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Panevin TS, Ananyeva LP. Pathogenetic rationale for prescribing menopausal hormone therapy for systemic sclerosis. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-538-545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Systemic scleroderma (SS) is characterized by dysregulation of the innate and adaptive immune systems, vasculopathy, and generalized fibrosis. As with most autoimmune diseases, women predominate among patients, who get sick 3–14 times more often than men. It is assumed that gender differences and modulation of sex hormones are essential in the pathogenesis of SS. Estrogens are able to influence the immune response, have a vasodilating effect and stimulate the synthesis of collagen in the skin. The development of SS leads to a significant decrease in the quality of life, psychological disorders associated with changes in appearance, as well as the need for lifelong medication with the frequent development of side effects. Age-related estrogen deficiency associated with the onset of menopause is accompanied by a decrease in the quality of life and, in some cases, a change in the clinical manifestations of somatic diseases. This review considers the impact of menopause and menopausal hormone therapy (MHT) on the course and clinical manifestations of systemic scleroderma. It is noted that SS in some cases is accompanied by an early onset of menopause. The use of MHT is not associated with the progression of cutaneous fibrosis, and may also improve the vascular manifestations of SS.
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2
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Fried ND, Whitehead A, Lazartigues E, Yue X, Gardner JD. Ovarian hormones do not mediate protection against pulmonary hypertension and right ventricular remodeling in female mice exposed to chronic, inhaled nicotine. Am J Physiol Heart Circ Physiol 2022; 323:H941-H948. [PMID: 36206053 PMCID: PMC9602789 DOI: 10.1152/ajpheart.00467.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
Electronic cigarette use has increased globally prompting calls for improved understanding of nicotine's cardiovascular health effects. Our group has previously demonstrated that chronic, inhaled nicotine induces pulmonary hypertension and right ventricular (RV) remodeling in male mice, but not female mice, suggesting sex differences in nicotine-related pathology. Clinically, biological females develop pulmonary hypertension more often but have less severe disease than biological males, likely because of the cardiopulmonary protective effects of estrogen. Nicotine is also metabolized more rapidly in biological females because of differences in cytochrome-P450 activity, which are thought to be mediated by female sex hormones. These findings led us to hypothesize that female mice are protected against nicotine-induced pulmonary hypertension by an ovarian hormone-dependent mechanism. In this study, intact and ovariectomized (OVX) female mice were exposed to chronic, inhaled nicotine or room air for 12 h/day for 10-12 wk. We report no differences in serum cotinine levels between intact and OVX mice. In addition, we found no structural (RV or left ventricular dimensions and Fulton index) or functional (RV systolic pressure, pulmonary vascular resistance, cardiac output, ejection fraction, and fractional shortening) evidence of cardiopulmonary dysfunction in intact or OVX mice. We conclude that ovarian hormones do not mediate cardiopulmonary protection against nicotine-induced pulmonary hypertension. Due to profound sex differences in clinical pulmonary hypertension pathogenesis and nicotine metabolism, further studies are necessary to elucidate mechanisms underlying protection from nicotine-induced pathology in female mice.NEW & NOTEWORTHY The emergence of electronic cigarettes poses a threat to cardiovascular and pulmonary health, but the direct contribution of nicotine to these disease processes is largely unknown. Our laboratory has previously shown that chronic, inhaled nicotine induces pulmonary hypertension and right ventricular remodeling in male mice, but not female mice. This study using a bilateral ovariectomy model suggests that the cardiopulmonary protection observed in nicotine-exposed female mice may be independent of ovarian hormones.
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Affiliation(s)
- Nicholas D Fried
- Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Anna Whitehead
- Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Eric Lazartigues
- Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Neuroscience Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Xinping Yue
- Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Jason D Gardner
- Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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3
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Rodriguez-Arias JJ, García-Álvarez A. Sex Differences in Pulmonary Hypertension. FRONTIERS IN AGING 2022; 2:727558. [PMID: 35822006 PMCID: PMC9261364 DOI: 10.3389/fragi.2021.727558] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) includes multiple diseases that share as common characteristic an elevated pulmonary artery pressure and right ventricular involvement. Sex differences are observed in practically all causes of PH. The most studied type is pulmonary arterial hypertension (PAH) which presents a gender bias regarding its prevalence, prognosis, and response to treatment. Although this disease is more frequent in women, once affected they present a better prognosis compared to men. Even if estrogens seem to be the key to understand these differences, animal models have shown contradictory results leading to the birth of the estrogen paradox. In this review we will summarize the evidence regarding sex differences in experimental animal models and, very specially, in patients suffering from PAH or PH from other etiologies.
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Affiliation(s)
| | - Ana García-Álvarez
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, IDIBAPS, Madrid, Spain.,Universidad de Barcelona, Barcelona, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Madrid, Spain
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4
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A Narrative Review of Pathogenetic and Histopathologic Aspects, Epidemiology, Classification Systems, and Disease Outcome Measures in Systemic Sclerosis. Clin Rev Allergy Immunol 2022; 64:358-377. [PMID: 35254622 PMCID: PMC10167186 DOI: 10.1007/s12016-022-08929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/03/2022]
Abstract
Systemic sclerosis (SSc) is a rare systemic autoimmune disease, characterized by the presence of three main actors: vasculopathy, immune activation, and fibrosis. This pathologic process is then translated in a clinical picture with great variability among different patients in terms of type of organ involvement, disease severity and prognosis. This heterogeneity is a main feature of SSc, which, in addition to the presence of early phases of the disease characterized by mild symptoms, can explain the high difficulty in establishing classification criteria, and in defining patients' subsets and disease outcomes. The definition of disease outcomes is particularly relevant in the setting of clinical trials, where the aim is to provide reliable endpoints, able to measure the magnitude of the efficacy of a certain drug or intervention. For this reason, in the last years, increasing efforts have been done to design measures of disease activity, damage, severity, and response to treatment, often in the context of composite indexes. When considering disease outcomes, the experience of the patient represents a relevant and complementary aspect. The tools able to capture this experience, the patient-reported outcomes, have been increasingly used in the last years in clinical practice and in clinical trials, both as primary and secondary endpoints. This comprehensive narrative review on SSc will therefore cover pathogenetic and histopathologic aspects, epidemiology, classification systems, and disease outcome measures, in order to focus on issues that are relevant for clinical research and design of clinical trials.
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5
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Cheng TC, Tabima DM, Caggiano LR, Frump AL, Hacker TA, Eickhoff JC, Lahm T, Chesler NC. Sex differences in right ventricular adaptation to pressure overload in a rat model. J Appl Physiol (1985) 2022; 132:888-901. [PMID: 35112927 PMCID: PMC8934674 DOI: 10.1152/japplphysiol.00175.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
With severe right ventricular (RV) pressure overload, women demonstrate better clinical outcomes compared with men. The mechanoenergetic mechanisms underlying this protective effect, and their dependence on female endogenous sex hormones, remain unknown. To investigate these mechanisms and their impact on RV systolic and diastolic functional adaptation, we created comparable pressure overload via pulmonary artery banding (PAB) in intact male and female Wistar rats and ovariectomized (OVX) female rats. At 8 wk after surgery, right heart catheterization demonstrated increased RV energy input [indexed pressure-volume area (iPVA)] in all PAB groups, with the greatest increase in intact females. PAB also increased RV energy output [indexed stroke or external work (iEW)] in all groups, again with the greatest increase in intact females. In contrast, PAB only increased RV contractility-indexed end-systolic elastance (iEes)] in females. Despite these sex-dependent differences, no statistically significant effects were observed in the ratio of RV energy output to input (mechanical efficiency) or in mechanoenergetic cost to pump blood with pressure overload. These metrics were similarly unaffected by loss of endogenous sex hormones in females. Also, despite sex-dependent differences in collagen content and organization with pressure overload, decreases in RV compliance and relaxation time constant (tau Weiss) were not determined to be sex dependent. Overall, despite sex-dependent differences in RV contractile and fibrotic responses, RV mechanoenergetics for this degree and duration of pressure overload are comparable between sexes and suggest a homeostatic target.NEW & NOTEWORTHY Sex differences in right ventricular mechanical efficiency and energetic adaptation to increased right ventricular afterload were measured. Despite sex-dependent differences in contractile and fibrotic responses, right ventricular mechanoenergetic adaptation was comparable between the sexes, suggesting a homeostatic target.
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Affiliation(s)
- Tik-Chee Cheng
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Diana M. Tabima
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura R. Caggiano
- 2University of California, Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Irvine, California
| | - Andrea L. Frump
- 3Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy A. Hacker
- 4Cardiovascular Physiology Core Facility, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jens C. Eickhoff
- 5Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Tim Lahm
- 3Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana,6Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado,7Richard L. Roudebush Department of Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Naomi C. Chesler
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin,2University of California, Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Irvine, California,8Department of Biomedical Engineering, University of California, Irvine, California
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6
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Association of premature menopause with incident pulmonary hypertension: A cohort study. PLoS One 2021; 16:e0247398. [PMID: 33690615 PMCID: PMC7946190 DOI: 10.1371/journal.pone.0247398] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/06/2021] [Indexed: 12/20/2022] Open
Abstract
Background Several forms of pulmonary hypertension (PH) disproportionately affect women. Animal and human studies suggest that estradiol exerts mixed effects on the pulmonary vasculature. Whether premature menopause represents a risk factor for PH is unknown. Methods and findings In this cohort study, women in the UK Biobank aged 40–69 years who were postmenopausal and had complete data available on reproductive history were included. Premature menopause, defined as menopause occurring before age 40 years. Postmenopausal women without premature menopause served as the reference group. The primary outcome was incident PH, ascertained by appearance of a qualifying ICD code in the participant’s UK Biobank study record. Of 136,715 postmenopausal women included, 5,201 (3.8%) had premature menopause. Participants were followed up for a median of 11.1 (interquartile range 10.5–11.8) years. The primary outcome occurred in 38 women (0.73%) with premature menopause and 409 (0.31%) without. After adjustment for age, race, ever-smoking, body-mass index, systolic blood pressure, antihypertensive medication use, non-high-density lipoprotein cholesterol, cholesterol-lowering medication use, C-reactive protein, prevalent type 2 diabetes, obstructive sleep apnea, heart failure, mitral regurgitation, aortic stenosis, venous thromboembolism, forced vital capacity (FVC), the forced expiratory volume in 1 second-to-FVC ratio, use of menopausal hormone therapy, and hysterectomy status, premature menopause was independently associated with PH (hazard ratio 2.13, 95% CI 1.31–3.23, P<0.001). In analyses of alternate menopausal age thresholds, risk of PH appeared to increase progressively with younger age at menopause (Ptrend <0.001), with 4.8-fold risk in women with menopause before age 30 years (95% CI 1.82–12.74, P = 0.002). Use of menopausal hormone therapy did not modify the association of premature menopause with PH. Conclusions Premature menopause may represent an independent risk factor for PH in women. Further investigation of the role of sex hormones in PH is needed in animal and human studies to elucidate pathobiology and identify novel therapeutic targets.
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7
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Jutiviboonsuk A, Salang L, Eamudomkarn N, Mahakkanukrauh A, Suwannaroj S, Foocharoen C. Prevalence and clinical associations with premature ovarian insufficiency, early menopause, and low ovarian reserve in systemic sclerosis. Clin Rheumatol 2020; 40:2267-2275. [PMID: 33244723 DOI: 10.1007/s10067-020-05522-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022]
Abstract
The low prevalence of pregnancy in women with systemic sclerosis (SSc) is due to multi-factorial causes, including premature ovarian insufficiency (POI). The study aimed to determine the prevalence of POI, early menopausal status, and any clinical associations of these among Thai female SSc patients. An analytical cross-sectional study was conducted among female SSc patients between 18 and 45 years of age. The eligible patients underwent blood testing for follicle stimulating hormone and anti-mullerian hormone levels, gynecologic examination, and transvaginal ultrasound for antral follicle count. We excluded patients having surgical amenorrhea, previous radiation, and history of hormonal contraception < 12 weeks and pregnancy. A total of 31 patients were included. The majority (67.7%) had diffuse cutaneous systemic sclerosis. Three patients were POI with a prevalence of 9.7%. The factors associated with POI were a high cumulative dose of cyclophosphamide (CYC) (p = 0.02) and the long duration of CYC used (p = 0.02). After excluding POI, early menopause was detected in 10 patients with a prevalence of 35.7%. The factors associated with early menopause were long disease duration (p = 0.02), high cumulative dose of CYC (p = 0.03), and high cumulative dose of prednisolone (p = 0.02). Low ovarian reserve according to POSEIDON definition was found in 28 patients with the prevalence of 90.3%. POI in Thai SSc was uncommon, whereas early menopause and low ovarian reserve were frequently revealed. A high cumulative dose of CYC was associated with both POI and early menopause. Physicians should be aware of reproductive outcomes and advise patients at risk. Key Points • POI is revealed in patients with SSc particularly in who received high cumulative dose of cyclophosphamide, while early menopause and low ovarian reserve were major reproductive problem among SSc. • Prescriptions for CYC for female SSc-both for young patients of reproductive age and premenopausal middle-aged women-should be concerned of the long-term effects on gonadal function.
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Affiliation(s)
- Arporn Jutiviboonsuk
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Lingling Salang
- Department of Obstetrics-Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Nuntasiri Eamudomkarn
- Department of Obstetrics-Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand.
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8
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Hughes M, Pauling JD, Armstrong-James L, Denton CP, Galdas P, Flurey C. Gender-related differences in systemic sclerosis. Autoimmun Rev 2020; 19:102494. [PMID: 32062031 DOI: 10.1016/j.autrev.2020.102494] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/19/2019] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis (SSc) is a complex autoimmune connective tissue disease which is characterised by autoimmunity, widespread tissue fibrosis of the skin and internal organs, and vasculopathic alterations. SSc is more common in women but has a more severe expression of disease including internal organ-based complications and higher mortality in men. The extant literature shows that although important pathophysiological sex differences are present in SSc, behavioural differences (e.g. higher smoking rates in men) and occupational exposures may contribute to poorer outcomes in men with SSc. The higher death male death rate in the general population and greater prevalence of lung fibrosis are likely the key factors responsible for excess mortality found in men. Other important factors include (but are not limited to) a greater prevalence of the disease subset, delayed time to diagnosis, and higher disease activity in early disease in men. SSc carries a significant burden of disease-related morbidity; however, no qualitative studies to date have focussed on gender differences in SSc. The purpose of this review is to provide a comprehensive overview of gender differences in SSc including (but not limited to) epidemiology, pathophysiology, clinical expression of disease, mortality, SSc in transgender individuals, and psychosocial aspects of disease.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, UK.
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK; Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | | | - Christopher P Denton
- Centre for Rheumatology, Royal Free Hospital, University College London, London, UK
| | - Paul Galdas
- Department of Health Sciences, University of York, York, UK
| | - Caroline Flurey
- Department of Health and Social Sciences, University of the West of England, Bristol, UK
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9
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Sex hormones and sex hormone-targeting therapies in systemic sclerosis: A systematic literature review. Semin Arthritis Rheum 2020; 50:140-148. [DOI: 10.1016/j.semarthrit.2019.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/29/2019] [Accepted: 07/18/2019] [Indexed: 01/19/2023]
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10
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Hester J, Ventetuolo C, Lahm T. Sex, Gender, and Sex Hormones in Pulmonary Hypertension and Right Ventricular Failure. Compr Physiol 2019; 10:125-170. [PMID: 31853950 DOI: 10.1002/cphy.c190011] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary hypertension (PH) encompasses a syndrome of diseases that are characterized by elevated pulmonary artery pressure and pulmonary vascular remodeling and that frequently lead to right ventricular (RV) failure and death. Several types of PH exhibit sexually dimorphic features in disease penetrance, presentation, and progression. Most sexually dimorphic features in PH have been described in pulmonary arterial hypertension (PAH), a devastating and progressive pulmonary vasculopathy with a 3-year survival rate <60%. While patient registries show that women are more susceptible to development of PAH, female PAH patients display better RV function and increased survival compared to their male counterparts, a phenomenon referred to as the "estrogen paradox" or "estrogen puzzle" of PAH. Recent advances in the field have demonstrated that multiple sex hormones, receptors, and metabolites play a role in the estrogen puzzle and that the effects of hormone signaling may be time and compartment specific. While the underlying physiological mechanisms are complex, unraveling the estrogen puzzle may reveal novel therapeutic strategies to treat and reverse the effects of PAH/PH. In this article, we (i) review PH classification and pathophysiology; (ii) discuss sex/gender differences observed in patients and animal models; (iii) review sex hormone synthesis and metabolism; (iv) review in detail the scientific literature of sex hormone signaling in PAH/PH, particularly estrogen-, testosterone-, progesterone-, and dehydroepiandrosterone (DHEA)-mediated effects in the pulmonary vasculature and RV; (v) discuss hormone-independent variables contributing to sexually dimorphic disease presentation; and (vi) identify knowledge gaps and pathways forward. © 2020 American Physiological Society. Compr Physiol 10:125-170, 2020.
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Affiliation(s)
- James Hester
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Corey Ventetuolo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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11
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Abstract
Scleroderma is an uncommon autoimmune disease of unknown cause that may affect any organ system in the body. Patients with scleroderma are prone to developing pulmonary complications, including pulmonary arterial hypertension (PAH), that are the leading cause of death in this population. This article describes scleroderma-related PAH and its diagnosis and management.
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12
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Batton KA, Austin CO, Bruno KA, Burger CD, Shapiro BP, Fairweather D. Sex differences in pulmonary arterial hypertension: role of infection and autoimmunity in the pathogenesis of disease. Biol Sex Differ 2018; 9:15. [PMID: 29669571 PMCID: PMC5907450 DOI: 10.1186/s13293-018-0176-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/09/2018] [Indexed: 01/14/2023] Open
Abstract
Registry data worldwide indicate an overall female predominance for pulmonary arterial hypertension (PAH) of 2–4 over men. Genetic predisposition accounts for only 1–5% of PAH cases, while autoimmune diseases and infections are closely linked to PAH. Idiopathic PAH may include patients with undiagnosed autoimmune diseases based on the relatively high presence of autoantibodies in this group. The two largest PAH registries to date report a sex ratio for autoimmune connective tissue disease-associated PAH of 9:1 female to male, highlighting the need for future studies to analyze subgroup data according to sex. Autoimmune diseases that have been associated with PAH include female-dominant systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, and thyroiditis as well as male-dominant autoimmune diseases like myocarditis which has been linked to HIV-associated PAH. The sex-specific association of PAH to certain infections and autoimmune diseases suggests that sex hormones and inflammation may play an important role in driving the pathogenesis of disease. However, there is a paucity of data on sex differences in inflammation in PAH, and more research is needed to better understand the pathogenesis underlying PAH in men and women. This review uses data on sex differences in PAH and PAH-associated autoimmune diseases from registries to provide insight into the pathogenesis of disease.
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Affiliation(s)
- Kyle A Batton
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Katelyn A Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Brian P Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA.
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13
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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14
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Kerkhof PLM, Khamaganova I. Sex-Specific Cardiovascular Comorbidities with Associations in Dermatologic and Rheumatic Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:489-509. [DOI: 10.1007/978-3-319-77932-4_30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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Abstract
Menopause occurs naturally in women at about 50 years of age. There is a wealth of data concerning the relationship of menopause to systemic lupus erythematosus, rheumatoid arthritis, and osteoarthritis; there are limited data concerning other rheumatic diseases. Age at menopause may affect the risk and course of rheumatic diseases. Osteoporosis, an integral part of inflammatory rheumatic diseases, is made worse by menopause. Hormone replacement therapy has been studied; its effects vary depending on the disease and even different manifestations within the same disease. Cyclophosphamide can induce early menopause, but there is underlying decreased ovarian reserve in rheumatic diseases.
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Affiliation(s)
- Mitali Talsania
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, 1000 Lincoln Blvd, Oklahoma City, OK 73104, USA
| | - Robert Hal Scofield
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, 1000 Lincoln Blvd, Oklahoma City, OK 73104, USA; Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast 13th Street, MS 24, Oklahoma City, OK 73104, USA; Medical Service, Department of Veterans Affairs Medical Center, 920 NE 13th Street, Oklahoma City, OK 73104, USA.
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16
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Umar S, Partow-Navid R, Ruffenach G, Iorga A, Moazeni S, Eghbali M. Severe pulmonary hypertension in aging female apolipoprotein E-deficient mice is rescued by estrogen replacement therapy. Biol Sex Differ 2017; 8:9. [PMID: 28344760 PMCID: PMC5360087 DOI: 10.1186/s13293-017-0129-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 03/03/2017] [Indexed: 12/12/2022] Open
Abstract
Background Apolipoprotein E (ApoE) is a multifunctional protein, and its deficiency leads to the development of atherosclerosis in mice. Patients with pulmonary hypertension (PH) have reduced expression of ApoE in lung tissue. ApoE is known to inhibit endothelial and smooth muscle cell proliferation and has anti-inflammatory and anti-platelet aggregation properties. Young ApoE-deficient mice have been shown to develop PH on high fat diet. The combined role of female sex and aging in the development of PH has not been investigated before. Here, we investigated the development of PH in young and middle-aged (MA) female ApoE-deficient mice and explored the role of exogenous estrogen (E2) replacement therapy for the aging females. Methods Wild type (WT) and ApoE-deficient female mice (Young and MA) were injected with a single intraperitoneal dose of monocrotaline (MCT, 60 mg/kg). Some ApoE-deficient MA female mice that received MCT were also treated with subcutaneous E2 pellets (0.03 mg/kg/day) from day 21 to 30 after MCT injection. Direct cardiac catheterization was performed terminally to record right ventricular systolic pressure (RVSP). Right ventricular (RV), left ventricular (LV), and interventricular septum (IVS) were dissected and weighed. Lung sections were examined using trichrome and immunofluorescence staining. Western blot analyses of lung and RV lysates were performed. Results In WT female mice, the severity of PH was similar between young and MA mice as RVSP was not significantly different (RVSP = 38.2 ± 1.2 in young vs. 40.5 ± 8.3 mmHg in MA, p < 0.05). In ApoE-deficient mice, MA females developed significantly severe PH (RVSP = 63 ± 10 mmHg) compared to young females (RVSP; 36 ± 3 mmHg, p < 0.05 vs. MA female). ApoE-deficient MA females also developed more severe RV hypertrophy compared to young females (RV hypertrophy index (RV/[LV + IVS]) = 0.53 ± 0.06 vs. 0.33 ± 0.01, p < 0.05). ApoE-deficient MA female mice manifested increased peripheral pulmonary artery muscularization and pulmonary fibrosis. E2 treatment of MA female ApoE-deficient mice resulted in a significant decrease in RVSP, reversal of pulmonary vascular remodeling, and RV hypertrophy. In MA female ApoE-deficient mice with PH, only the expression of ERβ in the lungs, but not in RV, was significantly downregulated, and it was restored by E2 treatment. The expression of ERα was not affected in either lungs or RV by PH. GPR30 was only detected in the RV, and it was not affected by PH in MA female ApoE-deficient mice. Conclusions Our results suggest that only aging female ApoE-deficient but not WT mice develop severe PH compared to younger females. Exogenous estrogen therapy rescued PH and RV hypertrophy in aging female ApoE-deficient mice possibly through restoration of lung ERβ.
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Affiliation(s)
- Soban Umar
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
| | - Rod Partow-Navid
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
| | - Gregoire Ruffenach
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
| | - Andrea Iorga
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
| | - Shayan Moazeni
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
| | - Mansoureh Eghbali
- Department of Anaesthesiology, Division of Molecular Medicine, David Geffen School of Medicine at UCLA, BH-160 CHS, 650 Charles E Young Dr. South, Los Angeles, CA 90095-7115 USA
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Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman SM, Nikpour M. Risk factors for development of pulmonary arterial hypertension in Australian systemic sclerosis patients: results from a large multicenter cohort study. BMC Pulm Med 2016; 16:134. [PMID: 27677579 PMCID: PMC5039932 DOI: 10.1186/s12890-016-0296-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is the leading cause of mortality in patients with systemic sclerosis (SSc). We sought to determine the incidence, prevalence and risk factors for PAH development in a large Australian SSc cohort. METHODS PAH was diagnosed on right heart catheterisation (mPAP >25 and PAWP <15 mmHg at rest). Patients with PH secondary to interstitial lung disease (ILD; defined as abnormal HRCT scan and FVC < 60 %) were excluded. Summary statistics, chi-square tests, univariate and multivariable logistic regression along with post-estimation diagnostics were used to determine the associations of different combinations of risk factors with PAH. RESULTS Among 1579 SSc patients, 8.4 % (132 patients) were diagnosed with PAH over a mean (±SD) follow-up of 3.2 (±2.5) years. The incidence of PAH in this cohort was 0.7 % per annum. Of these, 68.9 % had limited disease subtype (lcSSc). In multivariable regression analysis, the presence of anti-centromere antibody (ACA) (OR 1.6, 95 % CI 1.1-2.5, p = 0.03), oesphageal stricture (OR 2.0, 95 % CI 1.2-3.3, p = 0.006), calcinosis (OR 1.9, 95 % CI 1.2-2.9, p = 0.003), sicca symptoms (OR 1.6, 95 % CI 1.1-2.5, p = 0.03), mild ILD (OR 2.3, 95 % CI 1.5-3.7, p < 0.001) and digital ulcers (OR 1.6, 95 % CI 1.0-2.4, p = 0.03) were predictive of PAH. This model had an area under the curve of 0.7 and concordance of 91.8 %. When analysed by disease subtype, the presence of calcinosis (OR 2.2, 95 % CI 1.4-3.7, p = 0.01), sicca symptoms (OR 2.6, 95 % CI 1.5-4.6, p = 0.001), mild ILD (OR 2.3, 95 % CI 1.4-3.8, p = 0.001) and digital ulcers (OR 1.9, 95 % CI 1.2-3.7, p = 0.01) were predictive of PAH in lcSSc; and oesophageal stricture (OR 4.4, 95 % CI 1.9-10.5, p = 0.001), mild ILD (OR 2.8, 95 % CI 1.2-6.8, p = 0.02) and ACA (OR 5.2, 95 % CI 1.8-14.8, p = 0.002) were predictive of PAH in dcSSc. CONCLUSIONS The incidence and prevalence of PAH in this cohort are 0.7 % per annum and 8.4 %, respectively. The clinical-serologic risk factors for PAH differ based on disease subtype. In both subtypes, mild ILD is associated with PAH, suggesting the possibility of common pathogenic mechanisms underlying both of these disease manifestations. This model identifies a subset of patients at an appreciably higher risk of developing PAH, who should be screened and would in future, benefit from preventative therapies.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Molla Huq
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Wendy Stevens
- Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Candice Rabusa
- Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia. .,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.
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18
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Rusiecki J, Rao Y, Cleveland J, Rhinehart Z, Champion HC, Mathier MA. Sex and menopause differences in response to tadalafil: 6-minute walk distance and time to clinical worsening. Pulm Circ 2015; 5:701-6. [PMID: 26697177 DOI: 10.1086/683829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a female-predominant disease, but there are little data on treatment response by sex and menopausal status. In this retrospective analysis of the Pulmonary Arterial Hypertension and Response to Tadalafil (PHIRST) randomized clinical trial, we assessed treatment response between the sexes by examining change in 6-minute walk distance (6MWD) and time to clinical worsening (TCW). We examined the effect of menopausal status on the same treatment measures. 6MWD was recorded before and after 16 weeks of treatment with tadalafil or placebo in the PHIRST study cohort of 340 subjects (264 females, 76 males). A univariate analysis was used to assess the effect of sex on change in 6MWD and TCW. Multivariate linear regression and Cox proportional hazards models were built for 6MWD and TCW, respectively. Women were subdivided by age as a surrogate for menopausal status. The linear trend test and the log-rank test were performed on change in 6MWD and TCW by age. For tadalafil-treated patients, a significant difference in change in 6MWD by sex (mean: 48.6 m for males vs. 34.7 m for females; P = 0.01) was found, but it was not significant in multivariate analysis (P = 0.08). There was a trend toward a female age-dependent effect in change in 6MWD; the premenopausal group showed the greatest improvement. A significant sex- or age-dependent effect on TCW was not present. In conclusion, this retrospective analysis of the PHIRST trial suggests that men and premenopausal women may experience greater functional improvement when treated with tadalafil than older women, but there was no consistent sex or menopausal effect on TCW.
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Affiliation(s)
- Jennifer Rusiecki
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Youlan Rao
- United Therapeutics, Research Triangle Park, North Carolina, USA
| | - Jody Cleveland
- United Therapeutics, Research Triangle Park, North Carolina, USA
| | - Zachary Rhinehart
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hunter C Champion
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael A Mathier
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Lenna S, Assassi S, Farina GA, Mantero JC, Scorza R, Lafyatis R, Farber HW, Trojanowska M. The HLA-B*35 allele modulates ER stress, inflammation and proliferation in PBMCs from Limited Cutaneous Systemic Sclerosis patients. Arthritis Res Ther 2015; 17:363. [PMID: 26669670 PMCID: PMC4704539 DOI: 10.1186/s13075-015-0881-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022] Open
Abstract
Introduction HLA-B*35 is associated with increased risk of developing pulmonary hypertension in SSc patients. We previously reported that HLA-B*35 induces endothelial cell dysfunction via activation of ER stress/UPR and upregulation of the inflammatory response. Because PBMCs from lcSSc-PAH patients are also characterized by activation of ER stress/UPR and inflammation, the goal of this study was to assess whether the presence of HLA-B*35 contributes to those characteristics. Methods PBMCs were purified from healthy controls (n = 49 HC) and lcSSc patients, (n = 44 with PAH, n = 53 without PAH). PBMCs from each group were stratified for the presence of HLA-B*35. Global changes in gene expression in response to HLA-B*35, HLA-B*8 or empty lentivirus were investigated by microarray analysis in HC PBMCs. Total RNA was extracted and qPCR was performed to measure gene expression. Results ER stress markers, in particular the chaperones BiP and DNAJB1 were significantly elevated in PBMC samples carrying the HLA-B*35 allele. IL-6 expression was also significantly increased in HLA-B*35 lcSSc PBMCs and positively correlated with ER stress markers. Likewise, HMGB1 was increased in HLA-B*35-positive lcSSc PBMCs. Global gene expression analysis was used to further probe the role of HLA-B*35. Among genes downregulated by HLA-B*35 lentivirus were genes related to complement (C1QB, C1QC), cell cycle (CDNK1A) and apoptosis (Bax, Gadd45). Interestingly, complement genes (C1QC and C1QB) showed elevated expression in lcSSc without PAH, but were expressed at the low levels in lcSSc-PAH. The presence of HLA-B*35 correlated with the decreased expression of the complement genes. Furthermore, HLA-B*35 correlated with decreased expression of cyclin inhibitors (p21, p57) and pro-apoptotic genes (Bax, Gadd45) in lcSSc B35 subjects. FYN, a tyrosine kinase involved in proliferation of immune cells, was among the genes that were positively regulated by HLA-B*35. HLA-B*35 correlated with increased levels of FYN in lcSSc PBMCs. Conclusions Our study demonstrates that HLA-B*35 contributes to the dysregulated expression of selected ER stress, inflammation and proliferation related genes in lcSSc patient PBMCs, as well as healthy individuals, thus supporting a pathogenic role of HLA-B*35 in the development of PAH in SSc patients. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0881-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefania Lenna
- Arthritis Center, Boston University School of Medicine, 72 East Concord Street, E-5, Boston, MA, 02118, USA.
| | - Shervin Assassi
- Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
| | - G Alessandra Farina
- Arthritis Center, Boston University School of Medicine, 72 East Concord Street, E-5, Boston, MA, 02118, USA.
| | - Julio C Mantero
- Arthritis Center, Boston University School of Medicine, 72 East Concord Street, E-5, Boston, MA, 02118, USA.
| | - Raffaella Scorza
- Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, 20122, Italy.
| | - Robert Lafyatis
- Arthritis Center, Boston University School of Medicine, 72 East Concord Street, E-5, Boston, MA, 02118, USA. .,University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA.
| | - Harrison W Farber
- Pulmonary Center, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - Maria Trojanowska
- Arthritis Center, Boston University School of Medicine, 72 East Concord Street, E-5, Boston, MA, 02118, USA.
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20
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Marder W, Vinet É, Somers EC. Rheumatic autoimmune diseases in women and midlife health. Womens Midlife Health 2015; 1:11. [PMID: 28553545 PMCID: PMC5444314 DOI: 10.1186/s40695-015-0012-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 11/03/2015] [Indexed: 01/03/2023] Open
Abstract
Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (scleroderma) preferentially affect women, and are characterized by systemic inflammation leading to target organ dysfunction. The public health burden of autoimmune diseases, which collectively represent a leading cause of morbidity and mortality among women throughout adulthood, is substantial. While some features of these diseases have been observed to improve over the menopausal transition, such as disease flare rate in SLE and skin softening and thinning in scleroderma, others, such as swollen and tender joints and radiographically confirmed damage in RA may worsen. The general trends, however, are not consistent or conclusive for all disease-related manifestations. Of great importance is the recognition that comorbid diseases, including osteoporosis and accelerated cardiovascular disease, contribute excess morbidity and mortality that becomes increasingly apparent as women with autoimmune diseases undergo the menopausal transition.
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Affiliation(s)
- Wendy Marder
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI USA
| | - Évelyne Vinet
- Division of Rheumatology, McGill University Health Centre, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Canada
| | - Emily C. Somers
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI USA
- Department of Environmental Health Sciences, University of Michigan, 2800 Plymouth Rd, NCRC B14-G236, Ann Arbor, MI 48109-2800 USA
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21
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Valenzuela A, Nandagopal S, Steen VD, Chung L. Monitoring and Diagnostic Approaches for Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Rheum Dis Clin North Am 2015. [PMID: 26210131 DOI: 10.1016/j.rdc.2015.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary arterial hypertension (PAH) is one of the leading causes of death in patients with systemic sclerosis (SSc). Given the high prevalence and poor survival of SSc-PAH, and that aggressive management of mild disease may be associated with better outcomes, screening is critical. Right heart catheterization (RHC) is the gold standard for the definitive diagnosis of PAH, and should be performed in those patients in whom this diagnosis is suspected. Once a diagnosis of PAH is confirmed by RHC, treatment with PAH-specific therapies should be initiated as soon as possible.
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Affiliation(s)
- Antonia Valenzuela
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA
| | - Saranya Nandagopal
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 2nd Floor, Redwood City, CA 94063, USA
| | - Virginia D Steen
- Division of Rheumatology, Allergy, and Immunology, Georgetown University School of Medicine, Pasquerilla Health Center, 6th Floor 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA.
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22
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Lahm T, Tuder RM, Petrache I. Progress in solving the sex hormone paradox in pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2014; 307:L7-26. [PMID: 24816487 DOI: 10.1152/ajplung.00337.2013] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a devastating and progressive disease with marked morbidity and mortality. Even though being female represents one of the most powerful risk factors for PAH, multiple questions about the underlying mechanisms remain, and two "estrogen paradoxes" in PAH exist. First, it is puzzling why estrogens have been found to be protective in various animal models of PAH, whereas PAH registries uniformly demonstrate a female susceptibility to the disease. Second, despite the pronounced tendency for the disease to develop in women, female PAH patients exhibit better survival than men. Recent mechanistic studies in classical and in novel animal models of PAH, as well as recent studies in PAH patients, have significantly advanced the field. In particular, it is now accepted that estrogen metabolism and receptor signaling, as well as estrogen interactions with key pathways in PAH development, appear to be potent disease modifiers. A better understanding of these interactions may lead to novel PAH therapies. It is the purpose of this review to 1) review sex hormone synthesis, metabolism, and receptor physiology; 2) assess the context in which sex hormones affect PAH pathogenesis; 3) provide a potential explanation for the observed estrogen paradoxes and gender differences in PAH; and 4) identify knowledge gaps and future research opportunities. Because the majority of published studies investigated 17β-estradiol and/or its metabolites, this review will primarily focus on pulmonary vascular and right ventricular effects of estrogens. Data for other sex hormones will be discussed very briefly.
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Affiliation(s)
- Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, and Richard L. Roudebush VA Medical Center; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Rubin M Tuder
- Program in Translational Lung Research, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Denver, Colorado
| | - Irina Petrache
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, and Richard L. Roudebush VA Medical Center; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; and
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23
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The genetic basis of pulmonary arterial hypertension. Hum Genet 2014; 133:471-9. [DOI: 10.1007/s00439-014-1419-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/07/2014] [Indexed: 12/24/2022]
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24
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Farage MA, Miller KW, Maibach HI. Effects of menopause on autoimmune diseases. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.12.63] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Accurate diagnosis of pulmonary arterial hypertension can be challenging and often requires a high index of clinical suspicion. Use of a variety of noninvasive tests can help define the population of patients in whom invasive cardiac catheterization should be pursued. An understanding of the historical, physical exam, electrocardiographic, radiographic, and echocardiographic clues in the diagnosis is important. A ventilation-perfusion scan and careful assessment for left-to-right shunting are mandatory to avoid missing reasons for pulmonary hypertension that may require nonpharmacologic management. Right heart, and sometimes concomitant left heart, catheterization is required to establish the diagnosis and distinguish pulmonary arterial from pulmonary venous hypertension.
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Affiliation(s)
- Paul R Forfia
- Division of Cardiovascular Medicine, Pulmonary Hypertension and Right Heart Failure Program, Temple University Hospital, 3401 North Broad Street, 9th Floor, Parkinson Pavillion, Philadelphia, PA 19140, USA.
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26
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Armstrong AC, Bandeira ÂMP, Correia LCL, Melo HCO, Silveira CAM, Albuquerque E, Moraes JC, Silva AML, Lima JAC, Sobral DC. Pulmonary artery pressure, gender, menopause, and pregnancy in schistosomiasis-associated pulmonary hypertension. Arq Bras Cardiol 2013; 101:154-9. [PMID: 23821406 PMCID: PMC3998155 DOI: 10.5935/abc.20130130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 03/06/2013] [Indexed: 01/23/2023] Open
Abstract
Background Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major
concern worldwide. However, the role of gender specific contributing factors in
SPAH is unknown. Objective We investigated how systolic pulmonary artery pressure (SPAP) values and the
presence of severe SPAP relate to gender, menopausal status, and pregnancy history
in SPAH patients. Methods Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66
were enrolled in the study. Information about age, menopausal status, pregnancy,
echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP)
was collected from medical records. The relation between values of SPAP and mPAP
and their agreement for severe disease were assessed. Regression models assessed
the association of gender, menopausal status, and pregnancy history with SPAP
values and the presence of severe SPAP. Results Moderate correlation and good agreement for severe disease were found between mPAP
and SPAP. Mean SPAP values were similar for men and women. A trend toward higher
values of SPAP was found for non-menopausal women compared to men. Higher SPAP
values were found for menopausal compared to non-menopausal women; the values were
non-significant after adjustment for age. Pregnancy history had no association
with SPAP. Menopause and positive pregnancy had no association with severe SPAP.
Conclusion In SPAH patients, neither gender, nor menopausal status, nor pregnancy history
showed independent correlation with SPAP values assessed by echocardiography.
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Affiliation(s)
- Anderson C. Armstrong
- Escola de Medicina Johns Hopkins - Divisão de Cardiologia, Baltimore,
MD
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
- Mailing Address: Anderson C. Armstrong, 600 North Wolfe Street / Blalock
524. Baltimore, MD 21287-0409, USA. E-mail:
| | | | | | - Humberto C. O. Melo
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
| | | | - Eugênio Albuquerque
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
| | - Jeová C. Moraes
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
| | - Antônio M. L. Silva
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
| | - João A. C. Lima
- Escola de Medicina Johns Hopkins - Divisão de Cardiologia, Baltimore,
MD
| | - Dário C. Sobral
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
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27
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Lenna S, Farina AG, Martyanov V, Christmann RB, Wood TA, Farber HW, Scorza R, Whitfield ML, Lafyatis R, Trojanowska M. Increased expression of endoplasmic reticulum stress and unfolded protein response genes in peripheral blood mononuclear cells from patients with limited cutaneous systemic sclerosis and pulmonary arterial hypertension. ACTA ACUST UNITED AC 2013; 65:1357-66. [PMID: 23400395 DOI: 10.1002/art.37891] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 01/24/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH), a common complication of limited cutaneous systemic sclerosis (lcSSc), is associated with alterations of markers of inflammation and vascular damage in peripheral blood mononuclear cells (PBMCs). Endoplasmic reticulum (ER) stress and the unfolded protein response (UPR) have been implicated in autoimmune and inflammatory diseases. The goal of this study was to assess whether markers of ER stress and the UPR are present in PBMCs from lcSSc patients with PAH. METHODS PBMCs were purified from 36 healthy controls, 32 lcSSc patients with PAH, and 34 lcSSc patients without PAH. Gene expression in healthy control PBMCs stimulated with thapsigargin was analyzed by DNA microarray. Genes were validated by quantitative real-time reverse transcription-polymerase chain reaction in PBMCs from healthy controls and lcSSc patients. RESULTS Several ER stress/UPR genes, including BiP, activating transcription factor 4 (ATF-4), ATF-6, and a spliced form of X-box binding protein 1, were up-regulated in PBMCs from lcSSc patients, with the highest levels in patients with PAH. Thapsigargin up-regulated heat-shock proteins (HSPs) and interferon (IFN)-regulated genes in PBMCs from healthy controls. Selected HSP genes (particularly DnaJB1) and IFN-related genes were also found at significantly elevated levels in PBMCs from lcSSc patients, while IFN regulatory factor 4 expression was significantly decreased. There was a positive correlation between DnaJB1 and severity of PAH (measured by pulmonary artery pressure) (r = 0.56, P < 0.05) and between ER stress markers and interleukin-6 levels (r = 0.53, P < 0.0001) in PBMCs from lcSSc patients. CONCLUSION This study demonstrates an association between select ER stress/UPR markers and lcSSc with PAH, suggesting that ER stress and the UPR may contribute to the altered function of circulating immune cells in lcSSc.
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Affiliation(s)
- Stefania Lenna
- Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Strengthening the Case for the Influence of Sleep on Cardiovascular Health in Women. J Womens Health (Larchmt) 2013; 22:475-6. [DOI: 10.1089/jwh.2013.4442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by vasculopathy and excessive collagen production leading to fibrosis of the skin and internal organs. SSc patients are at risk of developing pulmonary hypertension (PH), a debilitating, progressive condition of the pulmonary vasculature that leads to right heart failure and death. This review is an updated summary of the epidemiology and risk factors for PH in SSc. We describe the current literature examining the incidence, prevalence, and demographic and clinical risk factors associated with PH in SSc. We also discuss classical and novel autoantibodies and potential biomarkers that may be helpful in the assessment of risk and prognosis of PH in SSc patients. The ultimate objective in understanding the risk of developing PH in SSc is early diagnosis and early initiation of appropriate therapy with the hope for improved outcomes for patients with SSc-PH.
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Otero R, Elías T, Jara L, Trujillo-Santos J, Bertoletti L, Nauffal D, Ruiz-Ruiz J, Blanco-Molina Á, Monreal M. Factors associated with elevated pulmonary arterial pressure levels on the echocardiographic assessment in patients with prior pulmonary embolism. Thromb Res 2013; 131:e191-5. [PMID: 23466216 DOI: 10.1016/j.thromres.2013.01.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/27/2013] [Accepted: 01/28/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Factors associated with the detection of raised systolic pulmonary artery pressure (sPAP) levels in patients with a prior episode of pulmonary embolism (PE) are not well known. METHODS We used the RIETE Registry database to identify factors associated with the finding of sPAP levels ≥50 mm Hg on trans-thoracic echocardiography, in 557 patients with a prior episode of acute, symptomatic PE. RESULTS Sixty-two patients (11.1%; 95% CI: 8.72-14.1) had sPAP levels ≥50 mm Hg. These patients were more likely women, older, and more likely had chronic lung disease, heart failure, renal insufficiency or leg varicosities than those with PAP levels <50mm Hg. During the index PE event, they more likely had recent immobility, and more likely presented with hypoxemia, increased sPAP levels, atrial fibrillation, or right bundle branch block. On multivariate analysis, women aged ≥70 years (hazard ratio [HR]: 2.0; 95% CI: 1.0-3.7), chronic heart or chronic lung disease (HR: 2.4; 95% CI: 1.3-4.4), atrial fibrillation at PE presentation (HR: 2.8; 95% CI: 1.3-6.1) or varicose veins (HR: 1.8; 95% CI: 1.0-3.3) were all associated with an increased risk to have raised sPAP levels. Chronic heart disease, varicose veins, and atrial fibrillation were independent predictors in women, while chronic heart disease, atrial fibrillation, a right bundle branch block or an S1Q3T3 pattern on the electrocardiogram were independent predictors in men. CONCLUSIONS Women aged ≥70 years more likely had raised sPAP levels than men after a PE episode. Additional variables influencing this risk seem to differ according to gender.
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Affiliation(s)
- Remedios Otero
- Department of Pneumonology, Hospital Universitario Virgen del Rocío, HUVR-IBIS, CIBERES, Sevilla, Spain.
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HLA-B35 and dsRNA induce endothelin-1 via activation of ATF4 in human microvascular endothelial cells. PLoS One 2013; 8:e56123. [PMID: 23441162 PMCID: PMC3575387 DOI: 10.1371/journal.pone.0056123] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 01/05/2013] [Indexed: 12/17/2022] Open
Abstract
Endothelin 1 (ET-1) is a key regulator of vascular homeostasis. We have recently reported that the presence of Human antigen class I, HLA-B35, contributes to human dermal microvascular endothelial cell (HDMEC) dysfunction by upregulating ET-1 and proinflammatory genes. Likewise, a Toll-like receptor 3 (TLR3) ligand, Poly(I:C), was shown to induce ET-1 expression in HDMECs. The goal of this study was to determine the molecular mechanism of ET-1 induction by these two agonists. Because HLA-B35 expression correlated with induction of Binding Immunoglobulin Protein (BiP/GRP78) and several heat shock proteins, we first focused on ER stress and unfolded protein response (UPR) as possible mediators of this response. ER stress inducer, Thapsigargin (TG), HLA-B35, and Poly(I:C) induced ET-1 expression with similar potency in HDMECs. TG and HLA-B35 activated the PERK/eIF2α/ATF4 branch of the UPR and modestly increased the spliced variant of XBP1, but did not affect the ATF6 pathway. Poly(I:C) also activated eIF2α/ATF4 in a protein kinase R (PKR)-dependent manner. Depletion of ATF4 decreased basal expression levels of ET-1 mRNA and protein, and completely prevented upregulation of ET-1 by all three agonists. Additional experiments have demonstrated that the JNK and NF-κB pathways are also required for ET-1 upregulation by these agonists. Formation of the ATF4/c-JUN complex, but not the ATF4/NF-κB complex was increased in the agonist treated cells. The functional role of c-JUN in responses to HLA-B35 and Poly(I:C) was further confirmed in ET-1 promoter assays. This study identified ATF4 as a novel activator of the ET-1 gene. The ER stress/UPR and TLR3 pathways converge on eIF2α/ATF4 during activation of endothelial cells.
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Umar S, Rabinovitch M, Eghbali M. Estrogen paradox in pulmonary hypertension: current controversies and future perspectives. Am J Respir Crit Care Med 2012; 186:125-31. [PMID: 22561960 DOI: 10.1164/rccm.201201-0058pp] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although the incidence of pulmonary hypertension is higher in female patients, numerous experimental studies have demonstrated better outcome in female animals, exacerbation of the disease after ovariectomy, and a strong protective effect of estrogen: a phenomenon known as the "estrogen paradox" of pulmonary hypertension. On the other hand, some clinical studies have indirectly linked estrogen to increased risk of portopulmonary hypertension, whereas others implicate increased estrogen metabolism and high levels of certain estrogen metabolites in promoting pulmonary vascular remodeling in familial pulmonary arterial hypertension. In this review we investigate the estrogen paradox through highlighting the differential receptor-mediated effects of estrogen. Although estrogen and estrogen receptor-based therapies have shown promise in rescuing preexisting pulmonary hypertension in animals, their role is yet to be defined in humans.
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Affiliation(s)
- Soban Umar
- Division of Molecular Medicine, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, USA
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Abstract
PURPOSE OF REVIEW The review provides an update of the epidemiology, pathogenesis, risk factors, screening and treatment of pulmonary arterial hypertension in systemic sclerosis. RECENT FINDINGS Several recent studies have investigated the utility of several noninvasive screening methods and the propagation of new treatments promise the clinician better outcomes than the current median survival time of 1 year for patients with scleroderma-related pulmonary arterial hypertension. SUMMARY Pulmonary hypertension is a frequent cause of morbidity and mortality in patients with systemic sclerosis. This review discusses the recent changes in the classification of pulmonary hypertension, especially the significance for the rheumatologist. A high clinical suspicion should be maintained, even in early scleroderma. Despite progress in echocardiography and biomarkers, right heart catheterization remains the only test that can diagnose pulmonary hypertension and differentiate pulmonary veno-occlusive disease from pulmonary arterial hypertension. The differentiation of these causes of pulmonary hypertension in the scleroderma patient is essential because the initiation of pulmonary vasodilators in veno-occlusive disease often leads to increased mortality. The role of screening with serum biomarkers and noninvasive testing remains controversial, and in this review we discuss the controversies and new recommendations in detail.
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Sioulas VD, Gracia CR. Ovarian stimulation and embryo banking for fertility preservation in a woman with severe mixed connective tissue disease: Is it safe? J Assist Reprod Genet 2011; 29:271-5. [PMID: 22205344 DOI: 10.1007/s10815-011-9697-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 12/13/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To report the first case of using assisted reproductive technologies (ART) for fertility preservation in a patient with mixed connective tissue disease (MCTD), secondary pulmonary hypertension (PH) and antiphospholipid syndrome (APS). DESIGN Case-report and review of the literature. SETTING Academic infertility practice and tertiary care center. PATIENT(S) A 25-year-old woman with MCTD, complicated with PH and APS, who was scheduled for gonadotoxic therapy INTERVENTION(S) Controlled ovarian hyperstimulation, egg retrieval, embryo banking. MAIN OUTCOME MEASURE(S) Successful ART cycle leading to embryo banking without worsening her underlying disease. RESULT(S) Following successful embryo cryopreservation, the patient experienced respiratory failure and other severe complications, resulting in a prolonged hospital stay. CONCLUSION(S) Controlled ovarian hyperstimulation for embryo banking in women with MCTD, PH and APS may pose a risk for potentially catastrophic complications. A multidisciplinary approach to these patients is necessary to optimize the outcomes of such procedures. More data are needed regarding the safety of fertility preservation technologies in patients with complex medical diseases.
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Affiliation(s)
- Vasileios D Sioulas
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
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Abstract
Pulmonary involvement is second in frequency only to esophageal involvement as a visceral complication of systemic sclerosis (SSc) and has surpassed renal involvement as the most common cause of death. Interstitial lung disease and pulmonary vascular disease, particularly pulmonary arterial hypertension, are the most commonly encountered types of lung involvement. Chronic aspiration, airway disease, neuromuscular weakness, extrinsic pulmonary restrictive pathology, pleural effusions, pneumothorax, and lung cancer cause clinically significant disease and occur commonly enough to be routinely considered in the assessment of the SSc patient with respiratory symptoms. Affected patients have a significantly worse prognosis than patients with SSc who are free of pulmonary involvement.
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MESH Headings
- Familial Primary Pulmonary Hypertension
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/pathology
- Hypertension, Pulmonary/therapy
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/epidemiology
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/pathology
- Lung Diseases, Interstitial/therapy
- Lung Neoplasms/etiology
- Lung Neoplasms/pathology
- Prevalence
- Prognosis
- Respiratory Aspiration/etiology
- Respiratory Aspiration/pathology
- Risk Factors
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/epidemiology
- Scleroderma, Systemic/pathology
- Scleroderma, Systemic/therapy
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Affiliation(s)
- Jérôme Le Pavec
- Université Paris-Sud, Centre National de Référence de l'Hypertension Artérielle Pulmonaire, Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine-Béclère, Assistance Publique, Hôpitaux de Paris, Clamart, France.
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Umar S, Iorga A, Matori H, Nadadur RD, Li J, Maltese F, van der Laarse A, Eghbali M. Estrogen rescues preexisting severe pulmonary hypertension in rats. Am J Respir Crit Care Med 2011; 184:715-23. [PMID: 21700911 DOI: 10.1164/rccm.201101-0078oc] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Pulmonary hypertension (PH) is characterized by progressive increase in pulmonary artery pressure leading to right ventricular (RV) hypertrophy, RV failure, and death. Current treatments only temporarily reduce severity of the disease, and an ideal therapy is still lacking. OBJECTIVES Estrogen pretreatment has been shown to attenuate development of PH. Because PH is not often diagnosed early, we examined if estrogen can rescue preexisting advanced PH. METHODS PH was induced in male rats with monocrotaline (60 mg/kg). At Day 21, rats were either treated with 17-β estradiol or estrogen (E2, 42.5 μg/kg/d), estrogen receptor-β agonist (diarylpropionitrile, 850 μg/kg/d), or estrogen receptor α-agonist (4,4',4"-[4-Propyl-(1H)-pyrazole-1,3,5-triyl] trisphenol, 850 μg/kg/d) for 10 days or left untreated to develop RV failure. Serial echocardiography, cardiac catheterization, immunohistochemistry, Western blot, and real-time polymerase chain reaction were performed. MEASUREMENTS AND MAIN RESULTS Estrogen therapy prevented progression of PH to RV failure and restored lung and RV structure and function. This restoration was maintained even after removal of estrogen at Day 30, resulting in 100% survival at Day 42. Estradiol treatment restored the loss of blood vessels in the lungs and RV. In the presence of angiogenesis inhibitor TNP-470 (30 mg/kg) or estrogen receptor-β antagonist (PHTPP, 850 μg/kg/d), estrogen failed to rescue PH. Estrogen receptor-β selective agonist was as effective as estrogen in rescuing PH. CONCLUSIONS Estrogen rescues preexisting severe PH in rats by restoring lung and RV structure and function that are maintained even after removal of estrogen. Estrogen-induced rescue of PH is associated with stimulation of cardiopulmonary neoangiogenesis, suppression of inflammation, fibrosis, and RV hypertrophy. Furthermore, estrogen rescue is likely mediated through estrogen receptor-β.
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Affiliation(s)
- Soban Umar
- University of California Los Angeles School of Medicine, Department of Anesthesiology, BH-160CHS, 650 Charles Young Drive, Los Angeles, CA 90095-7115, USA
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Lung involvement in systemic sclerosis. Presse Med 2010; 40:e3-e17. [PMID: 21195581 DOI: 10.1016/j.lpm.2010.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 08/25/2010] [Accepted: 08/27/2010] [Indexed: 01/22/2023] Open
Abstract
Scleroderma is a multisystem disease characterized by a severe inflammatory process and exuberant fibrosis. Lung involvement is a frequent complication and a leading cause of morbidity and mortality in this syndrome. Two major pulmonary syndromes are associated with scleroderma; a pulmonary vascular disorder evolving over time into relatively isolated pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD). Each syndrome, when present, is a cause of morbidity and significantly reduces survival of scleroderma patients when compared to patients free of lung complication. When pulmonary hypertension and ILD are combined, survival is further reduced. Current therapy appears to have no meaningful effect on either condition and, thus, there is a need for better understanding of underlying pathogenic mechanisms. This review focuses on clinical, diagnostic, and therapeutic features of PAH and ILD as well as other frequent but less debilitating lung complications of scleroderma.
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Tofovic SP. Estrogens and development of pulmonary hypertension: interaction of estradiol metabolism and pulmonary vascular disease. J Cardiovasc Pharmacol 2010; 56:696-708. [PMID: 20881610 PMCID: PMC3027839 DOI: 10.1097/fjc.0b013e3181f9ea8d] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe pulmonary arterial hypertension (PAH) is characterized by clustered proliferation of endothelial cells (ECs) in the lumina of small size pulmonary arteries resulting in concentric obliteration of the lumina and formation of complex vascular structures known as plexiform lesions. This debilitating disease occurs more frequently in women, yet both animal studies in classical models of PAH and limited clinical data suggest protective effects of estrogens: the estrogen paradox in pulmonary hypertension. Little is known about the role of estrogens in PAH, but one line of evidence strongly suggests that the vascular protective effects of 17β-estradiol (estradiol; E2) are mediated largely by its downstream metabolites. Estradiol is metabolized to 2-hydroxyestradiol (2HE) by CYP1A1/CYP1B1, and 2HE is converted to 2-methoxyestradiol (2ME) by catechol-O-methyl transferase. 2ME is extensively metabolized to 2-methoxyestrone, a metabolite that lacks biologic activity, but which may be converted back to 2ME. 2ME has no estrogenic activity, and its effects are mediated by estrogen receptors–independent mechanism(s). Notably, in systemic and pulmonary vascular ECs, smooth muscle cells, and fibroblasts, 2ME exerts stronger antimitotic effects than E2 itself. E2 and 2ME, despite having similar effects on other cardiovascular cells, have opposing effects on ECs; that is, in ECs, E2 is promitogenic, proangiogenic, and antiapoptotic, whereas 2ME is antimitogenic, antiangiogenic, and proapoptotic. This may have significant ramifications in severe PAH that involves uncontrolled proliferation of monoclonal apoptosis-resistant ECs. Based on its cellular effects, 2ME should be expected to attenuate the progression of disease and provide protection in severe PAH. In contrast, E2, due to its mitogenic, angiogenic, and antiapoptotic effects (otherwise desirable in normal quiescent ECs), may even adversely affect endothelial remodeling in PAH, and this may be even more significant if the E2's effects on injured endothelium are not opposed by 2ME (eg, in the event of reduced E2 conversion to 2ME due to hypoxia, inflammation, drugs, environmental factors, or genetic polymorphism of metabolizing enzymes). This review focuses on the effects of estrogens and their metabolites on pulmonary vascular pathobiology and the development of experimental PAH and offers potential explanation for the estrogen paradox in PAH. Furthermore, we propose that unbalanced estradiol metabolism may lead to the development of PAH. Recent animal data and studies in patients with PAH support this concept.
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Affiliation(s)
- Stevan P Tofovic
- Division of Pulmonary, Allergy and Critical Care Medicine, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Bridge side 542, 100 Technology Drive, Pittsburgh, PA 15219, USA.
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Galasso D, Mazzuca S, Marigliano N. Algoritmo diagnostico della sclerodermia. Early Systemic Sclerosis: criteri di definizione e valutazione diagnostica. ITALIAN JOURNAL OF MEDICINE 2010. [DOI: 10.1016/j.itjm.2010.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Sakao S, Tanabe N, Tatsumi K. The estrogen paradox in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2010; 299:L435-8. [PMID: 20656892 DOI: 10.1152/ajplung.00057.2010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Idiopathic pulmonary arterial hypertension (PAH) is a disabling condition characterized by PA vasoconstriction and remodeling as well as in situ thrombosis and eventual right heart failure. Idiopathic PAH occurs more frequently in females than in males. The female:male ratio is 1.64 ∼ 3.88:1. Although endogenous sex hormones including estrogen have been suggested to account for the observed gender differences in PAH, a precise pathobiology for the gender differences remains uncertain. Recent studies demonstrated that estrogen exerts beneficial effects on the pulmonary vasculature. However, it seems to contradict the female predominance that is observed in idiopathic PAH. Moreover, Sweeney and Voelkel (Sweeney L and Voelkel NF. Eur J Med Res 14: 433-442, 2009) showed that early and long-term estrogen exposure might be correlated with an increased risk of the development of PAH. Here we ask the question: Is estrogen a friend or a foe? According to accumulating evidence, we postulate that the different effects of estrogens on different target cells could account for this paradox, i.e., estrogens may exert beneficial effects only on the increased muscularization of vessel walls, but not on phenotypically altered endothelial cells. The effects of estrogens on the pulmonary vasculature are potent and complex, yet not fully understood. A better mechanistic understanding may allow for future therapeutic interventions in patients with PAH.
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Lenna S, Townsend DM, Tan FK, Kapanadze B, Markiewicz M, Trojanowska M, Scorza R. HLA-B35 upregulates endothelin-1 and downregulates endothelial nitric oxide synthase via endoplasmic reticulum stress response in endothelial cells. THE JOURNAL OF IMMUNOLOGY 2010; 184:4654-61. [PMID: 20335527 DOI: 10.4049/jimmunol.0903188] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The presence of the HLA-B35 allele has emerged as an important risk factor for the development of isolated pulmonary hypertension in patients with scleroderma, however the mechanisms underlying this association have not been fully elucidated. The goal of our study was to determine the molecular mechanisms that mediate the biological effects of HLA-B35 in endothelial cells (ECs). Our data demonstrate that HLA-B35 expression at physiological levels via adenoviral vector resulted in significantly increased endothelin-1 (ET-1) and a significantly decreased endothelial NO synthase (eNOS), mRNA, and protein levels. Furthermore, HLA-B35 greatly upregulated expression of chaperones, including heat shock proteins (HSPs) HSP70 (HSPA1A and HSPA1B) and HSP40 (DNAJB1 and DNAJB9), suggesting that HLA-B35 induces the endoplasmic reticulum (ER) stress and unfolded protein response in ECs. Examination of selected mediators of the unfolded protein response, including H chain binding protein (BiP; GRP78), C/Ebp homologous protein (CHOP; GADD153), endoplasmic reticulum oxidase, and protein disulfide isomerase has revealed a consistent increase of BiP expression levels. Accordingly, thapsigargin, a known ER stress inducer, stimulated ET-1 mRNA and protein levels in ECs. This study suggests that HLA-B35 could contribute to EC dysfunction via ER stress-mediated induction of ET-1 in patients with pulmonary hypertension.
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Affiliation(s)
- Stefania Lenna
- Arthritis Center, Boston University School of Medicine, Boston, MA 02118, USA
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Hachulla E, Launay D, Mouthon L, Sitbon O, Berezne A, Guillevin L, Hatron PY, Simonneau G, Clerson P, Humbert M. Is Pulmonary Arterial Hypertension Really a Late Complication of Systemic Sclerosis? Chest 2009; 136:1211-1219. [DOI: 10.1378/chest.08-3042] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hachulla E, de Groote P, Gressin V, Sibilia J, Diot E, Carpentier P, Mouthon L, Hatron PY, Jego P, Allanore Y, Tiev KP, Agard C, Cosnes A, Cirstea D, Constans J, Farge D, Viallard JF, Harle JR, Patat F, Imbert B, Kahan A, Cabane J, Clerson P, Guillevin L, Humbert M. The three-year incidence of pulmonary arterial hypertension associated with systemic sclerosis in a multicenter nationwide longitudinal study in France. ACTA ACUST UNITED AC 2009; 60:1831-9. [PMID: 19479881 DOI: 10.1002/art.24525] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE An algorithm for the detection of pulmonary arterial hypertension (PAH), based on the presence of dyspnea and the findings of Doppler echocardiographic evaluation of the velocity of tricuspid regurgitation (VTR) and right-sided heart catheterization (RHC), which was applied in a large multicenter systemic sclerosis (SSc) population, estimated the prevalence of PAH to be 7.85%. The aim of this observational study was to investigate the incidence of PAH and pulmonary hypertension (PH) during a 3-year followup of patients from the same cohort (the ItinérAIR-Sclérodermie Study). METHODS Patients with SSc and without evidence of PAH underwent evaluation for dyspnea and VTR at study entry and during subsequent visits. Patients in whom PAH was suspected because of a VTR of 2.8-3.0 meters/second and unexplained dyspnea or a VTR of >3.0 meters/second underwent RHC to confirm the diagnosis. RESULTS A total of 384 patients were followed up for a mean+/-SD of 41.03+/-5.66 months (median 40.92 months). At baseline, 86.7% of the patients were women, and the mean+/-SD age of the patients was 53.1+/-12.0 years. The mean+/-SD duration of SSc at study entry was 8.7+/-7.6 years. After RHC, PAH was diagnosed in 8 patients, postcapillary PH in 8 patients, and PH associated with severe pulmonary fibrosis in 2 patients. The incidence of PAH was estimated to be 0.61 cases per 100 patient-years. Two patients who exhibited a mean pulmonary artery pressure of 20-25 mm Hg at baseline subsequently developed PAH. CONCLUSION The estimated incidence of PAH among patients with SSc was 0.61 cases per 100 patient-years. The high incidence of postcapillary PH highlights the value of RHC in investigating suspected PAH.
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Affiliation(s)
- Eric Hachulla
- Hôpital Claude Huriez, Department of Internal Medicine, National Reference Center for Scleroderma, and University of Lille, Lille, France.
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Beretta L, Caronni M, Origgi L, Ponti A, Santaniello A, Scorza R. Hormone replacement therapy may prevent the development of isolated pulmonary hypertension in patients with systemic sclerosis and limited cutaneous involvement. Scand J Rheumatol 2009; 35:468-71. [PMID: 17343256 DOI: 10.1080/03009740600844498] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Isolated pulmonary hypertension (iPHT) is a near-fatal consequence of systemic sclerosis (SSc); in female patients, the risk of its development is increased during the post-menopausal period, when the protective effects of oestrogens on the endothelium decrease. In many animal and human models, hormone replacement therapy (HRT) and oestrogen administration proved efficacious in counteracting many mechanisms that might be implicated in the pathogenesis of iPHT. Accordingly, it has been hypothesized that HRT might help to prevent the development of iPHT. METHODS A retrospective cohort study was conducted on 61 SSc patients with the limited cutaneous form of the disease and no sign of pulmonary hypertension on echocardiogram (pulmonary artery pressure, PAP > 35 mmHg) at the time of menopause. All the patients had to be stably treated with calcium-channel blockers and not to have risk factors for secondary PHT throughout the duration of the observational period. RESULTS Twenty patients (32.8%) received HRT for a mean of 6.7 +/- 3.7 years. None of these patients developed iPHT after a mean of 7.2 +/- 3.5 years from menopause, whereas eight out of 41 patients not receiving HRT (19.5%) developed iPHT after a similar time period (7.5 +/- 3.9 years, p = 0.032). These rates were not explained by differences between the two groups with respect to autoantibodies, age, age at onset of SSc, diffusing capacity of the lung for carbon monoxide (DLCO) at menopause, or duration of therapy with calcium-channel blockers. CONCLUSION HRT administration may be effective in SSc post-menopausal women, preventing the development of iPHT.
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Affiliation(s)
- L Beretta
- Unit of Immunology, IRCCS Maggiore Policlinico Hospital, University of Milan, Milan, Italy
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Kampolis C, Plastiras SC, Vlachoyiannopoulos PG, Moyssakis I, Tzelepis GE. The presence of anti‐centromere antibodies may predict progression of estimated pulmonary arterial systolic pressure in systemic sclerosis. Scand J Rheumatol 2009; 37:278-83. [DOI: 10.1080/03009740801978871] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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2-methoxyestradiol attenuates bleomycin-induced pulmonary hypertension and fibrosis in estrogen-deficient rats. Vascul Pharmacol 2009; 51:190-7. [PMID: 19540933 DOI: 10.1016/j.vph.2009.06.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 05/01/2009] [Accepted: 06/09/2009] [Indexed: 12/13/2022]
Abstract
Pulmonary hypertension (PH) is a common and life-threatening complication of pulmonary fibrosis. Estradiol (E2) is protective in experimental PH, and its non-estrogenic metabolite 2-methoxyestradiol (2ME) prevents the development and retards the progression of monocrotaline-induced PH in male and female rats. However, the effects of E2 and 2ME on pulmonary fibrosis and associated PH have not been examined. Therefore, we compared the growth inhibitory effects of E2 and 2ME in human lung fibroblasts (hLFs) and pulmonary vascular smooth muscle cells (hPASMCs), and we investigated the effects of estrogen deficiency and 2ME on bleomycin-induced pulmonary fibrosis and PH. Intact and ovariectomized (OVX) female Sprague-Dawley rats were administered intratracheally either saline or bleomycin (15IU/kg), and a subset of OVX bleomycin-treated rats received 2ME (10microg/kg/h) for 21days. Estradiol had only limited inhibitory effects on growth in hPASMCs and no effect in hLFs, whereas 2ME exhibited strong and concentration-dependent (1-10microM) antimitogenic effects in both cell types. Bleomycin caused lung injury/PH (significantly increased lung and right ventricle (RV) weights, RV peak systolic pressure (RVPSP), and RV/left ventricle + septum ratio (RV/LV + S); caused medial hypertrophy and adventitial widening of pulmonary arteries; induced marked focal/diffuse fibrosis with diffuse infiltration of inflammatory (ED1+) cells; and resulted in 30% mortality). OVX exacerbated the disease and increased mortality (to 75%); whereas 2ME tended to reduce mortality (55.5%) and in surviving animals reduced RVPSP and RV/LV + S ratio, and attenuated vascular remodeling, pulmonary inflammation and fibrosis. This study suggests that 2ME may have protective effects in bleomycin-induced PH and fibrosis. Further investigation of 2ME in pulmonary fibrosis and PH is warranted.
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Nishida M, Hasegawa Y, Tanida I, Nakagawa E, Inaji H, Ohkita M, Matsumura Y. Preventive effects of raloxifene, a selective estrogen receptor modulator, on monocrotaline-induced pulmonary hypertension in intact and ovariectomized female rats. Eur J Pharmacol 2009; 614:70-6. [PMID: 19379725 DOI: 10.1016/j.ejphar.2009.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 04/03/2009] [Accepted: 04/09/2009] [Indexed: 01/20/2023]
Abstract
We investigated whether the chronic treatment with raloxifene, a selective estrogen receptor modulator, prevents the development of monocrotaline-induced pulmonary hypertension in ovary-intact and ovariectomized female rats. Four weeks after a single subcutaneous injection of monocrotaline (60 mg/kg), right ventricular systolic pressure, right ventricle-to-left ventricle plus septal weight ratio, pulmonary arterial medial thickening and endothelin-1 levels in right ventricular tissue increased significantly in both female rats, compared with saline-treated control rats. These monocrotaline-induced alterations were much greater in ovariectomized rats than the changes in intact females. Daily oral administration of raloxifene (10 mg/kg/day for 4 weeks) significantly attenuated the increase in right ventricular systolic pressure to the same levels in both groups of animals, but raloxifene suppressed the increases in right ventricle-to-left ventricle plus septal weight ratio and pulmonary arterial medial thickness more efficiently in ovariectomized females than the case with intact females. In addition, raloxifene completely suppressed the increase in right ventricular endothelin-1 levels in ovariectomized rats, but not in intact females. These data suggest that chronic treatment with raloxifene effectively prevents the development of monocrotaline-induced pulmonary hypertension in ovariectomized female rats than in intact females, at least in part, by suppressing right ventricular endothelin-1 overproduction.
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Affiliation(s)
- Masahiro Nishida
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
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Dvornyk V, Liu Y, Lu Y, Shen H, Lappe JM, Lei S, Recker RR, Deng H. Effect of menopause on gene expression profiles of circulating monocytes: a pilot in vivo microarray study. J Genet Genomics 2009; 34:974-83. [PMID: 18037134 DOI: 10.1016/s1673-8527(07)60110-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 08/09/2007] [Indexed: 11/28/2022]
Abstract
Menopause is one of the key physiological events in the female life and can increase the risk for a number of complex autoimmune, neurodegenerative, metabolic, and cardiovascular disorders. Circulating monocytes can differentiate into various cell types and play an important role in tissue morphogenesis and immune response. We studied gene expression profiles of peripheral blood monocytes in healthy pre- and postmenopausal women using Affymetrix Human U133A GeneChip array that contains probes for approximately 14,500 genes. Comparative analyses between the samples showed that 20 genes were up- and 20 were down-regulated. Of these genes, 28 were classified into six major GO categories relevant to such biological processes as the cell proliferation, immune response, cellular metabolism, and the others. The remaining 12 genes have yet unidentified biological functions. Our results support the hypothesis that functional state of circulating monocytes is indeed affected by menopause, and resulting changes may be determined through the genomewide gene expression profiling. Several differentially expressed genes identified in this study may be candidates for further studies of menopause-associated systemic autoimmune, neurodegenerative, and cardiovascular disorders. Our study is only the first attempt in this direction, but it lays a basis for further research.
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Affiliation(s)
- Volodymyr Dvornyk
- Laboratory of Molecular and Statistical Genetics, College of Life Sciences, Hunan Normal University, Changsha 410081, China
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The effects of estrogen on pulmonary artery vasoreactivity and hypoxic pulmonary vasoconstriction: potential new clinical implications for an old hormone. Crit Care Med 2008; 36:2174-83. [PMID: 18552699 DOI: 10.1097/ccm.0b013e31817d1a92] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent research recognizes gender as a major factor determining the outcomes in trauma, ischemia/reperfusion, shock, and sepsis. In particular, estrogen has been demonstrated to exert protective effects in these settings. The effects of estrogens on the pulmonary vasculature are potent and complex yet not fully understood. A better mechanistic understanding may allow for future therapeutic interventions in pulmonary hypertensive crises after cardiac surgery and during acute lung injury as well as in patients with pulmonary arterial hypertension. DATA SOURCES AND STUDY SELECTION We searched PubMed for articles in the English language by using the search words pulmonary hypertension, hypoxic pulmonary vasoconstriction, estrogen, estradiol, inflammation, acute injury, ischemia reperfusion, sepsis, trauma, and burns. These were used in various combinations. We read the abstracts of the relevant titles to confirm their relevance, and the full articles were then extracted. References from extracted articles were checked for any additional relevant articles. DATA EXTRACTION AND SYNTHESIS Estrogen plays a critical role in the improved outcomes in the settings of trauma, shock, sepsis, myocardial ischemia/reperfusion, and acute lung injury. Several new mechanisms of action have been identified. In the pulmonary vasculature, estrogen causes vasodilation and attenuates the vasoconstrictor response to various stimuli, including hypoxia. This is mediated by increased levels of prostacyclin and nitric oxide as well as decreased levels of endothelin-1. In addition, effects on intracellular signaling pathways and several kinases as well as anti-inflammatory mechanisms may contribute as well. Recent studies suggest the importance of acute, nongenomic effects. CONCLUSION Estrogen exerts a variety of nongenomic actions, which may allow for future therapeutic interventions in pulmonary vascular disease.
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