1
|
Yang M, Bi W, Zhang Z. Identification and validation of CCL5 as a key gene in HIV infection and pulmonary arterial hypertension. Front Cardiovasc Med 2024; 11:1417701. [PMID: 39119185 PMCID: PMC11306045 DOI: 10.3389/fcvm.2024.1417701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024] Open
Abstract
Background The relationship between human immunodeficiency virus (HIV) infection and pulmonary arterial hypertension (PAH) has garnered significant scrutiny. Individuals with HIV infection have a higher risk of developing PAH. However, the specific mechanism of HIV-associated PAH remains unclear. Our study aims at investigating the shared biomarkers in HIV infection and PAH and predicting the potential therapeutic target for HIV-associated PAH. Methods Data for HIV infection and PAH were downloaded from Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) analysis was performed to detect shared genes in HIV infection and PAH. Enrichment analysis was conducted to identify the function of common DEGs. Protein-protein interaction (PPI) analysis was used to detect key genes. These crucial genes were subsequently verified by RT-qPCR. Finally, candidate drugs were identified by using the Drug Signatures Database (DSigDB). Results Nineteen common DEGs were identified in HIV infection and PAH. Enrichment analysis exhibited that the functions of these genes were mainly enriched in inflammatory responses, mainly including cellular immunity and interaction between viral proteins and cytokines. By constructing PPI networks, we identified the key gene CC-type chemokine ligand 5 (CCL5), and we verified that CCL5 was highly expressed in hypoxia induced human pulmonary artery endothelial cells (hPAECs) and human pulmonary artery smooth muscle cells (hPASMCs). In addition, we predicted 10 potential drugs targeting CCL5 by Autodock Vina. Conclusion This study revealed that CCL5 might be a common biomarker of HIV infection and PAH and provided a new therapeutic target for HIV-associated PAH. However, further clinical validation is still indispensable.
Collapse
Affiliation(s)
- Mengyue Yang
- Department of Cardiology, Huazhong University of Science and Technology Union Shenzhen Hospital, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Wen Bi
- Department of Sports Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Zhijie Zhang
- Department of Cardiology, Huazhong University of Science and Technology Union Shenzhen Hospital, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| |
Collapse
|
2
|
Cook CM, Craddock VD, Ram AK, Abraham AA, Dhillon NK. HIV and Drug Use: A Tale of Synergy in Pulmonary Vascular Disease Development. Compr Physiol 2023; 13:4659-4683. [PMID: 37358518 PMCID: PMC10693986 DOI: 10.1002/cphy.c210049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Over the past two decades, with the advent and adoption of highly active anti-retroviral therapy, HIV-1 infection, a once fatal and acute illness, has transformed into a chronic disease with people living with HIV (PWH) experiencing increased rates of cardio-pulmonary vascular diseases including life-threatening pulmonary hypertension. Moreover, the chronic consequences of tobacco, alcohol, and drug use are increasingly seen in older PWH. Drug use, specifically, can have pathologic effects on the cardiovascular health of these individuals. The "double hit" of drug use and HIV may increase the risk of HIV-associated pulmonary arterial hypertension (HIV-PAH) and potentiate right heart failure in this population. This article explores the epidemiology and pathophysiology of PAH associated with HIV and recreational drug use and describes the proposed mechanisms by which HIV and drug use, together, can cause pulmonary vascular remodeling and cardiopulmonary hemodynamic compromise. In addition to detailing the proposed cellular and signaling pathways involved in the development of PAH, this article proposes areas ripe for future research, including the influence of gut dysbiosis and cellular senescence on the pathobiology of HIV-PAH. © 2023 American Physiological Society. Compr Physiol 13:4659-4683, 2023.
Collapse
Affiliation(s)
- Christine M Cook
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Vaughn D Craddock
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Anil K Ram
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ashrita A Abraham
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Navneet K Dhillon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
3
|
Madonna R, Fabiani S, Morganti R, Forniti A, Biondi F, Ridolfi L, Iapoce R, Menichetti F, De Caterina R. Exercise-Induced Pulmonary Hypertension Is Associated with High Cardiovascular Risk in Patients with HIV. J Clin Med 2022; 11:2447. [PMID: 35566573 PMCID: PMC9100247 DOI: 10.3390/jcm11092447] [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: 03/25/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/10/2022] Open
Abstract
Background and Aim: Pulmonary hypertension (PH) at rest can be preceded by the onset of exercise-induced PH (ExPH). We investigated its association with the cardiovascular (CV) risk score in patients with human immunodeficiency virus (HIV). Methods: In 46 consecutive patients with HIV with low (n = 43) or intermediate (n = 3) probability of resting PH, we evaluated the CV risk score based on prognostic determinants of CV risk. Diagnosis of ExPH was made by cardiopulmonary exercise test (CPET) and exercise stress echocardiogram (ESE). Results: Twenty-eight % (n = 13) of the enrolled patients had ExPH at both CPET and ESE, with good agreement between the two methods (Cohen’s kappa = 0.678). ExPH correlated directly with a higher CV score (p < 0.001). Patients with a higher CV score also had lower CD4+ T-cell counts (p = 0.001), a faster progression to acquired immunodeficiency syndrome (p < 0.001), a poor immunological response to antiretroviral therapy (p = 0.035), higher pulmonary vascular resistance (p = 0.003) and a higher right atrial area (p = 0.006). Conclusions: Isolated ExPH is associated with a high CV risk score in patients with HIV. Assessment of ExPH may better stratify CV risk in patients with HIV.
Collapse
Affiliation(s)
- Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Silvia Fabiani
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Riccardo Morganti
- Section of Statistics, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Arianna Forniti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Filippo Biondi
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Lorenzo Ridolfi
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| | - Riccardo Iapoce
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Francesco Menichetti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (S.F.); (A.F.); (R.I.); (F.M.)
| | - Raffaele De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (F.B.); (L.R.); (R.D.C.)
| |
Collapse
|
4
|
Hannemann J, Böger R. Dysregulation of the Nitric Oxide/Dimethylarginine Pathway in Hypoxic Pulmonary Vasoconstriction—Molecular Mechanisms and Clinical Significance. Front Med (Lausanne) 2022; 9:835481. [PMID: 35252268 PMCID: PMC8891573 DOI: 10.3389/fmed.2022.835481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/27/2022] [Indexed: 12/21/2022] Open
Abstract
The pulmonary circulation responds to hypoxia with vasoconstriction, a mechanism that helps to adapt to short-lived hypoxic episodes. When sustained, hypoxic pulmonary vasoconstriction (HPV) may become deleterious, causing right ventricular hypertrophy and failure, and contributing to morbidity and mortality in the late stages of several chronic pulmonary diseases. Nitric oxide (NO) is an important endothelial vasodilator. Its release is regulated, amongst other mechanisms, by the presence of endogenous inhibitors like asymmetric dimethylarginine (ADMA). Evidence has accumulated in recent years that elevated ADMA may be implicated in the pathogenesis of HPV and in its clinical sequelae, like pulmonary arterial hypertension (PAH). PAH is one phenotypic trait in experimental models with disrupted ADMA metabolism. In high altitude, elevation of ADMA occurs during long-term exposure to chronic or chronic intermittent hypobaric hypoxia; ADMA is significantly associated with high altitude pulmonary hypertension. High ADMA concentration was also reported in patients with chronic obstructive lung disease, obstructive sleep apnoea syndrome, and overlap syndrome, suggesting a pathophysiological role for ADMA-mediated impairment of endothelium-dependent, NO-mediated pulmonary vasodilation in these clinically relevant conditions. Improved understanding of the molecular (dys-)regulation of pathways controlling ADMA concentration may help to dissect the pathophysiology and find novel therapeutic options for these diseases.
Collapse
Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
- *Correspondence: Rainer Böger
| |
Collapse
|
5
|
Islam RK, Donnelly E, Islam KN. Circulating Hydrogen Sulfide (H 2S) and Nitric Oxide (NO) Levels Are Significantly Reduced in HIV Patients Concomitant with Increased Oxidative Stress Biomarkers. J Clin Med 2021; 10:jcm10194460. [PMID: 34640478 PMCID: PMC8509794 DOI: 10.3390/jcm10194460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022] Open
Abstract
Human immunodeficiency virus (HIV) attacks the immune system and weakens the ability to fight infections/disease. Furthermore, HIV infection confers approximately two-fold higher risk of cardiac events compared with the general population. The pathological mechanisms responsible for the increased incidence of cardiovascular disease in HIV patients are largely unknown. We hypothesized that increased oxidative stress and attenuated circulating levels of the cardioprotective gaseous signaling molecules, nitric oxide (NO), and hydrogen sulfide (H2S) were involved in the cardiovascular pathobiology observed in HIV patients. Plasma samples from both HIV patients and age-matched normal subjects were used for all assays. Oxidative stress was determined by analyzing the levels of advanced oxidation protein products (AOPP) and H2O2. Antioxidant levels were determined by measuring the levels of trolox equivalent capacity. ADMA, hs-CRP, and IL-6 were determined by using ELISA. The levels of H2S (free H2S and sulfane sulfur) and NO2 (nitrite) were determined in the plasma samples by using gas chromatography and HPLC, respectively. In the present study we observed a marked induction in the levels of oxidative stress and decreased antioxidant status in the plasma of HIV patients as compared with the controls. Circulating levels of the cardiovascular disease biomarkers: ADMA, hs-CRP (high-sensitivity C-reactive protein), and IL-6 were significantly increased in the circulatory system of HIV patients. The levels of both nitrite and H2S/sulfane sulfur were significantly reduced in the plasma of HIV patients as compared with normal subjects. Our data demonstrate significant increases in circulating biomarkers of oxidative stress and cardiovascular (CV) in conjunction with decreased bioavailability of H2S and NO in HIV patients. Diminished levels of these two cardioprotective gaseous signaling molecules may be involved in the pathogenesis of CV disease in the setting of HIV.
Collapse
Affiliation(s)
- Rahib K. Islam
- LSU Health Sciences Center, Department of Pharmacology, 1901 Perdido St., New Orleans, LA 70112, USA; (R.K.I.); (E.D.)
| | - Erinn Donnelly
- LSU Health Sciences Center, Department of Pharmacology, 1901 Perdido St., New Orleans, LA 70112, USA; (R.K.I.); (E.D.)
| | - Kazi N. Islam
- LSU Health Sciences Center, Department of Pharmacology, 1901 Perdido St., New Orleans, LA 70112, USA; (R.K.I.); (E.D.)
- Agricultural Research Development Program, College of Engineering, Science, Technology and Agriculture, Central State University, 1400 Brush Row Road, Wilberforce, OH 45384, USA
- Correspondence:
| |
Collapse
|
6
|
Madonna R, Fabiani S, Morganti R, Forniti A, Mazzola M, Menichetti F, De Caterina R. Exercise-induced pulmonary hypertension in HIV patients: Association with poor clinical and immunological status. Vascul Pharmacol 2021; 139:106888. [PMID: 34182165 DOI: 10.1016/j.vph.2021.106888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIM Exercise-induced pulmonary hypertension (Ex-PH) may represent the earliest sign of pulmonary arterial hypertension (PAH) in human immunodeficiency virus (HIV) patients. We investigated its association with clinical and immunological status, virologic control, and response to antiviral therapy. METHODS In 32 consecutive HIV patients with either low (n = 29) or intermediate probability (n = 3) of PH at rest, we evaluated the association of isolated ExPH with: time to HIV diagnosis; CD4+ T-cell count; clinical progression to acquired immunodeficiency syndrome (AIDS); development of resistance to antiretroviral therapy (ART); HIV RNA levels; time to beginning of ART; current use of protease inhibitors; combination of ART with boosters (ritonavir or cobicistat); immuno-virologic response to ART; and ART discontinuation. Isolated ExPH at stress echocardiography (ESE) was defined as absence of PH at rest and systolic pulmonary arterial pressure (sPAP) >45 mmHg or a >20 mmHg increase during low-intensity exercise cardiac output (<10 L/min). RESULTS In our cohort, 22% (n = 7) of the enrolled population developed ExPH which was inversely related to CD4+ T-cell count (p = 0.047), time to HIV diagnosis (p = 0.014) and time to onset of ART (p = 0.041). Patients with ExPH had a worse functional class than patients without ExPH (p < 0.001). ExPH and AIDS showed a trend (p = 0.093) to a direct relationship. AIDS patients had a higher pulmonary vascular resistance compared to patients without ExPH (p = 0.020) at rest echocardiography. CONCLUSIONS The presence of isolated ExPH associates with a worse clinical status and poor immunological control in HIV patients. Assessment of ExPH by ESE may help identify subgroups of HIV patients with a propensity to develop subclinical impairment of pulmonary circulation following poor control of HIV infection.
Collapse
Affiliation(s)
- Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Silvia Fabiani
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | | | - Arianna Forniti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Raffaele De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| |
Collapse
|
7
|
Lázár Z, Mészáros M, Bikov A. The Nitric Oxide Pathway in Pulmonary Arterial Hypertension: Pathomechanism, Biomarkers and Drug Targets. Curr Med Chem 2021; 27:7168-7188. [PMID: 32442078 DOI: 10.2174/0929867327666200522215047] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 02/20/2020] [Indexed: 11/22/2022]
Abstract
The altered Nitric Oxide (NO) pathway in the pulmonary endothelium leads to increased vascular smooth muscle tone and vascular remodelling, and thus contributes to the development and progression of pulmonary arterial hypertension (PAH). The pulmonary NO signalling is abrogated by the decreased expression and dysfunction of the endothelial NO synthase (eNOS) and the accumulation of factors blocking eNOS functionality. The NO deficiency of the pulmonary vasculature can be assessed by detecting nitric oxide in the exhaled breath or measuring the degradation products of NO (nitrite, nitrate, S-nitrosothiol) in blood or urine. These non-invasive biomarkers might show the potential to correlate with changes in pulmonary haemodynamics and predict response to therapies. Current pharmacological therapies aim to stimulate pulmonary NO signalling by suppressing the degradation of NO (phosphodiesterase- 5 inhibitors) or increasing the formation of the endothelial cyclic guanosine monophosphate, which mediates the downstream effects of the pathway (soluble guanylate cyclase sensitizers). Recent data support that nitrite compounds and dietary supplements rich in nitrate might increase pulmonary NO availability and lessen vascular resistance. This review summarizes current knowledge on the involvement of the NO pathway in the pathomechanism of PAH, explores novel and easy-to-detect biomarkers of the pulmonary NO.
Collapse
Affiliation(s)
- Zsófia Lázár
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Martina Mészáros
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Andras Bikov
- Department of Pulmonology, Semmelweis University, Budapest, Hungary,Manchester University NHS Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
8
|
Hannemann J, Zummack J, Hillig J, Böger R. Metabolism of asymmetric dimethylarginine in hypoxia: from bench to bedside. Pulm Circ 2020; 10:2045894020918846. [PMID: 32313644 PMCID: PMC7158260 DOI: 10.1177/2045894020918846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022] Open
Abstract
Acute hypoxia and chronic hypoxia induce pulmonary vasoconstriction. While hypoxic pulmonary vasoconstriction is a physiological response if parts of the lung are affected, global exposure to hypoxic conditions may lead to clinical conditions like high-altitude pulmonary hypertension. Nitric oxide is the major vasodilator released from the vascular endothelium. Nitric oxide-dependent vasodilation is impaired in hypoxic conditions. Inhibition of nitric oxide synthesis is the most rapid and easily reversible molecular mechanism to regulate nitric oxide-dependent vascular function in response to physiological and pathophysiological stimuli. Asymmetric dimethylarginine is an endogenous, competitive inhibitor of nitric oxide synthase and a risk marker for major cardiovascular events and mortality. Elevated asymmetric dimethylarginine has been observed in animal models of hypoxia as well as in human cohorts under chronic and chronic intermittent hypoxia at high altitude. In lowlanders, asymmetric dimethylarginine is high in patients with pulmonary hypertension. We have recently shown that high asymmetric dimethylarginine at sea level is a predictor for high-altitude pulmonary hypertension. Asymmetric dimethylarginine is a highly regulated molecule, both by its biosynthesis and metabolism. Methylation of L-arginine by protein arginine methyltransferases was shown to be increased in hypoxia. Furthermore, the metabolism of asymmetric dimethylarginine by dimethylarginine dimethylaminohydrolases (DDAH1 and DDAH2) is decreased in animal models of hypoxia. Whether these changes are caused by transcriptional or posttranslational modifications remains to be elucidated. Current data suggest a major role of asymmetric dimethylarginine in regulating pulmonary arterial nitric oxide production in hypoxia. Further studies are needed to decipher the molecular mechanisms regulating asymmetric dimethylarginine in hypoxia and to understand their clinical significance.
Collapse
Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Julia Zummack
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Jonas Hillig
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| |
Collapse
|
9
|
Basyal B, Jarrett H, Barnett CF. Pulmonary Hypertension in HIV. Can J Cardiol 2019; 35:288-298. [PMID: 30825951 DOI: 10.1016/j.cjca.2019.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 12/16/2022] Open
Abstract
Human immunodeficiency virus-associated pulmonary arterial hypertension (HIV-PAH) is important to recognize given its association with significant morbidity and mortality. With the introduction of antiretroviral therapy, the focus of disease management has largely shifted from treating immunodeficiency-related opportunistic infections to managing chronic cardiopulmonary complications. Symptoms are nonspecific, and a high index of clinical suspicion is needed to avoid significant delay in the diagnosis of HIV-PAH. Although several viral proteins have been implicated in the pathogenesis of HIV-PAH, the exact mechanism remains uncertain. Further studies are needed to elucidate precise pathogenic mechanisms, early diagnostic tools, and novel therapeutic targets to improve prognosis of this severe complication.
Collapse
Affiliation(s)
- Binaya Basyal
- MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC, USA
| | - Harish Jarrett
- MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC, USA; MedStar Georgetown University Hospital, Washington, DC, USA
| | - Christopher F Barnett
- MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC, USA; MedStar Georgetown University Hospital, Washington, DC, USA.
| |
Collapse
|
10
|
Cribbs SK, Crothers K, Morris A. Pathogenesis of HIV-Related Lung Disease: Immunity, Infection, and Inflammation. Physiol Rev 2019; 100:603-632. [PMID: 31600121 DOI: 10.1152/physrev.00039.2018] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Despite anti-retroviral therapy (ART), human immunodeficiency virus-1 (HIV)-related pulmonary disease continues to be a major cause of morbidity and mortality for people living with HIV (PLWH). The spectrum of lung diseases has changed from acute opportunistic infections resulting in death to chronic lung diseases for those with access to ART. Chronic immune activation and suppression can result in impairment of innate immunity and progressive loss of T cell and B cell functionality with aberrant cytokine and chemokine responses systemically as well as in the lung. HIV can be detected in the lungs of PLWH and has profound effects on cellular immune functions. In addition, HIV-related lung injury and disease can occur secondary to a number of mechanisms including altered pulmonary and systemic inflammatory pathways, viral persistence in the lung, oxidative stress with additive effects of smoke exposure, microbial translocation, and alterations in the lung and gut microbiome. Although ART has had profound effects on systemic viral suppression in HIV, the impact of ART on lung immunology still needs to be fully elucidated. Understanding of the mechanisms by which HIV-related lung diseases continue to occur is critical to the development of new preventive and therapeutic strategies to improve lung health in PLWH.
Collapse
Affiliation(s)
- Sushma K Cribbs
- Pulmonary Medicine, Department of Veterans Affairs, Atlanta, Georgia; Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia; Department of Medicine, Veterans Affairs Puget Sound Health Care System and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington; and Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristina Crothers
- Pulmonary Medicine, Department of Veterans Affairs, Atlanta, Georgia; Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia; Department of Medicine, Veterans Affairs Puget Sound Health Care System and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington; and Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alison Morris
- Pulmonary Medicine, Department of Veterans Affairs, Atlanta, Georgia; Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia; Department of Medicine, Veterans Affairs Puget Sound Health Care System and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington; and Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Clinical Value of Asymmetrical Dimethylarginine Detection in Patients with Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Cardiol Res Pract 2019; 2019:3741909. [PMID: 31485349 PMCID: PMC6710784 DOI: 10.1155/2019/3741909] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/29/2019] [Accepted: 07/27/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the clinical value of serum asymmetrical dimethylarginine (ADMA) in patients with connective tissue disease- (CTD-) associated pulmonary arterial hypertension (PAH). Methods 88 patients with CTD were recruited between December 2017 and August 2018 in Jiangxi Provincial People's Hospital. Patients were further divided into two groups: CTD-without PAH (n = 45 cases) and CTD-with PAH (n = 43 cases), according to the pulmonary systolic blood pressure measured by echocardiography. 40 healthy controls were also included (n = 40 cases). The clinical data, including laboratory examinations, echocardiographic measurements, pulmonary function, and serum ADMA levels determined by enzyme-linked immunosorbent assay, (ELISA) were collected. The correlation between ADMA levels and the occurrence of PAH, pulmonary function, and other laboratory indexes in CTD patients were analyzed. Statistical analyses were performed by SPSS (version 23); P < 0.05 was considered statistically significant. Results The serum levels of ADMA in the CTD-PAH group were significantly higher than those of the CTD-without PAH group and healthy control group (P < 0.05); the serum ADMA levels were (0.706 ± 0.153 μmol/L), (1.015 ± 0.122 μmol/L), and (0.661 ± 0.113 μmol/L), respectively. There was no significant difference between the CTD-without PAH group and healthy control group (P < 0.05). Correlation analysis showed that serum ADMA levels were positively correlated with sPAP and NT-proBNP and negatively correlated with DLCO% (r = 0.802, 0.475, −0.585, P < 0.001). Multivariate analysis indicated that elevated serum ADMA levels increased the risk for the appearance of PAH in CTD patients (OR = 57.460, P < 0.001). Using the receiver operating characteristic (ROC) curve analysis, at the cutoff level of 0.810 μmol/L, ADMA showed good diagnostic efficacy as follows: sensitivity was 97.7%, specificity was 75.6%, and the area under the curve (AUC) was 0.947 (P < 0.001). Conclusion Increased ADMA levels are independently associated with the presence and severity of PAH in CTD patients. The levels of ADMA in the serum may contribute to be a noninvasive indicator for early diagnosis of CTD-with PAH patients.
Collapse
|
12
|
Pulmonary hypertension in the global population of adolescents and adults living with HIV: a systematic review and meta-analysis. Sci Rep 2019; 9:7837. [PMID: 31127158 PMCID: PMC6534533 DOI: 10.1038/s41598-019-44300-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/13/2019] [Indexed: 12/19/2022] Open
Abstract
A systematic review and meta-analysis was conducted to estimate the prevalence of PH in adolescents and adults living with HIV at the global level. PubMed, EMBASE, Web of Science, and Global Index Medicus were searched to identify articles published until November 4, 2018. PH had to be investigated with transthoracic echography or right heart catheterization (RHC). A random-effects model was used to pool individual studies. Overall, 25 studies with 42,642 participants from 17 countries were included. One study reported the prevalence of PH among HIV-infected adults based on RHC: 0.5% (95% confidence interval (CI): 0.3–0.6). The global prevalence of PH based on echography was 8.3% (95% CI: 4.6–12.8; 22 studies) among HIV-infected adults. In subgroup analysis, there was no difference between regions, human development indicator, and HIV burden in countries. Among HIV-infected adolescents, the prevalence of PH based on echography was 14.0% (95% CI: 2.2–33.1; 2 studies). This study suggests a high prevalence of PH in the global adolescent and adult population infected with HIV. As such, PH in this vulnerable population should be prioritized by HIV healthcare providers, policy makers and stakeholders for improved detection, overall proper management and efficient control.
Collapse
|
13
|
Butrous G. Schistosome infection and its effect on pulmonary circulation. Glob Cardiol Sci Pract 2019; 2019:5. [PMID: 31024947 PMCID: PMC6472693 DOI: 10.21542/gcsp.2019.5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023] Open
Abstract
Schistosomiasis is the most common parasitic disease associated with pulmonary hypertension. It induces remodelling via complex inflammatory processes, which eventually produce the clinical manifestation of pulmonary hypertension. The pulmonary hypertension shows clinical signs and symptoms that are not distinguishable from other forms of pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Ghazwan Butrous
- Professor of Cardiopulmonary Sciences, Medway School of Pharmacy, University of Kent, UK and University of Greenwich, Central Ave, Gillingham, Chatham ME4 4BF, Kent, UK
| |
Collapse
|
14
|
Abstract
: Improved survival among HIV-1-infected individuals with the advent of antiretroviral therapy has clearly led to a greater prevalence of noninfectious complications. One of the most devastating sequelae in these individuals is the development of pulmonary arterial hypertension (PAH). Various epidemiological studies suggest worse survival of HIV-PAH patients when compared with other forms of PAH. Given that only a subset and not all HIV-infected individuals develop HIV-PAH, it is suggested that an additional second-hit of genetic or environmental trigger is needed for the development of PAH. In this context, it has been well documented that HIV patients who abuse illicit drugs such as stimulants, opioids, and the like, are more susceptible to develop PAH. In this review, we highlight the studies that support the significance of a double hit of HIV and drug abuse in the incidence of PAH and focus on the research that has been undertaken to unravel the pathobiology and vascular remodeling mechanisms underlying the deleterious synergy between HIV infection and drugs of abuse in orchestrating the development of PAH.
Collapse
|
15
|
Mondejar-Parreño G, Morales-Cano D, Barreira B, Callejo M, Ruiz-Cabello J, Moreno L, Esquivel-Ruiz S, Mathie A, Butrous G, Perez-Vizcaino F, Cogolludo A. HIV transgene expression impairs K + channel function in the pulmonary vasculature. Am J Physiol Lung Cell Mol Physiol 2018; 315:L711-L723. [PMID: 30136611 DOI: 10.1152/ajplung.00045.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection is an established risk factor for pulmonary arterial hypertension (PAH); however, the pathogenesis of HIV-related PAH remains unclear. Since K+ channel dysfunction is a common marker in most forms of PAH, our aim was to analyze whether the expression of HIV proteins is associated with impairment of K+ channel function in the pulmonary vascular bed. HIV transgenic mice (Tg26) expressing seven of the nine HIV viral proteins and wild-type (WT) mice were used. Hemodynamic assessment was performed by echocardiography and catheterization. Vascular reactivity was studied in endothelium-intact pulmonary arteries. K+ currents were recorded in freshly isolated pulmonary artery smooth muscle cells (PASMC) using the patch-clamp technique. Gene expression was assessed using quantitative RT-PCR. PASMC from Tg26 mice had reduced K+ currents and were more depolarized than those from WT. Whereas voltage-gated K+ channel 1.5 (Kv1.5) currents were preserved, pH-sensitive noninactivating background currents ( IKN) were nearly abolished in PASMC from Tg26 mice. Tg26 mice had reduced lung expression of Kv7.1 and Kv7.4 channels and decreased responses to the Kv7.1 channel activator L-364,373 assessed by vascular reactivity and patch-clamp experimental approaches. Although we found pulmonary vascular remodeling and endothelial dysfunction in Tg26 mice, this was not accompanied by changes in hemodynamic parameters. In conclusion, the expression of HIV proteins in vivo impairs pH-sensitive IKN and Kv7 currents. This negative impact of HIV proteins in K+ channels was not sufficient to induce PAH, at least in mice, but may play a permissive or accessory role in the pathophysiology of HIV-associated PAH.
Collapse
Affiliation(s)
- Gema Mondejar-Parreño
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Daniel Morales-Cano
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Bianca Barreira
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - María Callejo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Jesús Ruiz-Cabello
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain.,Centro de Investigación Cooperativa en Biomateriales, Donostia- San Sebastián , Spain.,Basque Foundation for Science , Bilbao , Spain.,Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense de Madrid , Madrid , Spain
| | - Laura Moreno
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Sergio Esquivel-Ruiz
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Alistair Mathie
- Medway School of Pharmacy, University of Kent and University of Greenwich , Chatham , United Kingdom
| | - Ghazwan Butrous
- Medway School of Pharmacy, University of Kent and University of Greenwich , Chatham , United Kingdom
| | - Francisco Perez-Vizcaino
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| | - Angel Cogolludo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain
| |
Collapse
|
16
|
Marra AM, Bossone E, Salzano A, D’Assante R, Monaco F, Ferrara F, Arcopinto M, Vriz O, Suzuki T, Cittadini A. Biomarkers in Pulmonary Hypertension. Heart Fail Clin 2018; 14:393-402. [DOI: 10.1016/j.hfc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
17
|
Abstract
PURPOSE OF REVIEW HIV-associated pulmonary arterial hypertension (HIV-PAH) is a well-recognized severe cardiovascular complication of HIV infection that confers an adverse prognosis irrespective of the stage of disease. This review will summarize the available data on HIV-PAH epidemiology and provide insights into the pathophysiology and therapeutic strategies currently available. RECENT FINDINGS Patients with HIV are several thousand times more likely to develop HIV-PAH compared to the incidence of idiopathic PAH. Several HIV viral proteins are implicated in the pathogenesis although the exact mechanism remains unknown. In the past two decades, there have been several new treatment strategies that appear effective in treating HIV-PAH. Novel pathophysiologic mechanisms implicating the transforming growth factor β receptor family may offer novel therapeutic targets in the future. SUMMARY As antiretroviral therapy continues to improve health outcomes for patients with HIV, there needs to be a shift in focus of care toward chronic noncommunicable diseases. Among cardiovascular disease-complicating chronic HIV infection, HIV-PAH is a severe progressive disease that leads to right heart failure and death. Currently available treatment strategies are effective, however, furthering our understanding of HIV-PAH will be critical as it is likely to become the commonest cause of PAH worldwide.
Collapse
|
18
|
Sandoval Gutiérrez JL. [Pulmonary arterial hypertension associated with human immunodeficiency virus: thirty years after its description]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:503-506. [PMID: 29655622 DOI: 10.1016/j.acmx.2018.03.003] [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: 07/19/2017] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 11/19/2022] Open
Abstract
The development of pulmonary arterial hypertension associated with human immunodeficiency virus reduces the probability of survival in the patient affected compared to those without cardiopulmonary disease. The pathophysiology is uncertain. There are several lines of research to associate the different proteins of the virus in the endothelial lesion. From a therapeutic point of view there are treatment modalities that allow an acceptable life expectancy.
Collapse
|
19
|
Abstract
: HIV in the antiretroviral therapy era is characterized by multimorbidity and the frequent occurrence of HIV-associated non-AIDS chronic health conditions. Respiratory symptoms and chronic pulmonary diseases, including chronic obstructive pulmonary disease, asthma, and cardiopulmonary dysfunction, are among the conditions that may present in persons living with HIV. Tobacco smoking, which is disproportionately high among persons living HIV, strongly contributes to the risk of pulmonary disease. Additionally, features associated with and at times unique to HIV, including persistent inflammation, immune cell activation, oxidative stress, and dysbiosis, may also contribute. This review summarizes the available literature regarding epidemiology of and risk factors for respiratory symptoms and chronic pulmonary disease in the current era.
Collapse
|
20
|
Abstract
Pulmonary complications remain among the most frequent causes of morbidity and mortality for individuals with HIV despite the advent of antiretroviral therapy (ART) and improvement in its efficacy and availability. The prevalence of non-infectious pulmonary diseases is rising in this population, reflecting both an increase in smoking and the independent risk associated with HIV. The unique mechanisms of pulmonary disease in these patients remain poorly understood, and direct effects of HIV, genetic predisposition, inflammatory pathways, and co-infections have all been implicated. Lung cancer, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension are the most prevalent non-infectious pulmonary diseases in persons with HIV, and the risk of each of these diseases is higher among HIV-infected (HIV+) persons than in the general population. This review discusses the latest advances in the literature on these important complications of HIV infection.
Collapse
Affiliation(s)
- M Triplette
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - K Crothers
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA, USA
| | - E F Attia
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
21
|
Sandqvist A, Schneede J, Kylhammar D, Henrohn D, Lundgren J, Hedeland M, Bondesson U, Rådegran G, Wikström G. Plasma L-arginine levels distinguish pulmonary arterial hypertension from left ventricular systolic dysfunction. Heart Vessels 2017; 33:255-263. [PMID: 28975394 PMCID: PMC5847178 DOI: 10.1007/s00380-017-1055-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/22/2017] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening condition, characterized by an imbalance of vasoactive substances and remodeling of pulmonary vasculature. Nitric oxide, formed from L-arginine, is essential for homeostasis and smooth muscle cell relaxation in PAH. Our aim was to compare plasma concentrations of L-arginine, asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA) in PAH compared to left ventricular systolic dysfunction (LVSD) and healthy subjects. This was an observational, multicenter study comparing 21 patients with PAH to 14 patients with LVSD and 27 healthy subjects. Physical examinations were obtained and blood samples were collected. Plasma levels of ADMA, SDMA, L-arginine, L-ornithine, and L-citrulline were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Plasma levels of ADMA and SDMA were higher, whereas L-arginine and L-arginine/ADMA ratio were lower in PAH patients compared to healthy subjects (p < 0.001). Patients with PAH also had lower levels of L-arginine than patients with LVSD (p < 0.05). L-Arginine correlated to 6 min walking distance (6MWD) (r s = 0.58, p = 0.006) and L-arginine/ADMA correlated to WHO functional class (r s = -0.46, p = 0.043) in PAH. In conclusion, L-arginine levels were significantly lower in treatment naïve PAH patients compared to patients with LVSD. Furthermore, L-arginine correlated with 6MWD in PAH. L-arginine may provide useful information in differentiating PAH from LVSD.
Collapse
Affiliation(s)
- Anna Sandqvist
- Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology, Umeå University, 901 87, Umeå, Sweden.
| | - Jörn Schneede
- Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology, Umeå University, 901 87, Umeå, Sweden
| | - David Kylhammar
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Dan Henrohn
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Jakob Lundgren
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Mikael Hedeland
- Department of Chemistry, National Veterinary Institute (SVA), Uppsala, Sweden.,Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry, Uppsala University, Uppsala, Sweden
| | - Ulf Bondesson
- Department of Chemistry, National Veterinary Institute (SVA), Uppsala, Sweden.,Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry, Uppsala University, Uppsala, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
22
|
Effect of statin on arginine metabolites in treated HIV-infection. Atherosclerosis 2017; 266:74-80. [PMID: 28992467 DOI: 10.1016/j.atherosclerosis.2017.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/24/2017] [Accepted: 09/27/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Asymmetric dimethylarginine (ADMA) is an inhibitor of nitric oxide and an independent risk factor for cardiovascular disease. We examined the effect of statin on ADMA in HIV + patients on stable ART, and whether such an effect contributes to the favorable changes on carotid intima media thickness. METHODS This is a secondary analysis of SATURN-HIV, in which HIV + adults on stable ART with HIV-1 RNA< 1000 copies/mL and LDL-cholesterol <130 mg/dL were randomized to 10 mg daily rosuvastatin or placebo. Arginine metabolites, ADMA, and markers of inflammation were assessed at baseline and 48 weeks. Carotid intima media thickness (c-IMT) was measured at baseline, 48 and 96 weeks. Spearman correlations, and linear mixed-effect models were used to study relationships among variables. RESULTS Overall, 79% were male, 68% African Americans, with a median age of 46 years. In the statin arm, no change in ADMA levels was observed at 48 weeks (0.70%), whereas a trend towards an increase in ADMA levels (23.78%) was observed in the placebo group (p = 0.06). Elevated baseline ADMA (highest tertile) was associated with a 0.04 mm increase in c-IMT (p = 0.03) after adjusting for statin and study duration. No interaction was seen between baseline ADMA and statin randomization on change in c-IMT (p = 0.21). CONCLUSIONS In HIV + subjects on ART, rosuvastatin suppressed the increase over time in ADMA levels. Elevated baseline levels of ADMA were associated with increases in c-IMT, regardless of statin assignment. The favorable effect of rosuvastatin on c-IMT appears to be independent of the arginine pathway.
Collapse
|
23
|
Hove-Skovsgaard M, Gaardbo JC, Kolte L, Winding K, Seljeflot I, Svardal A, Berge RK, Gerstoft J, Ullum H, Trøseid M, Nielsen SD. HIV-infected persons with type 2 diabetes show evidence of endothelial dysfunction and increased inflammation. BMC Infect Dis 2017; 17:234. [PMID: 28356058 PMCID: PMC5372333 DOI: 10.1186/s12879-017-2334-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Background Increased incidence of cardiovascular diseases (CVD) in both HIV infection and type 2 diabetes (T2D) compared to the general population has been described. Little is known about the combined effect of HIV infection and T2D on inflammation and endothelial function, both of which may contribute to elevated risk of CVD. Methods Cross-sectional study including 50 HIV-infected persons on combination anti-retroviral therapy (cART), with HIV RNA <200 copies/mL (n = 25 with T2D (HIV + T2D+), n = 25 without T2D (HIV + T2D-)) and 50 uninfected persons (n = 22 with T2D (HIV-T2D+) and n = 28 without T2D (HIV-T2D-)). Groups were matched on age and sex. High sensitive C-reactive protein (hsCRP) was used to determine inflammation (cut-off 3 mg/L). The marker of endothelial dysfunction asymmetric dimethylarginine (ADMA) was measured using high performance liquid chromatography. Trimethylamine-N-oxide (TMAO), a microbiota-dependent, pro-atherogenic marker was measured using stable isotope dilution LC/MS/MS. Results The percentage of HIV + T2D+, HIV + T2D-, HIV-T2D+, and HIV-T2D- with hsCRP above cut-off was 50%, 19%, 47%, and 11%, respectively. HIV + T2D+ had elevated ADMA (0.67 μM (0.63-0.72) compared to HIV + T2D- (0.60 μM (0.57-0.64) p = 0.017), HIV-T2D+ (0.57 μM (0.51-63) p = 0.008), and HIV-T2D- (0.55 μM (0.52-0.58) p < 0.001). No differences in TMAO between groups were found. However, a positive correlation between ADMA and TMAO was found in the total population (rs = 0.32, p = 0.001), which was mainly driven by a close correlation in HIV + T2D+ (rs = 0.63, p = 0.001). Conclusion Elevated inflammation and evidence of endothelial dysfunction was found in HIV-infected persons with T2D. The effect on inflammation was mainly driven by T2D, while both HIV infection and T2D may contribute to endothelial dysfunction. Whether gut microbiota is a contributing factor to this remains to be determined. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2334-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Malene Hove-Skovsgaard
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, opgang 86, 3 sal, Blegdamsvej 9, 2100 Kbh Ø, Copenhagen, Denmark
| | - Julie Christine Gaardbo
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, opgang 86, 3 sal, Blegdamsvej 9, 2100 Kbh Ø, Copenhagen, Denmark
| | - Lilian Kolte
- Department of Infectious Diseases, Hvidovre Hospital, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Kamilla Winding
- Centre of Inflammation and Metabolism, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asbjørn Svardal
- Department of Clinical Science, University of Bergen, N-5020, Bergen, Norway
| | - Rolf Kristian Berge
- Department of Clinical Science, University of Bergen, N-5020, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway
| | - Jan Gerstoft
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, opgang 86, 3 sal, Blegdamsvej 9, 2100 Kbh Ø, Copenhagen, Denmark
| | - Henrik Ullum
- Department of Clinical Immunology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Marius Trøseid
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Copenhagen, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway
| | - Susanne Dam Nielsen
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, opgang 86, 3 sal, Blegdamsvej 9, 2100 Kbh Ø, Copenhagen, Denmark.
| |
Collapse
|
24
|
Koudelka A, Ambrozova G, Klinke A, Fidlerova T, Martiskova H, Kuchta R, Rudolph TK, Kadlec J, Kuchtova Z, Woodcock SR, Freeman BA, Kubala L, Pekarova M. Nitro-Oleic Acid Prevents Hypoxia- and Asymmetric Dimethylarginine-Induced Pulmonary Endothelial Dysfunction. Cardiovasc Drugs Ther 2017; 30:579-586. [PMID: 27858190 DOI: 10.1007/s10557-016-6700-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
RATIONALE Pulmonary hypertension (PH) represents a serious health complication accompanied with hypoxic conditions, elevated levels of asymmetric dimethylarginine (ADMA), and overall dysfunction of pulmonary vascular endothelium. Since the prevention strategies for treatment of PH remain largely unknown, our study aimed to explore the effect of nitro-oleic acid (OA-NO2), an exemplary nitro-fatty acid (NO2-FA), in human pulmonary artery endothelial cells (HPAEC) under the influence of hypoxia or ADMA. METHODS HPAEC were treated with OA-NO2 in the absence or presence of hypoxia and ADMA. The production of nitric oxide (NO) and interleukin-6 (IL-6) was monitored using the Griess method and ELISA, respectively. The expression or activation of different proteins (signal transducer and activator of transcription 3, STAT3; hypoxia inducible factor 1α, HIF-1α; endothelial nitric oxide synthase, eNOS; intercellular adhesion molecule-1, ICAM-1) was assessed by the Western blot technique. RESULTS We discovered that OA-NO2 prevents development of endothelial dysfunction induced by either hypoxia or ADMA. OA-NO2 preserves normal cellular functions in HPAEC by increasing NO production and eNOS expression. Additionally, OA-NO2 inhibits IL-6 production as well as ICAM-1 expression, elevated by hypoxia and ADMA. Importantly, the effect of OA-NO2 is accompanied by prevention of STAT3 activation and HIF-1α stabilization. CONCLUSION In summary, OA-NO2 eliminates the manifestation of hypoxia- and ADMA-mediated endothelial dysfunction in HPAEC via the STAT3/HIF-1α cascade. Importantly, our study is bringing a new perspective on molecular mechanisms of NO2-FAs action in pulmonary endothelial dysfunction, which represents a causal link in progression of PH. Graphical Abstract ᅟ.
Collapse
Affiliation(s)
- Adolf Koudelka
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic
| | - Gabriela Ambrozova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic
| | - Anna Klinke
- International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,Department of Experimental Cardiology, University Hospital of Cologne, Kerpener Str. 62, 50924, Cologne, Germany
| | - Tana Fidlerova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic.,Faculty of Science, Institute of Experimental Biology, Masaryk University, Kamenice 5, 625 00, Brno, Czech Republic
| | - Hana Martiskova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,Faculty of Science, Institute of Experimental Biology, Masaryk University, Kamenice 5, 625 00, Brno, Czech Republic
| | - Radek Kuchta
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00, Brno, Czech Republic
| | - Tanja K Rudolph
- Department of Experimental Cardiology, University Hospital of Cologne, Kerpener Str. 62, 50924, Cologne, Germany
| | - Jaroslav Kadlec
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00, Brno, Czech Republic
| | - Zdenka Kuchtova
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00, Brno, Czech Republic
| | - Steven R Woodcock
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
| | - Bruce A Freeman
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
| | - Lukas Kubala
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic
| | - Michaela Pekarova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65, Brno, Czech Republic. .,International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Human immunodeficiency virus (HIV) is now managed as a chronic disease. Non-infectious pulmonary conditions have replaced infection as the biggest threat to lung health, particularly as HIV cohorts age, but there is no consensus on how best to maintain long-term lung health. We review the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension (PAH), and lung cancer in HIV-seropositive individuals. RECENT FINDINGS Diagnoses of COPD are now up to 50% more prevalent in HIV-seropositive individuals than HIV-uninfected controls, and prospective pulmonary function studies find significant impairment in 7% to more than 50% of HIV-seropositive individuals. The prevalence of HIV-PAH is 0.2-0.5%, and lung cancer is two to three times more prevalent in HIV-seropositive individuals. Although host factors such as age and smoking have a role, HIV is an independent contributor to the pathogenesis of COPD, PAH, and lung cancer. Chronic inflammation, immune senescence, oxidative stress, and direct effects of viral proteins are all potential pathogenetic mechanisms. Despite their prevalence, non-infectious lung diseases remain underrecognized and evidence for effective screening strategies in HIV-seropositive individuals is limited. SUMMARY COPD, PAH, and lung cancer are a growing threat to lung health in the highly active antiretroviral therapy era necessitating early recognition.
Collapse
Affiliation(s)
- Paul Collini
- aDepartment of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK bDepartment of Medicine, University of Pittsburgh, 628 NW Montefiore University Hospital, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
26
|
Rysz-Górzynska M, Gluba-Brzózka A, Sahebkar A, Serban MC, Mikhailidis DP, Ursoniu S, Toth PP, Bittner V, Watts GF, Lip GYH, Rysz J, Catapano AL, Banach M. Efficacy of Statin Therapy in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. Sci Rep 2016; 6:30060. [PMID: 27444125 PMCID: PMC4957081 DOI: 10.1038/srep30060] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/27/2016] [Indexed: 12/29/2022] Open
Abstract
Since the evidence regarding statin therapy in PAH has not been conclusive, we assessed the impact of statin therapy in PAH through a systematic review and meta-analysis of available studies. We searched selected databases up to August 1, 2015 to identify the studies investigating the effect of statin administration on PAH. Meta-analysis was performed using either a fixed-effects or random-effect model according to I(2) statistic. Meta-analysis of 8 studies with 665 patients did not suggest any significant improvement in 6-min walking distance (6MWD) by statin therapy (weighed mean difference [WMD]: -6.08 m, 95% confidence interval [CI]: -25.66, 13.50, p = 0.543; Q = 8.41, I(2) = 28.64%). Likewise, none of the other indices including pulmonary arterial pressure (WMD: -0.97 mmHg, 95%CI: -4.39, 2.44, p = 0.577; Q = 14.64, I(2) = 79.51%), right atrial pressure (WMD: 1.01 mmHg, 95%CI: -0.93, 2.96, p = 0.307; Q = 44.88, I(2) = 95.54%), cardiac index (WMD: 0.05 L/min/m(2), 95%CI: -0.05, 0.15, p = 0.323; Q = 3.82, I(2) = 21.42%), and pulmonary vascular resistance (WMD: -1.42 dyn*s/cm(5), 95%CI: -72.11, 69.27, p = 0.969; Q = 0.69, I(2) = 0%) was significantly altered by statin therapy. In conclusion, the results of the meta-analysis did not show a statistically significant effect of statin therapy in the improvement of 6MWD, pulmonary arterial pressure, right atrial pressure, cardiac index and pulmonary vascular resistance.
Collapse
Affiliation(s)
- Magdalena Rysz-Górzynska
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
- Healthy Aging Research Centre (HARC), Medical University of Lodz, Lodz, Poland
| | - Anna Gluba-Brzózka
- Healthy Aging Research Centre (HARC), Medical University of Lodz, Lodz, Poland
- Department of Nephrology, Hypertension and Family Medicine, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Metabolic Research Centre, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Maria-Corina Serban
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Functional Sciences, Discipline of Pathophysiology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK
| | - Sorin Ursoniu
- Department of Functional Sciences, Discipline of Public Health, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Peter P. Toth
- Preventive Cardiology, CGH Medical Center, Sterling, Illinois, USA
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Vera Bittner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gerald F. Watts
- Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Gregory Y. H. Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Jacek Rysz
- Healthy Aging Research Centre (HARC), Medical University of Lodz, Lodz, Poland
- Department of Nephrology, Hypertension and Family Medicine, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
| | - Alberico L. Catapano
- Department of Pharmacological and Biomolecular Sciences University of Milan and IRCCS Multimedica MilanoItaly
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
- Healthy Aging Research Centre (HARC), Medical University of Lodz, Lodz, Poland
| |
Collapse
|
27
|
Novel relationships of markers of monocyte activation and endothelial dysfunction with pulmonary dysfunction in HIV-infected persons. AIDS 2016; 30:1327-39. [PMID: 26990629 DOI: 10.1097/qad.0000000000001092] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Chronic obstructive pulmonary disease is a common comorbidity in HIV, with prevalence and severity of disease incompletely explained by risk factors such as smoking and age. Unique HIV-associated factors, including microbial translocation, monocyte activation, and endothelial dysfunction, have been described in other comorbidities, but have not been investigated in relation to pulmonary abnormalities in HIV. This study assessed the relationship of these pathologic processes to pulmonary function in HIV-infected and uninfected individuals and determined if relationships were unique to HIV. DESIGN Longitudinal observational study. METHODS Total 274 participants completed pulmonary function testing. Markers of inflammation (IL-6, IL-8, and TNFα), microbial translocation (lipopolysaccharide, sCD14), monocyte activation (sCD163, sCD14, and IL-2 receptor), and endothelial dysfunction (endothelin-1) were measured at baseline. Cross-sectional and longitudinal analyses were performed, adjusting for pertinent covariates. RESULTS In HIV-infected individuals, higher IL-6 and endothelin-1 associated with worse forced expiratory volume in one second (FEV1) percentage-predicted, and higher sCD163 associated with worse FEV1/forced vital capacity. IL-6, TNFα, lipopolysaccharide, sCD163, IL-2 receptor, and endothelin-1 associated with diffusing impairment. sCD163 and endothelin-1 interacted with HIV status in relationship to pulmonary function. In HIV-infected individuals only, baseline endothelin-1 was associated with lower FEV1, and sCD163 and endothelin-1 were associated with lower diffusing capacity during follow-up. CONCLUSION Circulating markers of HIV-associated humoral abnormalities are associated with airflow obstruction and diffusing impairment and baseline measures of monocyte activation and endothelial dysfunction associate with lower pulmonary function over time in HIV-infected persons. These findings suggest mechanisms of the disproportionate burden of chronic obstructive pulmonary disease in HIV-infected persons.
Collapse
|
28
|
Assessment of heat shock proteins and endothelial dysfunction in acute pulmonary embolism. Blood Coagul Fibrinolysis 2016; 27:378-83. [DOI: 10.1097/mbc.0000000000000456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Chinello P, Petrosillo N. Pharmacological treatment of HIV-associated pulmonary hypertension. Expert Rev Clin Pharmacol 2016; 9:715-25. [PMID: 26863919 DOI: 10.1586/17512433.2016.1151785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare but severe disease that results from chronic obstruction of small pulmonary arteries, leading to right ventricular failure and, ultimately, death. One established risk factor for the development of PAH is HIV infection. The presence of PAH is an independent risk factor for mortality in HIV-infected patients. This article will focus on HIV-associated PAH (HIV-PAH) with special considerations to the available treatments. With the approval of the soluble guanylate cyclase stimulator riociguat, a new drug class has become available in addition to the already existing prostanoids, endothelin receptor antagonists, and phosphodiesterase type 5 inhibitors. Guidelines for the treatment of idiopathic PAH and guidelines for antiretroviral therapy should be followed for the treatment of HIV-PAH.
Collapse
Affiliation(s)
- Pierangelo Chinello
- a 2nd Infectious Diseases Unit , "L. Spallanzani" National Institute for Infectious Diseases , Rome , Italy
| | - Nicola Petrosillo
- a 2nd Infectious Diseases Unit , "L. Spallanzani" National Institute for Infectious Diseases , Rome , Italy
| |
Collapse
|
30
|
Edwards NJ, Grill MF, Choi HA, Ko NU. Frequency and Risk Factors for Cerebral Arterial Disease in a HIV/AIDS Neuroimaging Cohort. Cerebrovasc Dis 2016; 41:170-6. [PMID: 26751784 DOI: 10.1159/000442755] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/23/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Infection with HIV predisposes patients to a myriad of neurologic disorders, including cerebrovascular disease. The pathophysiology is likely multifactorial, with proposed mechanisms including infectious vasculitis, HIV-induced endothelial dysfunction and adverse effects of combination antiretroviral therapy (cART). Epidemiologic data on clinically evident cerebral vasculopathy in HIV-infected adults is scarce, even though stroke hospitalizations are rising in this patient population. METHODS A total of 6,298 HIV-infected adults (San Francisco General Hospital, 2000-2013) were screened to generate a cohort of patients with dedicated neuroimaging of the intra- and extracranial cerebral vasculature. We extracted information regarding the extent of HIV disease (including serial viral load and CD4 counts), cardiovascular disease risk factors and exposure to cART (cross-referenced with pharmacy records) and performed multivariate logistic regression analysis to identify predictors of vasculopathy. RESULTS Of 144 patients, 55 patients (38.2%) had radiographic evidence of cerebral vasculopathy. Twenty (13.9%) had a vasculopathy characterized by vessel dolichoectasia and intracranial aneurysm formation. Thirty-five patients (24.3%) had intra- and or extracranial stenosis/occlusion. cART use (OR 2.27, 95% CI 1.03-5) and tobacco abuse (OR 2.35, 95% CI 1.04-5.25) were independently associated with the development of any vasculopathy, whereas cART use was also an independent risk factor for the stenosis/occlusion subtype specifically (OR 2.87, 95% CI 1.11-7.45). CONCLUSIONS There was a high frequency of cerebral arterial disease in this neuroimaging cohort of HIV/AIDS patients. A history of cART use and a history of tobacco abuse were independent risk factors for vasculopathy, though these findings should be confirmed with large-scale prospective studies.
Collapse
Affiliation(s)
- Nancy J Edwards
- Departments of Neurology and Neurosurgery, University of Texas Health Science at Houston, Houston, Tex., USA
| | | | | | | |
Collapse
|
31
|
Parikh RV, Ma Y, Scherzer R, Heringer AS, Macgregor JS, Martin JN, Deeks SG, Ganz P, Hsue PY. Endothelin-1 Predicts Hemodynamically Assessed Pulmonary Arterial Hypertension in HIV Infection. PLoS One 2016; 11:e0146355. [PMID: 26752193 PMCID: PMC4709102 DOI: 10.1371/journal.pone.0146355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/06/2015] [Indexed: 12/23/2022] Open
Abstract
Background HIV infection is an independent risk factor for PAH, but the underlying pathogenesis remains unclear. ET-1 is a robust vasoconstrictor and key mediator of pulmonary vascular homeostasis. Higher levels of ET-1 predict disease severity and mortality in other forms of PAH, and endothelin receptor antagonists are central to treatment, including in HIV-associated PAH. The direct relationship between ET-1 and PAH in HIV-infected individuals is not well described. Methods We measured ET-1 and estimated pulmonary artery systolic pressure (PASP) with transthoracic echocardiography (TTE) in 106 HIV-infected individuals. Participants with a PASP ≥ 30 mmHg (n = 65) underwent right heart catheterization (RHC) to definitively diagnose PAH. We conducted multivariable analysis to identify factors associated with PAH. Results Among 106 HIV-infected participants, 80% were male, the median age was 52 years and 77% were on antiretroviral therapy. ET-1 was significantly associated with higher values of PASP [14% per 0.1 pg/mL increase in ET-1, p = 0.05] and PASP ≥ 30 mmHg [PR (prevalence ratio) = 1.24, p = 0.012] on TTE after multivariable adjustment for PAH risk factors. Similarly, among the 65 individuals who underwent RHC, ET-1 was significantly associated with higher values of mean pulmonary artery pressure and PAH (34%, p = 0.003 and PR = 2.43, p = 0.032, respectively) in the multivariable analyses. Conclusions Higher levels of ET-1 are independently associated with HIV-associated PAH as hemodynamically assessed by RHC. Our findings suggest that excessive ET-1 production in the setting of HIV infection impairs pulmonary endothelial function and contributes to the development of PAH.
Collapse
Affiliation(s)
- Rushi V. Parikh
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, United States of America
| | - Yifei Ma
- Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
| | - Rebecca Scherzer
- Division of Endocrinology and Metabolism, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Amanda S. Heringer
- San Francisco General Hospital Cardiology Division, University of California San Francisco, San Francisco, California, United States of America
| | - John S. Macgregor
- San Francisco General Hospital Cardiology Division, University of California San Francisco, San Francisco, California, United States of America
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Steven G. Deeks
- San Francisco General Hospital Positive Health Program, University of California San Francisco, San Francisco, California, United States of America
| | - Peter Ganz
- San Francisco General Hospital Cardiology Division, University of California San Francisco, San Francisco, California, United States of America
| | - Priscilla Y. Hsue
- San Francisco General Hospital Cardiology Division, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
32
|
Pekarova M, Koudelka A, Kolarova H, Ambrozova G, Klinke A, Cerna A, Kadlec J, Trundova M, Sindlerova Svihalkova L, Kuchta R, Kuchtova Z, Lojek A, Kubala L. Asymmetric dimethyl arginine induces pulmonary vascular dysfunction via activation of signal transducer and activator of transcription 3 and stabilization of hypoxia-inducible factor 1-alpha. Vascul Pharmacol 2015; 73:138-48. [PMID: 26091577 DOI: 10.1016/j.vph.2015.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/02/2015] [Accepted: 06/15/2015] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertension (PH), associated with imbalance in vasoactive mediators and massive remodeling of pulmonary vasculature, represents a serious health complication. Despite the progress in treatment, PH patients typically have poor prognoses with severely affected quality of life. Asymmetric dimethyl arginine (ADMA), endogenous inhibitor of endothelial nitric oxide synthase (eNOS), also represents one of the critical regulators of pulmonary vascular functions. The present study describes a novel mechanism of ADMA-induced dysfunction in human pulmonary endothelial and smooth muscle cells. The effect of ADMA was compared with well-established model of hypoxia-induced pulmonary vascular dysfunction. It was discovered for the first time that ADMA induced the activation of signal transducer and activator of transcription 3 (STAT3) and stabilization of hypoxia inducible factor 1α (HIF-1α) in both types of cells, associated with drastic alternations in normal cellular functions (e.g., nitric oxide production, cell proliferation/Ca(2+) concentration, production of pro-inflammatory mediators, and expression of eNOS, DDAH1, and ICAM-1). Additionally, ADMA significantly enhanced the hypoxia-mediated increase in the signaling cascades. In summary, increased ADMA may lead to manifestation of PH phenotype in human endothelial and smooth muscle cells via the STAT3/HIF-1α cascade. Therefore this signaling pathway represents the potential pathway for future clinical interventions in PH.
Collapse
Affiliation(s)
- Michaela Pekarova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic.
| | - Adolf Koudelka
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Hana Kolarova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Gabriela Ambrozova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Anna Klinke
- Department of Experimental Cardiology, University Hospital of Cologne, Kerpener Str. 62, 50924 Cologne, Germany
| | - Anna Cerna
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Jaroslav Kadlec
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00 Brno, Czech Republic
| | - Maria Trundova
- Institute of Biotechnology, Academy of Sciences of the Czech Republic, v.v.i., BIOCEV, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Lenka Sindlerova Svihalkova
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Radek Kuchta
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00 Brno, Czech Republic
| | - Zdenka Kuchtova
- Faculty of Electrical Engineering and Communication, Brno University of Technology, Technicka 3058/10, 616 00 Brno, Czech Republic
| | - Antonin Lojek
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic
| | - Lukas Kubala
- Institute of Biophysics, Academy of Sciences of the Czech Republic, v.v.i., Kralovopolska 135, 612 65 Brno, Czech Republic; International Clinical Research Center - Center of Biomolecular and Cellular Engineering, St. Anne's University Hospital, Brno, Czech Republic
| |
Collapse
|
33
|
Butrous G. Human immunodeficiency virus-associated pulmonary arterial hypertension: considerations for pulmonary vascular diseases in the developing world. Circulation 2015; 131:1361-70. [PMID: 25869003 DOI: 10.1161/circulationaha.114.006978] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ghazwan Butrous
- From School of Pharmacy, University of Kent, Canterbury, UK; and Pulmonary Vascular Research Institute, Canterbury, UK.
| |
Collapse
|
34
|
Zhang S, Yang T, Xu X, Wang M, Zhong L, Yang Y, Zhai Z, Xiao F, Wang C. Oxidative stress and nitric oxide signaling related biomarkers in patients with pulmonary hypertension: a case control study. BMC Pulm Med 2015; 15:50. [PMID: 25934483 PMCID: PMC4477508 DOI: 10.1186/s12890-015-0045-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxidative stress (OS) and reduced nitric oxide (NO) bioavailability contribute to the pathogenesis of pulmonary hypertension (PH). Whether there are associations between OS and NO signaling biomarkers and whether these biomarkers are associated with the severity of PH remain unclear. METHODS Blood samples were collected from 35 healthy controls and 35 patients with pulmonary arterial hypertension (PAH, n = 12) or chronic thromboembolic pulmonary hypertension (CTEPH, n = 23). The mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance index (PVRI) were measured by right heart catheterization. We measured the derivative of reactive oxygen molecules (d-ROMs), biological antioxidant potential (BAP) and superoxide dismutase (SOD) by automatic biochemical analyzer, malondialdehyde (MDA) and asymmetric dimethylarginine (ADMA) by enzyme-linked immunosorbent assay. The relationship between oxidative-antioxidative biomarkers and ADMA, as well as their association with pulmonary hemodynamics, were analyzed. RESULTS Compared with age- and gender-matched controls, there was no significant difference of d-ROMs in PAH and CTEPH patients; MDA was increased in CTEPH patients (P = 0.034); BAP and SOD were decreased in PAH (P = 0.014, P < 0.001) and CTEPH patients (P = 0.015, P < 0.001); ADMA level was significantly higher in PAH (P = 0.007) and CTEPH patients (P < 0.001). No association between oxidative-antioxidative biomarkers and ADMA was found. Serum ADMA concentration was correlated with mPAP (r = 0.762, P = 0.006) and PVRI (r = 0.603, P = 0.038) in PAH patients. CONCLUSIONS The antioxidative potential and NO signaling are impaired in PAH and CTEPH. Increased serum ADMA level is associated with unfavorable pulmonary hemodynamics in PAH patients. Thus, ADMA may be useful in the severity evaluation and risk stratification of PAH.
Collapse
Affiliation(s)
- Shuai Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, People's Republic of China.
| | - Ting Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, People's Republic of China.
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, People's Republic of China. .,National Clinical Research Center of Respiratory Diseases, Beijing, People's Republic of China.
| | - Meng Wang
- Department of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China.
| | - Linye Zhong
- Department of Pulmonary and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, People's Republic of China.
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, People's Republic of China.
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, People's Republic of China.
| | - Fei Xiao
- National Clinical Research Center of Respiratory Diseases, Beijing, People's Republic of China. .,Department of Cell Biology, Institute of Geriatrics, Beijing Hospital, Beijing, People's Republic of China.
| | - Chen Wang
- National Clinical Research Center of Respiratory Diseases, Beijing, People's Republic of China. .,Department of Respiratory Medicine, Capital Medical University, Beijing, People's Republic of China. .,China-Japan Friendship Hospital, Beijing, People's Republic of China.
| |
Collapse
|
35
|
Correale M, Palmiotti GA, Lo Storto MM, Montrone D, Foschino Barbaro MP, Di Biase M, Lacedonia D. HIV-associated pulmonary arterial hypertension: from bedside to the future. Eur J Clin Invest 2015; 45:515-28. [PMID: 25715739 DOI: 10.1111/eci.12427] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/23/2015] [Indexed: 12/27/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening complication of HIV infection. The prevalence of HIV-associated PAH (HIV-PAH) seems not to be changed over time, regardless of the introduction of highly active antiretroviral therapy (HAART). In comparison with the incidence of idiopathic PAH in the general population (1-2 per million), HIV-infected patients have a 2500-fold increased risk of developing PAH. HIV-PAH treatment is similar to that for all PAH conditions and includes lifestyle changes, general treatments and specific treatments.
Collapse
|
36
|
Beltrán LM, Rubio-Navarro A, Amaro-Villalobos JM, Egido J, García-Puig J, Moreno JA. Influence of immune activation and inflammatory response on cardiovascular risk associated with the human immunodeficiency virus. Vasc Health Risk Manag 2015; 11:35-48. [PMID: 25609975 PMCID: PMC4293933 DOI: 10.2147/vhrm.s65885] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients infected with the human immunodeficiency virus (HIV) have an increased cardiovascular risk. Although initially this increased risk was attributed to metabolic alterations associated with antiretroviral treatment, in recent years, the attention has been focused on the HIV disease itself. Inflammation, immune system activation, and endothelial dysfunction facilitated by HIV infection have been identified as key factors in the development and progression of atherosclerosis. In this review, we describe the epidemiology and pathogenesis of cardiovascular disease in patients with HIV infection and summarize the latest knowledge on the relationship between traditional and novel inflammatory, immune activation, and endothelial dysfunction biomarkers on the cardiovascular risk associated with HIV infection.
Collapse
Affiliation(s)
- Luis M Beltrán
- Metabolic-Vascular Unit, Fundación IdiPAZ-Hospital Universitario La Paz, Madrid, Spain
| | - Alfonso Rubio-Navarro
- Vascular, Renal, and Diabetes Research Lab, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | | | - Jesús Egido
- Vascular, Renal, and Diabetes Research Lab, IIS-Fundación Jiménez Díaz, Madrid, Spain ; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain ; Fundación Renal Iñigo Alvarez de Toledo-Instituto Reina Sofía de Investigaciones Nefrológicas (FRIAT-IRSIN), Madrid, Spain
| | - Juan García-Puig
- Metabolic-Vascular Unit, Fundación IdiPAZ-Hospital Universitario La Paz, Madrid, Spain
| | - Juan Antonio Moreno
- Vascular, Renal, and Diabetes Research Lab, IIS-Fundación Jiménez Díaz, Madrid, Spain
| |
Collapse
|
37
|
L'Huillier AG, Posfay-Barbe KM, Pictet H, Beghetti M. Pulmonary Arterial Hypertension among HIV-Infected Children: Results of a National Survey and Review of the Literature. Front Pediatr 2015; 3:25. [PMID: 25905096 PMCID: PMC4387937 DOI: 10.3389/fped.2015.00025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/19/2015] [Indexed: 01/07/2023] Open
Abstract
Since the advent of highly active anti-retroviral therapy, HIV-related mortality has decreased dramatically. As a consequence, patients are living longer, and HIV infection is becoming a chronic disease. Patients and caretakers have to deal with chronic complications of infection and treatment, such as cardiovascular diseases, which now represent an important health issue, even in the pediatric population. Prevalence of pulmonary arterial hypertension (PAH) in the adult HIV population is around 0.4-0.6%, which is around 1000- to 2500-fold more prevalent than in the general population. In recent adult PAH registries, HIV has been identified as the fourth cause of PAH, accounting for approximately 6-7% of cases. Therefore, regular screening is recommended in HIV-infected adults by many experts. If HIV-associated PAH is mainly reported in HIV-infected adults, pediatric cases have also been, albeit rarely, described. This scarcity may be due to a very low PAH prevalence, or due to the lack of systematic cardiovascular screening in pediatric patients. As PAH may manifest only years or decades after infection, a systematic screening should perhaps also be recommended to HIV-infected children. In this context, we retrospectively looked for PAH screening in children included in our national Swiss Mother and Child HIV cohort study. A questionnaire was sent to all pediatric infectious disease specialists taking care of HIV-infected children in the cohort. The questions tried to identify symptoms suggestive of cardiovascular risk factors and asked which screening test was performed. In the 71 HIV-infected children for which we obtained an answer, no child was known for PAH. However, only two had been screened for PAH, and the diagnosis was not confirmed. In conclusion, PAH in HIV-infected children is possibly underestimated due to lack of screening. Systematic echocardiographic evaluation should be performed in HIV-infected children.
Collapse
Affiliation(s)
- Arnaud Grégoire L'Huillier
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Geneva University Hospitals , Geneva , Switzerland
| | - Klara Maria Posfay-Barbe
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Geneva University Hospitals , Geneva , Switzerland
| | - Hiba Pictet
- Faculty of Medicine, University of Geneva , Geneva , Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Pediatrics, Geneva University Hospitals , Geneva , Switzerland
| |
Collapse
|
38
|
Dasgupta A, Bowman L, D'Arsigny CL, Archer SL. Soluble guanylate cyclase: a new therapeutic target for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Clin Pharmacol Ther 2014; 97:88-102. [PMID: 25670386 DOI: 10.1002/cpt.10] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/03/2014] [Indexed: 01/08/2023]
Abstract
Nitric oxide (NO) activates soluble guanylate cyclase (sGC) by binding its prosthetic heme group, thereby catalyzing cyclic guanosine monophosphate (cGMP) synthesis. cGMP causes vasodilation and may inhibit smooth muscle cell proliferation and platelet aggregation. The NO-sGC-cGMP pathway is disordered in pulmonary arterial hypertension (PAH), a syndrome in which pulmonary vascular obstruction, inflammation, thrombosis, and constriction ultimately lead to death from right heart failure. Expression of sGC is increased in PAH but its function is reduced by decreased NO bioavailability, sGC oxidation and the related loss of sGC's heme group. Two classes of sGC modulators offer promise in PAH. sGC stimulators (e.g., riociguat) require heme-containing sGC to catalyze cGMP production, whereas sGC activators (e.g., cinaciguat) activate heme-free sGC. Riociguat is approved for PAH and yields functional and hemodynamic benefits similar to other therapies. Its main serious adverse effect is dose-dependent hypotension. Riociguat is also approved for inoperable chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
- A Dasgupta
- Department of Medicine, Queen's University, Etherington Hall, Kingston, Ontario, Canada
| | | | | | | |
Collapse
|