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Augmentation of Natriuretic Peptide Bioactivity via Combined Inhibition of Neprilysin and Phosphodiesterase-9 in Heart Failure. JACC. HEART FAILURE 2022; 11:227-239. [PMID: 36752488 DOI: 10.1016/j.jchf.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The natriuretic peptides (NPs) are potent natriuretic/diuretic and vasodilatory factors, and augmentation of their levels or signaling via inhibition of the enzymes neprilysin (NEP) and phosphodiesterase 9 (PDE9), respectively, has beneficial actions in heart failure (HF). OBJECTIVES The authors investigated dual enhancement of NP bioactivity by combining PDE9 inhibition and NEP inhibition in HF using an ovine model. METHODS Eight sheep with pacing-induced HF received on 4 separate days intravenous PDE9 inhibition (PF-04749982), NEP inhibition (SCH-32615), PDE9 inhibition + NEP inhibition (PI+NI), and vehicle control treatment. RESULTS Compared with the control treatment, NEP inhibition significantly increased plasma NP concentrations with a corresponding rise in second messenger cyclic guanosine monophosphate (cGMP), whereas PDE9 inhibition increased circulating cGMP with a negligible effect on NP levels. Combined PI+NI elevated plasma NPs to an extent comparable to that seen with NEP inhibition alone but further increased cGMP, resulting in a rise in the cGMP-to-NP ratio. All active treatments reduced mean arterial pressure, left atrial pressure, pulmonary arterial pressure, and peripheral resistance, with combined PI+NI further reducing mean arterial pressure and left atrial pressure relative to either inhibitor separately. Active treatments increased urine volume and sodium, potassium and creatinine excretion, and creatinine clearance, in association with rises in urine cGMP levels. PI+NI induced a significantly greater natriuresis and increase in urinary cGMP relative to either inhibitor singly. CONCLUSIONS The present study demonstrates for the first time that combined PI+NI has additional beneficial hemodynamic and renal effects when compared with either PDE9 inhibition or NEP inhibition alone. The superior efficacy of this 2-pronged augmentation of NP bioactivity supports PI+NI as a potential therapeutic strategy for HF.
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2
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Grange RMH, Preedy MEJ, Renukanthan A, Dignam JP, Lowe VJ, Moyes AJ, Pérez-Ternero C, Aubdool AA, Baliga RS, Hobbs AJ. Multidrug resistance proteins preferentially regulate natriuretic peptide-driven cGMP signalling in the heart and vasculature. Br J Pharmacol 2022; 179:2443-2459. [PMID: 34131904 DOI: 10.1111/bph.15593] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE cGMP underpins the bioactivity of NO and natriuretic peptides and is key to cardiovascular homeostasis. cGMP-driven responses are terminated primarily by PDEs, but cellular efflux via multidrug resistance proteins (MRPs) might contribute. Herein, the effect of pharmacological blockade of MRPs on cGMP signalling in the heart and vasculature was investigated in vitro and in vivo. EXPERIMENTAL APPROACH Proliferation of human coronary artery smooth muscle cells (hCASMCs), vasorelaxation of murine aorta and reductions in mean arterial BP (MABP) in response to NO donors or natriuretic peptides were determined in the absence and presence of the MRP inhibitor MK571. The ability of MRP inhibition to reverse morphological and contractile deficits in a murine model of pressure overload-induced heart failure was also explored. KEY RESULTS MK571 attenuated hCASMC growth and enhanced the anti-proliferative effects of NO and atrial natriuretic peptide (ANP). MRP blockade caused concentration-dependent relaxations of murine aorta and augmented responses to ANP (and to a lesser extent NO). MK571 did not decrease MABP per se but enhanced the hypotensive actions of ANP and improved structural and functional indices of disease severity in experimental heart failure. These beneficial actions of MRP inhibition were associated with a greater intracellular:extracellular cGMP ratio in vitro and in vivo. CONCLUSIONS AND IMPLICATIONS MRP blockade promotes the cardiovascular functions of natriuretic peptides in vitro and in vivo, with more modest effects on NO. MRP inhibition may have therapeutic utility in cardiovascular diseases triggered by dysfunctional cGMP signalling, particularly those associated with altered natriuretic peptide bioactivity. LINKED ARTICLES This article is part of a themed issue on cGMP Signalling in Cell Growth and Survival. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.11/issuetoc.
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Affiliation(s)
- Robert M H Grange
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael E J Preedy
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aniruthan Renukanthan
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vanessa J Lowe
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amie J Moyes
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Cristina Pérez-Ternero
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aisah A Aubdool
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Reshma S Baliga
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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3
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Numata G, Takimoto E. Cyclic GMP and PKG Signaling in Heart Failure. Front Pharmacol 2022; 13:792798. [PMID: 35479330 PMCID: PMC9036358 DOI: 10.3389/fphar.2022.792798] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Cyclic guanosine monophosphate (cGMP), produced by guanylate cyclase (GC), activates protein kinase G (PKG) and regulates cardiac remodeling. cGMP/PKG signal is activated by two intrinsic pathways: nitric oxide (NO)-soluble GC and natriuretic peptide (NP)-particulate GC (pGC) pathways. Activation of these pathways has emerged as a potent therapeutic strategy to treat patients with heart failure, given cGMP-PKG signaling is impaired in heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Large scale clinical trials in patients with HFrEF have shown positive results with agents that activate cGMP-PKG pathways. In patients with HFpEF, however, benefits were observed only in a subgroup of patients. Further investigation for cGMP-PKG pathway is needed to develop better targeting strategies for HFpEF. This review outlines cGMP-PKG pathway and its modulation in heart failure.
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Affiliation(s)
- Genri Numata
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
- Department of Advanced Translational Research and Medicine in Management of Pulmonary Hypertension, The University of Tokyo Hospital, Tokyo, Japan
| | - Eiki Takimoto
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
- Division of Cardiology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, United States
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4
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Tettey A, Jiang Y, Li X, Li Y. Therapy for Pulmonary Arterial Hypertension: Glance on Nitric Oxide Pathway. Front Pharmacol 2021; 12:767002. [PMID: 34867394 PMCID: PMC8633825 DOI: 10.3389/fphar.2021.767002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/25/2021] [Indexed: 01/11/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe disease with a resultant increase of the mean pulmonary arterial pressure, right ventricular hypertrophy and eventual death. Research in recent years has produced various therapeutic options for its clinical management but the high mortality even under treatment remains a big challenge attributed to the complex pathophysiology. Studies from clinical and non-clinical experiments have revealed that the nitric oxide (NO) pathway is one of the key pathways underlying the pathophysiology of PAH. Many of the essential drugs used in the management of PAH act on this pathway highlighting its significant role in PAH. Meanwhile, several novel compounds targeting on NO pathway exhibits great potential to become future therapy medications. Furthermore, the NO pathway is found to interact with other crucial pathways. Understanding such interactions could be helpful in the discovery of new drug that provide better clinical outcomes.
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Affiliation(s)
- Abraham Tettey
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
| | - Yujie Jiang
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
| | - Xiaohui Li
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha, China
| | - Ying Li
- Department of Health Management, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha, China
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5
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Maron BA, Abman SH, Elliott CG, Frantz RP, Hopper RK, Horn EM, Nicolls MR, Shlobin OA, Shah SJ, Kovacs G, Olschewski H, Rosenzweig EB. Pulmonary Arterial Hypertension: Diagnosis, Treatment, and Novel Advances. Am J Respir Crit Care Med 2021; 203:1472-1487. [PMID: 33861689 PMCID: PMC8483220 DOI: 10.1164/rccm.202012-4317so] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The diagnosis and management of pulmonary arterial hypertension (PAH) includes several advances, such as a broader recognition of extrapulmonary vascular organ system involvement, validated point-of-care clinical assessment tools, and focus on the early initiation of multiple pharmacotherapeutics in appropriate patients. Indeed, a principal goal in PAH today is an early diagnosis for prompt initiation of treatment to achieve a minimal symptom burden; optimize the patient's biochemical, hemodynamic, and functional profile; and limit adverse events. To accomplish this end, clinicians must be familiar with novel risk factors and the revised hemodynamic definition for PAH. Fresh insights into the role of developmental biology (i.e., perinatal health) may also be useful for predicting incident PAH in early adulthood. Emergent or underused approaches to PAH management include a novel TGF-β ligand trap pharmacotherapy, remote pulmonary arterial pressure monitoring, next-generation imaging using inert gas-based magnetic resonance and other technologies, right atrial pacing, and pulmonary arterial denervation. These and other PAH state of the art advances are summarized here for the wider pulmonary medicine community.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Steven H Abman
- Section of Pulmonary Medicine, Children's Hospital Colorado and the University of Colorado Anschutz Medical Center, University of Colorado, Aurora, Colorado
| | - C Greg Elliott
- Intermountain Medical Center and the University of Utah, Salt Lake City, Utah
| | - Robert P Frantz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Rachel K Hopper
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Graduate School of Medical Sciences, Cornell University, New York, New York
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System and School of Medicine, Stanford University, Stanford, California
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Horst Olschewski
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; and
| | - Erika B Rosenzweig
- Department of Pediatrics and.,Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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6
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Petraina A, Nogales C, Krahn T, Mucke H, Lüscher TF, Fischmeister R, Kass DA, Burnett JC, Hobbs AJ, Schmidt HHHW. Cyclic GMP modulating drugs in cardiovascular diseases: Mechanism-based network pharmacology. Cardiovasc Res 2021; 118:2085-2102. [PMID: 34270705 PMCID: PMC9302891 DOI: 10.1093/cvr/cvab240] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/14/2021] [Indexed: 12/13/2022] Open
Abstract
Mechanism-based therapy centred on the molecular understanding of disease-causing pathways in a given patient is still the exception rather than the rule in medicine, even in cardiology. However, recent successful drug developments centred around the second messenger cyclic guanosine-3′-5′-monophosphate (cGMP), which is regulating a number of cardiovascular disease modulating pathways, are about to provide novel targets for such a personalized cardiovascular therapy. Whether cGMP breakdown is inhibited or cGMP synthesis is stimulated via guanylyl cyclases or their upstream regulators in different cardiovascular disease phenotypes, the outcomes seem to be so far uniformly protective. Thus, a network of cGMP-modulating drugs has evolved that act in a mechanism-based, possibly causal manner in a number of cardiac conditions. What remains a challenge is the detection of cGMPopathy endotypes amongst cardiovascular disease phenotypes. Here, we review the growing clinical relevance of cGMP and provide a glimpse into the future on how drugs interfering with this pathway may change how we treat and diagnose cardiovascular diseases altogether.
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Affiliation(s)
- Alexandra Petraina
- Department of Pharmacology and Personalised Medicine, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Cristian Nogales
- Department of Pharmacology and Personalised Medicine, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Thomas Krahn
- Department of Pharmacology and Personalised Medicine, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | - Thomas F Lüscher
- Royal Brompton and Harefield Hospital Trust and Imperial College, London, SW3 6NP, UK.,Center for Molecular Cardiology, University of Zurich, Switzerland
| | | | - David A Kass
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John C Burnett
- Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Harald H H W Schmidt
- Department of Pharmacology and Personalised Medicine, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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7
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Chaumais MC, Djessas MRA, Thuillet R, Cumont A, Tu L, Hebert G, Gaignard P, Huertas A, Savale L, Humbert M, Guignabert C. Additive protective effects of sacubitril/valsartan and bosentan on vascular remodelling in experimental pulmonary hypertension. Cardiovasc Res 2021; 117:1391-1401. [PMID: 32653925 DOI: 10.1093/cvr/cvaa200] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/03/2020] [Accepted: 07/03/2020] [Indexed: 01/26/2023] Open
Abstract
AIMS Although right ventricular (RV) function is an important determinant of morbidity and mortality in patients with pulmonary arterial hypertension (PAH), there is no treatment targeting directly the RV. We evaluate the efficacy of sacubitril/valsartan (LCZ 696) as add-on therapy to bosentan in rats with severe pulmonary hypertension (PH). METHODS AND RESULTS Combination therapy of LCZ 696 and bosentan has additive vascular protective effects against the pulmonary vascular remodelling and PH in two preclinical models of severe PH. Compared with monotherapy, co-treatment of LCZ 696 (30 or 68 mg/kg/day for 2 weeks, per os) and bosentan (100 mg/kg/day for 2 weeks, per os) started 7 days after monocrotaline (MCT) injection substantially reduces pulmonary pressures, vascular remodelling, and RV hypertrophy and fibrosis in rats. Consistent with these observations, co-treatment of rats with established PH induced by sugen/hypoxia (SuHx) with LCZ 696 (30 mg/kg/day for 3 weeks, per os) and bosentan (100 mg/kg/day for 3 weeks, per os) started 5 weeks after Sugen injection partially attenuate total pulmonary vascular resistance and cardiovascular structures. We also obtained evidence showing that LCZ 696 has anti-proliferative effect on cultured human pulmonary artery smooth muscle cells derived from patients with idiopathic PAH, an effect that is more pronounced in presence of bosentan. Finally, we found that the plasma levels of atrial natriuretic peptide (ANP) and cyclic guanosine monophosphate (cGMP) are higher in rats co-treated with LCZ 696 (30 mg/kg/day) and bosentan (100 mg/kg/day) than in MCT and SuHx rats treated with vehicle. CONCLUSION Dual therapy with LCZ 696 plus bosentan proved significantly superior beneficial effect to LCZ 696 or bosentan alone on vascular remodelling and severity of experimental PH.
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MESH Headings
- Aminobutyrates/pharmacology
- Angiotensin II Type 1 Receptor Blockers/pharmacology
- Animals
- Atrial Natriuretic Factor/blood
- Biphenyl Compounds/pharmacology
- Bosentan/pharmacology
- Cell Proliferation/drug effects
- Cells, Cultured
- Cyclic GMP/blood
- Disease Models, Animal
- Disease Progression
- Drug Combinations
- Drug Therapy, Combination
- Endothelin Receptor Antagonists/pharmacology
- Familial Primary Pulmonary Hypertension/drug therapy
- Familial Primary Pulmonary Hypertension/metabolism
- Familial Primary Pulmonary Hypertension/physiopathology
- Humans
- Male
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Neprilysin/antagonists & inhibitors
- Protease Inhibitors/pharmacology
- Pulmonary Arterial Hypertension/drug therapy
- Pulmonary Arterial Hypertension/metabolism
- Pulmonary Arterial Hypertension/physiopathology
- Pulmonary Artery/drug effects
- Pulmonary Artery/metabolism
- Pulmonary Artery/physiopathology
- Rats, Wistar
- Valsartan/pharmacology
- Vascular Remodeling/drug effects
- Rats
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Affiliation(s)
- Marie-Camille Chaumais
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Pharmacie, 92290, Châtenay-Malabry, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pharmacie, Hôpital Bicêtre, 94270, Le Kremlin-Bicêtre, France
| | - Mohamed Reda Amar Djessas
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
| | - Raphaël Thuillet
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
| | - Amélie Cumont
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
| | - Ly Tu
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
| | - Guillaume Hebert
- Hôpital Marie Lannelongue, Service pharmacie, 92350, Le Plessis-Robinson, France
| | - Pauline Gaignard
- Université Paris-Saclay, Faculté de Pharmacie, 92290, Châtenay-Malabry, France
- AP-HP, Laboratoire de biochimie, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Alice Huertas
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM, UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94270, Le Kremlin-Bicêtre, France
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8
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Dignam JP, Scott TE, Kemp-Harper BK, Hobbs AJ. Animal models of pulmonary hypertension: Getting to the heart of the problem. Br J Pharmacol 2021; 179:811-837. [PMID: 33724447 DOI: 10.1111/bph.15444] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
Despite recent therapeutic advances, pulmonary hypertension (PH) remains a fatal disease due to the development of right ventricular (RV) failure. At present, no treatments targeted at the right ventricle are available, and RV function is not widely considered in the preclinical assessment of new therapeutics. Several small animal models are used in the study of PH, including the classic models of exposure to either hypoxia or monocrotaline, newer combinational and genetic models, and pulmonary artery banding, a surgical model of pure RV pressure overload. These models reproduce selected features of the structural remodelling and functional decline seen in patients and have provided valuable insight into the pathophysiology of RV failure. However, significant reversal of remodelling and improvement in RV function remains a therapeutic obstacle. Emerging animal models will provide a deeper understanding of the mechanisms governing the transition from adaptive remodelling to a failing right ventricle, aiding the hunt for druggable molecular targets.
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Affiliation(s)
- Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, Victoria, Australia
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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9
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Tran JS, Havakuk O, McLeod JM, Hwang J, Kwong HY, Shavelle D, Zile MR, Elkayam U, Fong MW, Grazette LP. Acute pulmonary pressure change after transition to sacubitril/valsartan in patients with heart failure reduced ejection fraction. ESC Heart Fail 2021; 8:1706-1710. [PMID: 33522140 PMCID: PMC8006690 DOI: 10.1002/ehf2.13225] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/14/2020] [Accepted: 01/11/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Sacubitril/valsartan combines renin–angiotensin–aldosterone system inhibition with amplification of natriuretic peptides. In addition to well‐described effects, natriuretic peptides exert direct effects on pulmonary vasculature. The effect of sacubitril/valsartan on pulmonary artery pressure (PAP) has not been fully defined. Methods and results This was a retrospective case‐series of PAP changes following transition from angiotensin‐converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) to sacubitril/valsartan in patients with heart failure reduced ejection fraction and a previously implanted CardioMEMS™ sensor. Pre‐sacubitril/valsartan and post‐sacubitril/valsartan PAPs were compared for each patient by examining averaged consecutive daily pressure readings from 1 to 5 days before and after sacubitril/valsartan exposure. PAP changes were also compared between patients based on elevated trans‐pulmonary gradients (trans‐pulmonary gradient ≥ 12 mmHg) at time of CardioMEMS™ sensor implantation. The cohort included 18 patients, 72% male, mean age 60.1 ± 13.6 years. There was a significant decrease in PAPs associated with transition from ACEI/ARB to sacubitril/valsartan. The median (interquartile range) pre‐treatment and post‐treatment change in mean, systolic and diastolic PAPs were −3.6 (−9.8, −0.7) mmHg (P < 0.001), −6.5 (−15.0, −2.0) mmHg (P = 0.001), and −2.5 (−5.7, −0.7) (P = 0.001), respectively. The decrease in PAPs was independent of trans‐pulmonary gradient (F(1,16) = 0.49, P = 0.49). Conclusions In this retrospective case series, transition from ACEI/ARB to sacubitril/valsartan was associated with an early and significant decrease in PAPs.
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Affiliation(s)
- Jeffrey S Tran
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - Ofer Havakuk
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA.,Department of Cardiology, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Jennifer M McLeod
- Department of Medicine, Montefiore Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, New York, NY, USA
| | - Jennifer Hwang
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - Hoi Yan Kwong
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - David Shavelle
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - Michael R Zile
- Division of Cardiology, RHJ Department of Veterans Affairs Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | - Uri Elkayam
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - Michael W Fong
- Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC), Los Angeles, CA, USA
| | - Luanda P Grazette
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, FL, USA
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10
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Ehteshami-Afshar S, Mooney L, Dewan P, Desai AS, Lang NN, Lefkowitz MP, Petrie MC, Rizkala AR, Rouleau JL, Solomon SD, Swedberg K, Shi VC, Zile MR, Packer M, McMurray JJV, Jhund PS, Hawkins NM. Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF. J Am Heart Assoc 2021; 10:e019238. [PMID: 33522249 PMCID: PMC7955331 DOI: 10.1161/jaha.120.019238] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure with reduced ejection fraction, associated with undertreatment and worse outcomes. New treatments for heart failure with reduced ejection fraction may be particularly important in patients with concomitant COPD. Methods and Results We examined outcomes in 8399 patients with heart failure with reduced ejection fraction, according to COPD status, in the PARADIGM‐HF (Prospective Comparison of Angiotensin Receptor Blocker–Neprilysin Inhibitor With Angiotensin‐Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Cox regression models were used to compare COPD versus non‐COPD subgroups and the effects of sacubitril/valsartan versus enalapril. Patients with COPD (n=1080, 12.9%) were older than patients without COPD (mean 67 versus 63 years; P<0.001), with similar left ventricular ejection fraction (29.9% versus 29.4%), but higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; median, 1741 pg/mL versus 1591 pg/mL; P=0.01), worse functional class (New York Heart Association III/IV 37% versus 23%; P<0.001) and Kansas City Cardiomyopathy Questionnaire–Clinical Summary Score (73 versus 81; P<0.001), and more congestion and comorbidity. Medical therapy was similar in patients with and without COPD except for beta‐blockade (87% versus 94%; P<0.001) and diuretics (85% versus 80%; P<0.001). After multivariable adjustment, COPD was associated with higher risks of heart failure hospitalization (hazard ratio [HR], 1.32; 95% CI, 1.13–1.54), and the composite of cardiovascular death or heart failure hospitalization (HR, 1.18; 95% CI, 1.05–1.34), but not cardiovascular death (HR, 1.10; 95% CI, 0.94–1.30), or all‐cause mortality (HR, 1.14; 95% CI, 0.99–1.31). COPD was also associated with higher risk of all cardiovascular hospitalization (HR, 1.17; 95% CI, 1.05–1.31) and noncardiovascular hospitalization (HR, 1.45; 95% CI, 1.29–1.64). The benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points. Conclusions In PARADIGM‐HF, COPD was associated with lower use of beta‐blockers and worse health status and was an independent predictor of cardiovascular and noncardiovascular hospitalization. Sacubitril/valsartan was beneficial in this high‐risk subgroup. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01035255.
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Affiliation(s)
| | - Leanne Mooney
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Pooja Dewan
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Akshay S Desai
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - Jean L Rouleau
- Institut de Cardiologie Université de Montréal Montréal Québec Canada
| | - Scott D Solomon
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | | | - Victor C Shi
- Novartis Pharmaceutical Corporation East Hanover NJ
| | - Michael R Zile
- Department of Medicine Medical University of South Carolina Charleston SC
| | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterImperial College Dallas TX USA.,Imperial College London UK
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
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11
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Abstract
Heart failure (HF) is a common consequence of several cardiovascular diseases and is understood as a vicious cycle of cardiac and hemodynamic decline. The current inventory of treatments either alleviates the pathophysiological features (eg, cardiac dysfunction, neurohumoral activation, and ventricular remodeling) and/or targets any underlying pathologies (eg, hypertension and myocardial infarction). Yet, since these do not provide a cure, the morbidity and mortality associated with HF remains high. Therefore, the disease constitutes an unmet medical need, and novel therapies are desperately needed. Cyclic guanosine-3',5'-monophosphate (cGMP), synthesized by nitric oxide (NO)- and natriuretic peptide (NP)-responsive guanylyl cyclase (GC) enzymes, exerts numerous protective effects on cardiac contractility, hypertrophy, fibrosis, and apoptosis. Impaired cGMP signaling, which can occur after GC deactivation and the upregulation of cyclic nucleotide-hydrolyzing phosphodiesterases (PDEs), promotes cardiac dysfunction. In this study, we review the role that NO/cGMP and NP/cGMP signaling plays in HF. After considering disease etiology, the physiological effects of cGMP in the heart are discussed. We then assess the evidence from preclinical models and patients that compromised cGMP signaling contributes to the HF phenotype. Finally, the potential of pharmacologically harnessing cardioprotective cGMP to rectify the present paucity of effective HF treatments is examined.
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12
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Zhang Y, Xu CB. The roles of endothelin and its receptors in cigarette smoke-associated pulmonary hypertension with chronic lung disease. Pathol Res Pract 2020; 216:153083. [PMID: 32825951 DOI: 10.1016/j.prp.2020.153083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/03/2020] [Accepted: 06/22/2020] [Indexed: 01/23/2023]
Abstract
Chronic exposure to cigarette smoke is the major risk factor for the development of pulmonary hypertension (PH) with chronic lung disease (i.e. PH group III). The pathogenesis of smoke-associated PH group III in chronic obstructive pulmonary disease (COPD) involves cigarette smoke exposure-induced damage to lung tissue and dysfunction of pulmonary system with increased synthesis and release of endothelin-1 (ET-1), hypoxia, inflammation, pulmonary vascular remodeling. Many studies have demonstrated that cigarette smoke exposure induces activation of mitogen-activated protein kinase (MAPK) signal pathway that leads to up-regulation of ET-1 and its receptors with the receptor-mediated enhanced contraction, proliferation of pulmonary vascular smooth muscle cells, pulmonary vascular remodeling, elevated pulmonary arterial pressure and finally PH group III. This mini-review article aims to summarize the current state of understanding on the roles of cigarette smoke-induced up-regulation of ET-1 and its receptors in the development of PH group III. Understanding the underlying molecular mechanisms that cigarette smoke exposure leads to PH group III may provide a novel strategy for the treatment.
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Affiliation(s)
- Yaping Zhang
- Shaanxi Key Laboratory of Ischemic Cardiovascular Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Shaanxi, Xi'an, China
| | - Cang-Bao Xu
- Shaanxi Key Laboratory of Ischemic Cardiovascular Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Shaanxi, Xi'an, China.
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13
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Abstract
Investigations into the mixed muscle-secretory phenotype of cardiomyocytes from the atrial appendages of the heart led to the discovery that these cells produce, in a regulated manner, two polypeptide hormones - the natriuretic peptides - referred to as atrial natriuretic factor or atrial natriuretic peptide (ANP) and brain or B-type natriuretic peptide (BNP), thereby demonstrating an endocrine function for the heart. Studies on the gene encoding ANP (NPPA) initiated the field of modern research into gene regulation in the cardiovascular system. Additionally, ANP and BNP were found to be the natural ligands for cell membrane-bound guanylyl cyclase receptors that mediate the effects of natriuretic peptides through the generation of intracellular cGMP, which interacts with specific enzymes and ion channels. Natriuretic peptides have many physiological actions and participate in numerous pathophysiological processes. Important clinical entities associated with natriuretic peptide research include heart failure, obesity and systemic hypertension. Plasma levels of natriuretic peptides have proven to be powerful diagnostic and prognostic biomarkers of heart disease. Development of pharmacological agents that are based on natriuretic peptides is an area of active research, with vast potential benefits for the treatment of cardiovascular disease.
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14
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Sommer N, Ghofrani HA, Pak O, Bonnet S, Provencher S, Sitbon O, Rosenkranz S, Hoeper MM, Kiely DG. Current and future treatments of pulmonary arterial hypertension. Br J Pharmacol 2020; 178:6-30. [PMID: 32034759 DOI: 10.1111/bph.15016] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 01/25/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
Therapeutic options for pulmonary arterial hypertension (PAH) have increased over the last decades. The advent of pharmacological therapies targeting the prostacyclin, endothelin, and NO pathways has significantly improved outcomes. However, for the vast majority of patients, PAH remains a life-limiting illness with no prospect of cure. PAH is characterised by pulmonary vascular remodelling. Current research focusses on targeting the underlying pathways of aberrant proliferation, migration, and apoptosis. Despite success in preclinical models, using a plethora of novel approaches targeting cellular GPCRs, ion channels, metabolism, epigenetics, growth factor receptors, transcription factors, and inflammation, successful transfer to human disease with positive outcomes in clinical trials is limited. This review provides an overview of novel targets addressed by clinical trials and gives an outlook on novel preclinical perspectives in PAH. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Natascha Sommer
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
| | - Hossein A Ghofrani
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Oleg Pak
- Cardiopulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
| | - Sebastien Bonnet
- Groupe de recherche en hypertension pulmonaire Centre de recherche de IUCPQ, Universite Laval Quebec, Quebec City, Quebec, Canada
| | - Steve Provencher
- Groupe de recherche en hypertension pulmonaire Centre de recherche de IUCPQ, Universite Laval Quebec, Quebec City, Quebec, Canada
| | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France. Inserm UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Stephan Rosenkranz
- Klinik III für Innere Medizin, Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Cologne, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research (DZL), Hanover, Germany
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital and Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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15
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Zern EK, Cheng S, Wolfson AM, Hamilton MA, Zile MR, Solomon SD, Kittleson MM. Angiotensin Receptor-Neprilysin Inhibitor Therapy Reverses Pulmonary Hypertension in End-Stage Heart Failure Patients Awaiting Transplantation. Circ Heart Fail 2020; 13:e006696. [PMID: 32059634 DOI: 10.1161/circheartfailure.119.006696] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Emily K Zern
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (E.K.Z., S.C., M.A.H., M.M.K.)
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (E.K.Z., S.C., M.A.H., M.M.K.)
| | | | - Michele A Hamilton
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (E.K.Z., S.C., M.A.H., M.M.K.)
| | - Michael R Zile
- Department of Cardiology, Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (E.K.Z., S.C., M.A.H., M.M.K.)
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16
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Clements RT, Vang A, Fernandez-Nicolas A, Kue NR, Mancini TJ, Morrison AR, Mallem K, McCullough DJ, Choudhary G. Treatment of Pulmonary Hypertension With Angiotensin II Receptor Blocker and Neprilysin Inhibitor Sacubitril/Valsartan. Circ Heart Fail 2019; 12:e005819. [PMID: 31707802 DOI: 10.1161/circheartfailure.119.005819] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Angiotensin II has been implicated in maladaptive right ventricular (RV) hypertrophy and fibrosis associated with pulmonary hypertension (PH). Natriuretic peptides decrease RV afterload by promoting pulmonary vasodilation and inhibiting vascular remodeling but are degraded by neprilysin. We hypothesized that angiotensin receptor blocker and neprilysin inhibitor, sacubitril/valsartan (Sac/Val, LCZ696), will attenuate PH and improve RV function by targeting both pulmonary vascular and RV remodeling. METHODS PH was induced in rats using the SU5416/hypoxia model (Su/Hx), followed by 6-week treatment with placebo, Sac/Val, or Val alone. There were 4 groups: CON-normoxic animals with placebo (n=18); PH-Su/Hx rats+placebo (n=34); PH+Sac/Val (N=24); and PH+Val (n=16). RESULTS In animals with PH, treatment with Sac/Val but not Val resulted in significant reduction in RV pressure (mm Hg: PH: 62±4, PH+Sac/Val: 46±5), hypertrophy (RV/LV+S: PH: 0.74±0.06, PH+Sac/Val: 0.46±0.06), collagen content (µg/50 µg protein: PH: 8.2±0.3, PH+Sac/Val: 6.4±0.4), pressures and improvement in RVs (mm/s: PH: 31.2±1.8, PH+Sac/Val: 43.1±3.6) compared with placebo. This was associated with reduced pulmonary vascular wall thickness, increased lung levels of ANP (atrial natriuretic peptide), BNP (brain-type natriuretic peptide), and cGMP, and decreased plasma endothelin-1 compared with PH alone. Also, PH+Sac/Val animals had altered expression of PKC isozymes in RV tissue compared with PH alone. CONCLUSIONS Sac/Val reduces pulmonary pressures, vascular remodeling, as well as RV hypertrophy in a rat model of PH and may be appropriate for treatment of pulmonary hypertension and RV dysfunction.
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Affiliation(s)
- Richard T Clements
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.).,Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI (R.T.C.).,Department of Biomedical and Pharmaceutical Science, College of Pharmacy, University of Rhode Island, Kingston, RI (R.T.C.)
| | - Alexander Vang
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.)
| | - Ana Fernandez-Nicolas
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.).,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.F.-N., A.R.M., G.C.)
| | - Nouaying R Kue
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.)
| | - Thomas J Mancini
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.)
| | - Alan R Morrison
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.).,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.F.-N., A.R.M., G.C.)
| | - Krishna Mallem
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.)
| | - Danielle J McCullough
- Department of Anatomical Sciences, Edward Via College of Osteopathic Medicine-Auburn Campus, AL (D.J.M.)
| | - Gaurav Choudhary
- Vascular Research Laboratory, Providence VA Medical Center, RI (R.T.C., A.V.A.B., A.F.-N., N.R.K., T.J.M., A.R.M., K.M., G.C.).,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.F.-N., A.R.M., G.C.)
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17
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Hobbs AJ, Moyes AJ, Baliga RS, Ghedia D, Ochiel R, Sylvestre Y, Doré CJ, Chowdhury K, Maclagan K, Quartly HL, Sofat R, Smit A, Schreiber BE, Coghlan GJ, MacAllister RJ. Neprilysin inhibition for pulmonary arterial hypertension: a randomized, double-blind, placebo-controlled, proof-of-concept trial. Br J Pharmacol 2019; 176:1251-1267. [PMID: 30761523 DOI: 10.1111/bph.14621] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/29/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Pulmonary arterial hypertension (PAH) is an incurable, incapacitating disorder resulting from increased pulmonary vascular resistance, pulmonary arterial remodelling, and right ventricular failure. In preclinical models, the combination of a PDE5 inhibitor (PDE5i) with a neprilysin inhibitor augments natriuretic peptide bioactivity, promotes cGMP signalling, and reverses the structural and haemodynamic deficits that characterize PAH. Herein, we conducted a randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of repurposing the neprilysin inhibitor, racecadotril, in PAH. EXPERIMENTAL APPROACH Twenty-one PAH patients stable on PDE5i therapy were recruited. Acute haemodynamic and biochemical changes following a single dose of racecadotril or matching placebo were determined; this was followed by a 14-day safety and efficacy evaluation. The primary endpoint in both steps was the maximum change in circulating atrial natriuretic peptide (ANP) concentration (Δmax ), with secondary outcomes including pulmonary and systemic haemodynamics plus mechanistic biomarkers. KEY RESULTS Acute administration of racecadotril (100 mg) resulted in a 79% increase in the plasma ANP concentration and a 106% increase in plasma cGMP levels, with a concomitant 14% fall in pulmonary vascular resistance. Racecadotril (100 mg; t.i.d.) treatment for 14 days resulted in a 19% rise in plasma ANP concentration. Neither acute nor chronic administration of racecadotril resulted in a significant drop in mean arterial BP or any serious adverse effects. CONCLUSIONS AND IMPLICATIONS This Phase IIa evaluation provides proof-of-principle evidence that neprilysin inhibitors may have therapeutic utility in PAH and warrants a larger scale prospective trial.
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Affiliation(s)
- Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amie J Moyes
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Reshma S Baliga
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Dipa Ghedia
- Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
| | - Rachel Ochiel
- Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Kate Maclagan
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Harriet L Quartly
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Reecha Sofat
- Centre for Clinical Pharmacology, Rayne Institute, London, UK
| | - Angelique Smit
- Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Gerry J Coghlan
- Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
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