappeared in 42 of 53 patients. No obvious adverse reactions occurred during the TLV treatment period. These results suggest that adding TLV to targeted drug and traditional diuretic therapies is effective for patients with PH. However, more data are required to support these findings.

Advances in the Study of Inhaled Formulations for the Treatment of Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a serious disease with reduced systemic circulation and low bioavailability associated with conventional and dosed therapy, which inhaled drugs can avoid. A mean pulmonary artery pressure (mPAP) of ≥25 mmHg (1 mmHg = 0.133 kPa) at rest or ≥30 mmHg during exercise and a pulmonary capillary pressure or left atrial pressure (PLA) of ≤15 mmHg can be diagnosed with PAH. Pulmonary hypertension is classified into primary PAH and secondary PAH according to the presence or absence of principles or risk factors. The main symptoms of pulmonary hypertension include dyspnoea, syncope, weakness, chest pain, and the presence of varying degrees of peripheral oedema. It is a highly pathogenic and life-threatening disease and can lead to delays in treatment if not diagnosed in time. In the past few years, the studies related to this progressed slowly, which brought great harm to patients with PAH. Reports showed that patients diagnosed with PAH should receive routine preventative care, such as pneumococcal and influenza vaccinations. Inhalation therapy is mainly used for the treatment of respiratory diseases and is of great interest due to the concentration of the drug in the airways and lung tissues. Therefore, the present situation of pulmonary hypertension and the characteristics of inhalation preparation were reviewed in this paper to provide some related cue for the treatment of pulmonary hypertension. In the future, it is necessary to develop more treatment methods for pulmonary hypertension.

Therapeutic augmentation of NO-sGC-cGMP signalling: lessons learned from pulmonary arterial hypertension and heart failure

The nitric oxide (NO)-guanylate cyclase (GC)-cyclic guanosine monophosphate (cGMP) pathway plays an important role in cardiovascular, pulmonary and renal function. Phosphodiesterase-5 inhibitors (PDE-5i) inhibit cGMP degradation, whereas both soluble guanylate cyclase (sGC) stimulators and sGC activators directly increase sGC. PDE-5i (e.g. sildenafil, tadalafil) and sGC stimulators (e.g. riociguat, vericiguat) have been extensively used in pulmonary artery hypertension (PAH) and heart failure (HF). PDE-5i have also been used in end-stage HF before and after left ventricular (LV) assist device (LVAD) implantation. Augmentation of NO-GC-cGMP signalling with PDE-5i causes selective pulmonary vasodilation, which is highly effective in PAH but may have controversial, potentially adverse effects in HF, including pre-LVAD implant due to device unmasking of PDE-5i-induced RV dysfunction. In contrast, retrospective analyses have demonstrated that PDE-5i have beneficial effects when initiated post LVAD implant due to the improved haemodynamics of the supported LV and the pleiotropic actions of these compounds. sGC stimulators, in turn, are effective both in PAH and in HF due to their balanced pulmonary and systemic vasodilation, and as such they are preferable to PDE-5i if the use of a pulmonary vasodilator is needed in HF patients, including those listed for LVAD implantation. Regarding the effectiveness of PDE-5i and sGC stimulators when initiated post LVAD implant, these two groups of compounds should be tested in a randomized control trial.

PTEN as a Therapeutic Target in Pulmonary Hypertension Secondary to Left-heart Failure: Effect of HO-3867 and Supplemental Oxygenation

Pulmonary hypertension (PH) is a condition when the pressure in the lung blood vessels is elevated. This leads to increase in thickness of the blood vessels and increases the workload of the heart and lungs. The incidence and prevalence of PH has been on the increase in the last decade. It is estimated that PH affects about 1% of the global population and about 10% of individuals >65 years of age. Of the various types, Group 2 PH is the most common type seen in the elderly population. Fixed PH or PH refractive to therapies is considered a contraindication for heart transplantation; the 30-day mortality in heart transplant recipients is significantly increased in the subset of this population. In general, the pathobiology of PH involves multiple factors including hypoxia, oxidative stress, growth factor receptors, vascular stress, etc. Hence, it is challenging and important to identify specific mechanisms, diagnosis and develop effective therapeutic strategies. The focus of this manuscript is to review some of the important pathobiological processes and mechanisms in the development of PH. Results from our previously reported studies, including targeted treatments along with some new data on PH secondary to left-heart failure, are presented.