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Zeng C, Liu J, Zheng X, Hu X, He Y. Prostaglandin and prostaglandin receptors: present and future promising therapeutic targets for pulmonary arterial hypertension. Respir Res 2023; 24:263. [PMID: 37915044 PMCID: PMC10619262 DOI: 10.1186/s12931-023-02559-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH), Group 1 pulmonary hypertension (PH), is a type of pulmonary vascular disease characterized by abnormal contraction and remodeling of the pulmonary arterioles, manifested by pulmonary vascular resistance (PVR) and increased pulmonary arterial pressure, eventually leading to right heart failure or even death. The mechanisms involved in this process include inflammation, vascular matrix remodeling, endothelial cell apoptosis and proliferation, vasoconstriction, vascular smooth muscle cell proliferation and hypertrophy. In this study, we review the mechanisms of action of prostaglandins and their receptors in PAH. MAIN BODY PAH-targeted therapies, such as endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, activators of soluble guanylate cyclase, prostacyclin, and prostacyclin analogs, improve PVR, mean pulmonary arterial pressure, and the six-minute walk distance, cardiac output and exercise capacity and are licensed for patients with PAH; however, they have not been shown to reduce mortality. Current treatments for PAH primarily focus on inhibiting excessive pulmonary vasoconstriction, however, vascular remodeling is recalcitrant to currently available therapies. Lung transplantation remains the definitive treatment for patients with PAH. Therefore, it is imperative to identify novel targets for improving pulmonary vascular remodeling in PAH. Studies have confirmed that prostaglandins and their receptors play important roles in the occurrence and development of PAH through vasoconstriction, vascular smooth muscle cell proliferation and migration, inflammation, and extracellular matrix remodeling. CONCLUSION Prostacyclin and related drugs have been used in the clinical treatment of PAH. Other prostaglandins also have the potential to treat PAH. This review provides ideas for the treatment of PAH and the discovery of new drug targets.
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Affiliation(s)
- Cheng Zeng
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No.139, Middle Ren-min Road, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jing Liu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No.139, Middle Ren-min Road, Changsha, 410011, Hunan Province, People's Republic of China
| | - Xialei Zheng
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No.139, Middle Ren-min Road, Changsha, 410011, Hunan Province, People's Republic of China
| | - Xinqun Hu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No.139, Middle Ren-min Road, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Yuhu He
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No.139, Middle Ren-min Road, Changsha, 410011, Hunan Province, People's Republic of China.
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Nowrouzi-Sohrabi P, Tabrizi R, Hessami K, Shabani-Borujeni M, Hosseini-Bensenjan M, Rezaei S, Jalali M, Keshavarz P, Ahmadizar F. The effects of beraprost sodium on renal function and cardiometabolic profile in patients with diabetes mellitus: a systematic review and meta-analysis of clinical trials. Int Urol Nephrol 2021; 54:111-120. [PMID: 34019221 DOI: 10.1007/s11255-021-02887-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to assess renal function and cardiometabolic biomarkers after treatment with beraprost sodium in patients with diabetes mellitus. METHODS We systemically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library up to August 2020. Statistical heterogeneities were computed using Cochrane's Q test and I2 test. A fixed- or random-effects model was used to calculate the weighted mean difference (WMD) and corresponding 95% confidence intervals (CI). RESULTS From 341citations, seven trials were included into our meta-analysis. Our findings demonstrated that beraprost sodium intake significantly decreased blood urea nitrogen (BUN) (WMD = -5.62, 95% CI [-8.49, -2.74], P < 0.001) and cystatin C (WMD = -0.57, 95% CI [-0.68, -0.46], P < 0.001). Beraprost sodium intake had no significant effect on fasting blood sugar (FBS), hemoglobin A1c (HbA1c), cholesterol (TC), triglycerides (TG), HDL-C, LDL-C, systolic blood pressure (SBP), diastolic blood pressure (DBP), and creatinine (Cr) in patients with diabetes receiving beraprost sodium in comparison with the controls. CONCLUSION Our meta-analysis revealed that beraprost sodium administration significantly decreased BUN and cystatin C levels in patients with diabetes. However, no significant effect was observed on the cardiometabolic profile.
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Affiliation(s)
- Peyman Nowrouzi-Sohrabi
- Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran. .,Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Kamran Hessami
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Shabani-Borujeni
- Faculty of Pharmacy, Department of Clinical Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahla Rezaei
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Nutrition Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Jalali
- Nutrition Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pedram Keshavarz
- Department of Radiology, Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fariba Ahmadizar
- Department of Epidemiology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
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Wang L, Zhu X, Zhao LP, Wang M, Liu X, Chen Y, Chen J, Xu W. Effect of beraprost on pulmonary hypertension due to left ventricular systolic dysfunction. Medicine (Baltimore) 2019; 98:e14965. [PMID: 31008926 PMCID: PMC6494404 DOI: 10.1097/md.0000000000014965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Beraprost is used to treat peripheral chronic arterial occlusive disease. However, the efficacy and safety of beraprost in patients with pulmonary hypertension (PH) due to left ventricular systolic dysfunction (PH-HFrEF) remains unknown. The primary objective of this study was to determine the effects of beraprost on PH-HFrEF.We prospectively recruited patients with PH-HFrEF as determined by echocardiography and right cardiac catheterization. Beraprost sodium was given orally (1 μg/kg/d) added to the usual treatment, and patients were evaluated at 1-year follow-up.Twenty-five patients were recruited with baseline systolic pulmonary artery pressure (PAP) of 49.5 ± 10.8 mm Hg. Systolic PAP results at 3, 6, 9, and 12 months were 39.1 ± 8.1, 30.4 ± 5.2, 27.7 ± 3.0, and 27.0 ± 4.7 mm Hg, respectively, which were all significantly lower than systolic PAP at baseline (P < .05). Left ventricular ejection fraction results at 6 months (43.5 ± 7.0%), 9 months (47.0 ± 5.5%), and 12 months (48.2 ± 4.8%) were significantly higher than at baseline (34.7 ± 9.2%) (P < .05). Six-minute walking distance at 3 months (282.8 ± 80.6 m), 6 months (367.1 ± 81.2 m), 9 months (389.8 ± 87.1 m), and 12 months (395.7 ± 83.4 m) increased with time, and all were significantly higher than baseline (190.1 ± 75.5 m) (P < .05). One patient developed atrial fibrillation and recovered to sinus rhythm after intravenous administration of amiodarone. There were no instances of cardiac-related death, severe bleeding, or severe impairment of liver function.Routine oral administration of beraprost sodium added to the usual treatment may improve cardiopulmonary hemodynamics and exercise capacityin patients with PH-HFrEF.
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Affiliation(s)
- Li Wang
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
- Emergency Department, The Seventh People's Hospital of Suzhou, China
| | - Xinyi Zhu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Liang-Ping Zhao
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Maosong Wang
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Xiang Liu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Yuqi Chen
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - JianChang Chen
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - WeiTing Xu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
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Cannillo M, D'Ascenzo F, Grosso Marra W, Cerrato E, Calcagno A, Omedè P, Bonora S, Mancone M, Vizza D, DiNicolantonio JJ, Pianelli M, Barbero U, Gili S, Annone U, Raviola A, Salera D, Mistretta E, Vilardi I, Colaci C, Abbate A, Zoccai GB, Moretti C, Gaita F. Heart failure in patients with human immunodeficiency virus: a review of the literature. J Cardiovasc Med (Hagerstown) 2016; 16:383-9. [PMID: 25058690 DOI: 10.2459/jcm.0000000000000168] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Coronary artery disease represents the leading cause of death for HIV patients treated with highly active antiretroviral treatment. Besides this, an extensive amount of data related to the risk of overt heart failure and consequently of atrial fibrillation and sudden cardiac death (SCD) in this population has been reported. It seems that persistent deregulation of immunity in HIV-infected patients is a common pathway related to both of these adverse clinical outcomes. Despite the fact that atrial fibrillation and heart failure are relatively common in HIV, few data are reported about screening, diagnosis, and potential treatment of these conditions.
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Affiliation(s)
- Margherita Cannillo
- aCittà Della Salute e Della Scienza, Division of Cardiology, University of Turin, Italy bUnit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy cDepartment of Cardiovascular and Pulmonary Sciences, Policlinico Umberto I 'Sapienza', University of Rome, Italy dWegmans Pharmacy, Ithaca, NY, USA eVCU Pauley Heart Center, Richmond, VA, USA
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Use of outcome measures in pulmonary hypertension clinical trials. Am Heart J 2015; 170:419-29.e3. [PMID: 26385024 DOI: 10.1016/j.ahj.2015.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of surrogate measures in pulmonary hypertension (PH) clinical trials and how it relates to clinical practice. BACKGROUND Studies of pulmonary arterial hypertension (PAH) employ a variety of surrogate measures in addition to clinical events because of a small patient population, participant burden, and costs. The use of these measures in PH drug trials is poorly defined. METHODS We searched PubMed/MEDLINE/Embase for randomized or prospective cohort PAH clinical treatment trials from 1985 to 2013. Extracted data included intervention, trial duration, study design, patient characteristics, and primary and secondary outcome measures. To compare with clinical practice, we assessed the use of surrogate measures in a clinical sample of patients on PH medications at Duke University Medical Center between 2003 and 2014. RESULTS Between 1985 and 2013, 126 PAH trials were identified and analyzed. Surrogate measures served as primary endpoints in 119 trials (94.0%). Inclusion of invasive hemodynamics decreased over time (78.6%, 75.0%, 52.2%; P for trend = .02), while functional testing (7.1%, 60.0%, 81.5%; P for trend < .0001) and functional status or quality of life (0%, 47.6%, 62.8%; P for trend < .0001) increased in PAH trials over the same time periods. Echocardiography data were reported as a primary or secondary outcome in 32 trials (25.4%) with increased use from 1985-1994 to 1995-2004 (7.1% vs 35.0%, P = .04), but the trend did not continue to 2005-2013 (25.0%). In comparison, among 450 patients on PAH therapies at our institution between 2003 and 2013, clinical assessments regularly incorporated serial echocardiography and 6-minute walk distance tests (92% and 95% of patients, respectively) and repeat measurement of invasive hemodynamics (46% of patients). CONCLUSIONS The majority of PAH trials have utilized surrogate measures as primary endpoints. The use of these surrogate endpoints has evolved significantly over time with increasing use of patient-centered endpoints and decreasing or stable use of imaging and invasive measures. In contrast, imaging and invasive measures are commonly used in contemporary clinical practice. Further research is needed to validate and standardize currently used measures.
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Dewachter L, Naeije R. Beraprost sodium MR for the treatment of pulmonary arterial hypertension. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.961422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kang BJ, Lee SD, Oh YM, Lee JS. Improved survival of Korean patients with idiopathic pulmonary arterial hypertension after the introduction of targeted therapies. Heart Lung 2014; 43:561-8. [PMID: 25151431 DOI: 10.1016/j.hrtlng.2014.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 07/19/2014] [Accepted: 07/19/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We compared the survival of patients with idiopathic pulmonary arterial hypertension (IPAH), receiving conventional and targeted therapies. BACKGROUND IPAH is an incurable disease with high mortality. To manage IPAH, several targeted therapies have been used in Korea. METHODS We performed a retrospective study of 71 patients diagnosed with IPAH in a tertiary hospital between January 1994 and February 2013. Patients were classified into "conventional therapy group" (treated with conventional therapies and/or beraprost) and "targeted therapy group" (treated with targeted therapies other than beraprost). RESULTS The median age of the patients was 33 years and 50 patients were female. The survival rate at 1, 3, 5, and 10 years was 80.1% 62.0%, 51.5%, and 26.8%, respectively. The survival rate in the targeted therapy group was greater than in the conventional therapy group (p-value = 0.026). CONCLUSIONS We believe targeted therapies would improve survival benefits in IPAH patients.
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Affiliation(s)
- Byung Ju Kang
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea; Center for Pulmonary Hypertension and Venous Thromboembolism, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea; Center for Pulmonary Hypertension and Venous Thromboembolism, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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8
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Mukherjee B, Howard L. Combination therapy in pulmonary arterial hypertension: do we have the right strategy? Expert Rev Respir Med 2014; 5:191-205. [DOI: 10.1586/ers.11.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Pulmonary artery hypertension (PAH) is a pathological condition of small pulmonary arteries, characterised by vascular proliferation and remodelling. The pulmonary artery pressure and pulmonary vascular resistance progressively rise, leading to right heart failure and death. Pulmonary artery hypertension may be secondary to various conditions, or it may be idiopathic where no underlying cause is identifiable. Earlier, only symptomatic treatment was available for such patients which did not change the natural history of the disease. However, over the years, improvement in understanding the pathogenesis has resulted in the development of targeted approaches to the treatment of PAH. Survival advantage has also been shown with some of the pharmacologic agents. This review article discusses the current management strategy for PAH with special emphasis on an idiopathic variety, in an Indian context.
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Affiliation(s)
- Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
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10
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Safdar Z. Treatment of pulmonary arterial hypertension: The role of prostacyclin and prostaglandin analogs. Respir Med 2011; 105:818-27. [DOI: 10.1016/j.rmed.2010.12.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 11/23/2010] [Accepted: 12/20/2010] [Indexed: 11/24/2022]
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Satoh T, Satoh T, Saji T, Watanabe H, Ogawa S, Takehara K, Tanabe N, Yamada N, Yao A, Miyaji K, Nakanishi N, Suzuki Y, Fujiwara T, Kuriyama T. A phase III, multicenter, collaborative, open-label clinical trial of sildenafil in Japanese patients with pulmonary arterial hypertension. Circ J 2011; 75:677-82. [PMID: 21304214 DOI: 10.1253/circj.cj-10-0671] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is evidence that phosphodiesterase type-5 is effective for the treatment of pulmonary arterial hypertension (PAH). METHODS AND RESULTS A phase III, multicenter, open-label clinical trial of sildenafil 20mg t.i.d. was conducted in 21 Japanese patients with PAH to examine its efficacy, safety, and pharmacokinetics. The present trial consisted of a screening period and 12-week treatment. Patients who were enrolled in the present trial increased their 6-min walking distance of administration increased at week 12 by 84.2m from baseline. Hemodynamic parameters (eg, mean pulmonary artery pressure and pulmonary vascular resistance), Borg dyspnea scores, and plasma brain natriuretic peptide concentrations also improved compared to baseline. Most patients improved or sustained WHO functional class. Seven subjects, who were examined for the pharmacokinetics of sildefanil, showed relatively large interindividual variations in the C(max), AUC(0-8), C(ss,av), and C(trough) of the drug. Any serious adverse events, severe adverse events, and deaths were not observed. Most of events of undeniable causality were mild or moderate in severity. Sildefanil was well tolerated by the subjects. CONCLUSIONS Sildenafil 20mg t.i.d. was effective and safe for Japanese patients with PAH.
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Affiliation(s)
- Toru Satoh
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan.
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Abstract
Major advances have been made in the understanding and treatment of pulmonary hypertension in the last few years. Without treatment (medication) for idiopathic pulmonary arterial hypertension, which is a rare and potentially fatal condition, the survival time is only about 3 years after diagnosis. However, if pulmonary hypertension is secondary to other causes such as congenital heart disease, it is possible to survive for 30 years or more without treatment. The condition can affect children at any age, from fetal life to adulthood. Patients with pulmonary hypertension can present to the respiratory pediatrician with unresponsive asthma, to the neurologist with faints, or to the general pediatrician with failure to thrive. Over the last few years there have been significant developments in the available therapy for managing this complicated disease. There is now a generally recognized ladder of long-term therapy for chronic pulmonary hypertension. Treatment can start with oxygen at home at night or even during the day. Next is the use of oral phosphodiesterase inhibitors, mostly type V, such as sildenafil, which enhance endogenous nitric oxide. More potent are the endothelin receptor antagonists and the most potent are the prostanoids, especially epoprostenol, which is given by constant intravenous infusion. In addition to interventional catheterization with atrial septostomy, these agents have improved the prognostic outlook. This article reviews the current knowledge about the etiology, investigation, and treatment of children with pulmonary hypertension in the clinical setting.
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Affiliation(s)
- Robert Tulloh
- Department of Congenital Heart Disease, Bristol Royal Hospital for Children and Bristol Royal Infirmary, Bristol, England.
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Hawkins A, Tulloh R. Treatment of pediatric pulmonary hypertension. Vasc Health Risk Manag 2009; 5:509-24. [PMID: 19554091 PMCID: PMC2697585 DOI: 10.2147/vhrm.s4171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Indexed: 12/04/2022] Open
Abstract
Pulmonary hypertension was once thought to be a rare condition and only managed in specialized centers. Now however, with the advent of echocardiography, it is found in many clinical scenarios, in the neonate with chronic lung disease, in the acute setting in the intensive care unit, in connective tissue disease and in cardiology pre- and postoperatively. We have a better understanding of the pathological process and have a range of medication which is starting to be able to palliate this previously fatal condition. This review describes the areas that are known in this condition and those that are less familiar. The basic physiology behind pulmonary hypertension and pulmonary vascular disease is explained. The histopathologic process and the various diagnostic tools are described and are followed by the current and future therapy at our disposal.
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Affiliation(s)
- Amy Hawkins
- Department of Congenital Heart Disease, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK
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Kunieda T, Nakanishi N, Matsubara H, Ohe T, Okano Y, Kondo H, Nishimura M, Shirato K, Tanabe N, Homma S, Yoshida S, Inokuma S, Kodama M, Koike T, Hishida H. Effects of Long-Acting Beraprost Sodium (TRK-100STP) in Japanese Patients With Pulmonary Arterial Hypertension. Int Heart J 2009; 50:513-29. [DOI: 10.1536/ihj.50.513] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Takeyoshi Kunieda
- Department of Cardiovascular Medicine, Kaken Hospital, Clinical Medical Research Center, International University of Health and Welfare
| | - Norifumi Nakanishi
- Division of Cardiology, Department of Medicine, National Cardiovascular Center
| | - Hiromi Matsubara
- Division of Cardiology, National Hospital Organization Okayama Medical Center
| | - Tohru Ohe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yoshiaki Okano
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine
| | - Hirobumi Kondo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine
| | - Masaharu Nishimura
- First Department of Medicine, Hokkaido University Graduate School of Medicine
| | - Kunio Shirato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Nobuhiro Tanabe
- Department of Respirology, Chiba University Graduate School of Medicine
| | - Satoshi Homma
- Cardiovascular Division, Institute of Clinical Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba
| | - Shunji Yoshida
- Division of Rheumatology and Infectious Diseases, Department of Internal Medicine, Fujita Health University School of Medicine
| | - Shigeko Inokuma
- Department of Allergy and Immunological Diseases, Tokyo Metropolitan Komagome Hospital
| | - Makoto Kodama
- First Department of Internal Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Takao Koike
- Second Department of Medicine, Hokkaido University Graduate School of Medicine
| | - Hitoshi Hishida
- Division of Cardiology, Department of Internal Medicine, Fujita Health University School of Medicine
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Oyamada J, Toyono M, Shimada S, Aoki-Okazaki M, Tamura M, Takahashi T. Long-term administration of beraprost sodium for pulmonary arterial hypertension associated with congenital heart disease. Intern Med 2009; 48:1531-4. [PMID: 19721298 DOI: 10.2169/internalmedicine.48.2251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is often associated with congenital heart disease (CHD). Acute administration of beraprost reduces pulmonary vascular resistance in patients with idiopathic PAH and PAH associated with CHD; however, little is known about whether or not long-term treatment with oral beraprost benefits these patients. We report the case of a patient suffering from severe PAH associated with large patent ductus arteriosus (PDA), who was considered to be ineligible for PDA closure using a conventional treatment strategy. Eventually, long-term administration of oral beraprost ameliorated the degree of PAH and the patient subsequently underwent successful closure of the PDA.
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Affiliation(s)
- Jun Oyamada
- Pediatrics, Reproductive and Developmental Medicine, Akita University, Akita.
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Boutet K, Montani D, Jaïs X, Yaïci A, Sitbon O, Simonneau G, Humbert M. Review: Therapeutic advances in pulmonary arterial hypertension. Ther Adv Respir Dis 2008; 2:249-65. [DOI: 10.1177/1753465808094762] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by vasoconstriction, in situ thrombosis, and vascular remodeling of small pulmonary arteries inducing increased pulmonary arterial resistance. Conventional treatment is based on life style modification and nonspecific treatment (warfarine, diuretics, oxygen). Calcium channel blockers are vasodilatators that have been shown to be of great efficacy in a very specific subpopulation of patients with PAH. For the majority of patients, specific PAH therapies are still lacking. Numerous studies evaluating prostacyclin agonists, endothelin-receptor antagonists, and phosphodiesterase type 5 inhibitors are now available to guide therapeutic choices. Despite those important advances there is still no cure for PAH. Fortunately, research is ongoing and many drugs show promises.
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Affiliation(s)
- K. Boutet
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - David Montani
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Xavier Jaïs
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Azzedine Yaïci
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Oliver Sitbon
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Gérald Simonneau
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Marc Humbert
- Université Paris-Sud 11, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation respiratoire, Hôpital Antoine-Béclère, Assistance Publique - Hôpitaux de Paris, Clamart, France, marc.humbert @abc.aphp.fr
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Lee J, Kim H, Jeong J, Park E, Hwang K, Yang S, Jeong J. Determination of beraprost in human plasma by a high-performance liquid chromatography–tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 859:229-33. [DOI: 10.1016/j.jchromb.2007.09.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 09/19/2007] [Accepted: 09/29/2007] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) has been a disease with limited treatment options and poor prognosis. This article reviews the recent advances that took place in the medical management of PAH. RECENT FINDINGS Sildenafil is a type 5 cGMP-specific phosphodiesterase inhibitor originally developed to treat erectile dysfunction. Multiple uncontrolled and randomized controlled trials have proven that it is useful in the treatment of PAH and it was approved by the US Food and Drug Administration. The switch from continuous intravenous infusion of epoprostenol to subcutaneous infusion of treprostinil has been proven feasible and safe. Bosentan has been shown effective as a monotherapy and it also improves survival in patients with functional classes III and IV. In smaller clinical trials bosentan has improved symptoms in different forms of PAH. Combinations of drugs of different classes such as prostanoids, endothelin receptor blockers and sildenafil are tested, and such a strategy improves both symptoms and survival. Animal models and anecdotal clinical experience suggest the possibility of using imatinib mesylate in PAH. SUMMARY With the approval of sildenafil, treatment options for this difficult disease have improved significantly. Combinations of drugs of different groups are promising and need further exploration.
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Affiliation(s)
- B K S Sastry
- Consultant Cardiologist, CARE Hospitals, Nampally, Hyderabad, India.
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19
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Abstract
Idiopathic pulmonary arterial hypertension is a rare and potentially fatal condition. Without treatment, survival is only approximately 2.8 years from diagnosis. However, if the pulmonary hypertension is secondary to other causes, especially to congenital heart disease, it is possible to survive for 30 years or more without treatment. In recent years, remarkable progress has been made, risk factors have been identified and improved imaging techniques, including echocardiography, computer tomography and magnetic resonance imaging, are available. The condition can affect children at any age from fetal life through to adulthood. Patients can present to the respiratory pediatrician with unresponsive asthma, to the neurologist with faints or to the general pediatrician with failure to thrive. Over the last few years there have been significant developments in the available therapy for managing this complicated disease, which have improved the prognostic outlook, such as oral bosentan and sildenafil, intravenous epoprostenol and interventional catheterization with atrial septostomy. This article reviews the current knowledge about causation, investigation and treatment of children with pulmonary hypertension in the clinical setting.
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Affiliation(s)
- Robert Tulloh
- Department of Congenital Heart Disease, Bristol Royal Hospital for Children and Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8BJ, UK.
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20
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Hackman AM, Lackner TE. Pharmacotherapy for idiopathic pulmonary arterial hypertension during the past 25 years. Pharmacotherapy 2006; 26:68-94. [PMID: 16506350 DOI: 10.1592/phco.2006.26.1.68] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To review the current pharmacotherapy for idiopathic pulmonary arterial hypertension (IPAH). METHODS A search of the primary literature was conducted by using MEDLINE, the National Institutes of Health medical research Web site (www.clinicaltrials.gov), and the United States Food and Drug Administration's Center for Drug Evaluation and Research Web site (www.fda.gov/cder). RESULTS Until the early 1980s, conventional therapy for IPAH consisted of anticoagulation, diuretics, digitalis extracts, and supplemental oxygen, yet the 5-year mortality rate remained at 66%. Calcium channel blocker therapy was introduced with the hope that it would improve survival in patients with IPAH, but it was found to be effective in only approximately 25% of patients. In 1996, intravenous epoprostenol was the first drug to show long-term benefit on hemodynamics, exercise capacity, and survival. However, administration of epoprostenol requires a permanently indwelling central venous catheter, and tachyphylaxis is common, necessitating continuous dosage escalations. Subsequently, treprostinil, a prostacyclin analog of epoprostenol that can be administered by continuous subcutaneous infusion, was introduced, followed by aerosolized iloprost, a prostacyclin analog for inhalation. An increasing understanding of the multiple pathogeneses of IPAH led to the discovery of another target for drug therapy, and bosentan, an orally administered agent, became the first endothelin-receptor antagonist approved for treatment of IPAH. Most recently, the phosphodiesterase inhibitor, sildenafil, has received approval from the United States Food and Drug Administration for the treatment of IPAH. CONCLUSION Recently developed pharmacotherapies offer greater effectiveness and safety than traditional agents for the treatment of IPAH.
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Affiliation(s)
- Anna M Hackman
- Veterans Administration Medical Center, Pharmacy Department, One Veterans Drive, Minneapolis, MN 55417, USA.
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21
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Vizza CD, Badagliacca R, Sciomer S, Poscia R, Battagliese A, Schina M, Agati L, Fedele F. Mid-term efficacy of beraprost, an oral prostacyclin analog, in the treatment of distal CTEPH: a case control study. Cardiology 2006; 106:168-73. [PMID: 16645271 DOI: 10.1159/000092920] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Accepted: 02/14/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prostanoids are a well-established therapy for pulmonary arterial hypertension (PAH), and observational studies suggest their efficacy even in chronic thromboembolic pulmonary hypertension (CTEPH) patients. OBJECTIVE To compare the effects of 6 months of treatment with beraprost, an orally-active prostacyclin analog, in patients with distal CTEPH and PAH. DESIGN Case-control study. POPULATION Sixteen patients with severe pulmonary hypertension (NYHA II-IV), eight with distal CTEPH matched with eight patients with idiopathic PAH for similar effort tolerance. METHODS All patients were in stable clinical and hemodynamic condition for 3 months with maximal standard therapy. During the titration phase (4 weeks) beraprost was increased to maximal tolerated dose (mean daily dosage: CTEPH 275 +/- 47 microg, PAH 277 +/- 47 microg) in adjunction of standard therapy, patients were followed-up for 6 months. MAIN OUTCOME MEASURES World Heart Organization (WHO) functional class, exercise capacity measured by distance walked in 6 min, and systolic pulmonary pressure (echocardiography), were evaluated at baseline, and at 1-, 3- and 6-month interval. RESULTS At 6 months WHO class decreased significantly in both groups (CTEPH from 2.7 +/- 0.6 to 2.0 +/- 0.24, p < 0.05; PAH from 3.0 +/- 0.26 to 2.1 +/- 0.25, p < 0.05), similarly the 6-min walk distance increased significantly from baseline (CTEPH from 312 +/- 31 to 373 +/- 29 m, p < 0.003; PAH from 303 +/- 31 to 347 +/- 29, p < 0.0003). Systolic pulmonary artery pressure showed a trend toward lower value (CTEPH from 85 +/- 7 m to 81 +/- 6 mm Hg, p = NS; PAH from 89 +/- 7 to 82 +/- 5, p = NS). During the observation period we did not have any death. The drug was well-tolerated with minor side-effects. CONCLUSION In patients with CTEPH beraprost had similar mid-term clinical and hemodynamic improvements than in patients with PAH.
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Affiliation(s)
- Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, University La Sapienza, Rome, Italy.
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22
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Ishikawa S, Kawasaki A, Neya K, Kugawa S, Hayama T, Ueda K. Beraprost sodium-induced hypotension in two patients after cardiac surgery. Int Heart J 2006; 47:319-23. [PMID: 16607058 DOI: 10.1536/ihj.47.319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Two episodes of hypotension caused by oral beraprost sodium administration following cardiac surgery are described. The first case was a 67-year-old female who underwent concomitant surgery for mitral valve replacement, tricuspid annuloplasty, and a radiofrequency maze procedure for atrial fibrillation. The second case was a 45-year-old female who underwent 4-vessel coronary artery bypass grafting associated with endarterectomy in the right coronary artery. Beraprost sodium was administered for the treatment of residual pulmonary hypertension in the first case, and was initiated as an antiplatelet agent following coronary endarterectomy in the second case. Hypotension occurred at approximately one hour after beraprost sodium administration in both cases. Careful observation to prevent this adverse effect is critical after the administration of beraprost sodium, especially in patients who have undergone cardiac surgery.
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Affiliation(s)
- Susumu Ishikawa
- Department of Cardiovascular Surgery, Teikyo University School of Medicine, Japan
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Dandel M, Lehmkuhl HB, Hetzer R. Advances in the Medical Treatment of Pulmonary Hypertension. Kidney Blood Press Res 2006; 28:311-24. [PMID: 16534227 DOI: 10.1159/000090186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Increased pulmonary precapillary vascular resistance due to vasoconstriction and vasoproliferative processes is the basic pathophysiological mechanism in the development of pulmonary hypertension (PH). With the exception of pulmonary venous hypertension, where the primary cause of PH is left ventricular failure or mitral valvular disease, all the other PH categories will benefit to a greater or lesser extent from pulmonary vasodilator and antivasoproliferative therapy. Today, for this purpose, in addition to intravenous prostacyclin (epoprostenol), which is restricted to severe pulmonary arterial hypertension (NYHA class IV and late class III), other therapeutic options such as treatment with more stable prostacyclin analogs (oral beraprost, aerosolized iloprost), endothelin-receptor antagonists (bosentan) or phosphodiesterase inhibitors (sildenafil) are also available and these are especially useful for the treatment of the early stages of the disease. The recent progress in medical therapy has markedly increased the life expectancy in patients with pulmonary arterial hypertension and substantially improved their quality of life. Chronic hemodialysis (HD) patients show higher endothelin-1 (ET-1) activity in comparison to healthy individuals and there is evidence that the increase of pulmonary vascular resistance in these patients is at least in part mediated by ET-1. Recent data show good results after PH therapy with the endothelin-receptor antagonist bosentan in HD patients. Also prostacyclin and its analogs, as well as phosphodiesterase inhibitors, can be useful for the treatment of pulmonary hypertension in patients with chronic renal failure.
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Affiliation(s)
- Michael Dandel
- Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.
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Limsuwan A, Pienvichit P, Khowsathit P. Beraprost therapy in children with pulmonary hypertension secondary to congenital heart disease. Pediatr Cardiol 2005; 26:787-91. [PMID: 16132278 DOI: 10.1007/s00246-005-0925-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a report on children with severe pulmonary hypertension secondary to congenital heart disease who received 6 months of beraprost therapy. The children had an increase in intracardiac left-to-right shunt and a reduction of the pulmonary-to-systemic vascular resistance ratio, whereas the pulmonary artery pressure was not significantly changed.
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Affiliation(s)
- A Limsuwan
- Division of Pediatric Cardiology, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand.
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25
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Okyay K, Cemri M, Boyac B, Yalcn R, Cengel A. Use of Long-Term Combined Therapy With Inhaled Iloprost and Oral Sildenafil in an Adult Patient With Eisenmenger Syndrome. Cardiol Rev 2005; 13:312-4. [PMID: 16230890 DOI: 10.1097/01.crd.0000181618.29506.1e] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eisenmenger syndrome is characterized by elevated pulmonary vascular resistance and right-to-left shunting of blood through a systemic to pulmonary circulation connection. Treatment requires either lung transplantation with intracardiac repair or heart-lung transplantation. There are inadequate data regarding treatment alternatives when the patient is not a candidate for surgery. In this article, we report on the case of a 68-year-old woman with Eisenmenger syndrome related to congenital heart disease who was treated with inhaled iloprost and oral sildenafil for 2 years.
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Affiliation(s)
- Kaan Okyay
- Department of Cardiology, Gazi University Medical School, Ankara, Turkey.
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Shen J, He B, Wang B. Effects of Lipo-Prostaglandin E1on Pulmonary Hemodynamics and Clinical Outcomes in Patients With Pulmonary Arterial Hypertension. Chest 2005. [DOI: 10.1016/s0012-3692(15)50417-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Karatza AA, Bush A, Magee AG. Safety and efficacy of Sildenafil therapy in children with pulmonary hypertension. Int J Cardiol 2005; 100:267-73. [PMID: 15823634 DOI: 10.1016/j.ijcard.2004.09.002] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Revised: 06/21/2004] [Accepted: 09/04/2004] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Sildenafil is a selective Phosphodiesterase-5 inhibitor that has been reported to be a potent pulmonary vasodilator. We evaluated the safety, efficacy and pharmacokinetics of oral Sildenafil in a case series of children with pulmonary hypertension. METHODS Three children, 1 with primary pulmonary hypertension (patient 1) and 2 with pulmonary hypertension associated with congenital heart disease (patients 2 and 3) were enrolled. Sildenafil was started at 0.5 mg/kg 4-hourly and the dose increased to 1.0 and then to 2.0 mg/kg/dose. Patients were assessed at baseline and then monthly for a total of 6 visits. RESULTS All patients reported increased exercise capacity with improvement in New York Heart Association functional class. The distance walked during the 6-min test increased by 74% (patient 1), 75% (patient 2) and 25% (patient 3) and oxyhaemoglobin saturations increased from 79%, 97% and 80% to 93%, 100% and 93%, respectively. There were no side effects and no fall in systemic blood pressure. Sildenafil plasma levels 1 h after a 0.5, 1.0 and 2 mg/kg dose of Sildenafil were 109+/-87, 150+/-62 and 368+/-200 ng/ml, respectively. They fell to 211+/-106 ng/ml 3 h after the 2.0 mg/kg dose. CONCLUSIONS Medium term Sildenafil therapy improves oxyhaemoglobin saturations and exercise tolerance in children with pulmonary hypertension without any side effects. Mean plasma levels 1 h after doses of 0.5-2.0 mg/kg are similar to the maximum plasma concentrations reported in adults receiving doses within the therapeutic range. Sildenafil use in children appears to be safe and may be beneficial in the management of pulmonary arterial hypertension.
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Affiliation(s)
- Ageliki A Karatza
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, UK
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Paramothayan NS, Lasserson TJ, Wells AU, Walters EH. Prostacyclin for pulmonary hypertension in adults. Cochrane Database Syst Rev 2005; 2005:CD002994. [PMID: 15846646 PMCID: PMC7004255 DOI: 10.1002/14651858.cd002994.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Primary pulmonary hypertension (PPH) is progressive, resulting in right ventricular failure. Pulmonary hypertension can be idiopathic or associated with other conditions. Prostacyclin is a potent vasodilator and inhibitor of platelet aggregation, and can be given orally, subcutaneously, intravenously or inhaled via a nebuliser. OBJECTIVES To determine the efficacy of prostacyclin or one of its analogues in idiopathic primary pulmonary hypertension. SEARCH STRATEGY Electronic searches were carried out with pre-specified terms. Searches were current as of July 2004. SELECTION CRITERIA Two reviewers selected randomised controlled trials (RCTs) involving adults with pulmonary hypertension for inclusion. DATA COLLECTION AND ANALYSIS Study quality was assessed and data extracted independently by two reviewers. Outcomes were analysed as continuous and dichotomous outcomes. We sub-grouped data where possible by aetiology of PH (PPH, PH secondary to connective tissue disorder or mixed populations). MAIN RESULTS Nine RCTs of mixed duration (3 days-52 weeks), recruiting 1175 participants were included (NYHA functional classes II-IV). Intravenous prostacyclin versus usual care (four studies): There were significant improvements in exercise capacity of around 90 metres, cardiopulmonary haemodynamics and NYHA functional class over 3 days-12 weeks. Effects were consistent in primary and secondary pulmonary hypertension. Oral prostacyclin versus placebo (two studies): Short-term data (3-6 months) indicated that there was a significant improvement in exercise capacity, but data from one study of 52 weeks reported no significant difference at 12 months. No significant differences were observed for any other outcome. Subcutaneous treprostinil versus placebo (two studies, 8-12 weeks):One large study reported a significant median improvement in exercise capacity of around 16 metres. Cardiopulmonary haemodynamics and symptom scores favoured treprostinil. Infusion site pain and withdrawals due to adverse events were more frequent with treprostinil. Inhaled prostacyclin versus placebo (one study, 12 weeks):There was a significant increase in exercise capacity of approximately 36 metres. Treatment led to better symptom scores and functional class status than with placebo. Subgroup analyses reported by individual studies showed a better exercise capacity in participants with PPH, than those participants with PH secondary to other diseases. Side effects and adverse events were common in the studies. AUTHORS' CONCLUSIONS There is evidence that intravenous prostacyclin in addition to conventional therapy at tolerable doses optimised by titration, can confer some short-term benefits (up to 12 weeks of treatment) in exercise capacity, NYHA functional class and cardiopulmonary haemodynamics. There is also some evidence that patients with more severe disease based upon NYHA functional class showed a greater response to treatment.
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Affiliation(s)
- N S Paramothayan
- Respiratory Medicine, St Helier Hospital NHS Trust, Wrythe Lane, Carshalton, Surrey, UK.
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Emmel M, Keuth B, Schickendantz S. Paradoxical increase of pulmonary vascular resistance during testing of inhaled iloprost. Heart 2004; 90:e2. [PMID: 14676265 PMCID: PMC1768033 DOI: 10.1136/heart.90.1.e2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2003] [Indexed: 11/04/2022] Open
Abstract
The case of a 14 month old girl with primary pulmonary hypertension treated with domiciliary oxygen is described. After invasive evaluation and testing of nitric oxide with very good response, the testing was repeated to study the effect of inhaled iloprost on pulmonary vascular resistance (PVR). An unexpected and severe increase of PVR was observed, rising from 392 dynes x s x cm(-5) with oxygen to a maximum of 1192 dynes x s x cm(-5) with oxygen and iloprost. Underlying ventilatory and technical problems were excluded. While inhaled iloprost has been described to be highly effective in the treatment of primary pulmonary hypertension, the possibility of contrary "paradoxical" reactions in isolated patients is emphasised, with a dramatic increase of PVR and a possible adverse outcome.
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Affiliation(s)
- M Emmel
- University of Cologne, Cologne, Germany.
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30
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31
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Nauser TD, Stites SW. Pulmonary hypertension: new perspectives. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2003; 9:155-62. [PMID: 12826774 DOI: 10.1111/j.1527-5299.2002.01050.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The World Health Organization symposium offers a new treatment-oriented classification of pulmonary hypertension based on an improved understanding of its pathophysiology. Regardless of the etiology, severe or unrelieved pulmonary hypertension leads to right heart failure. Symptoms and signs of pulmonary hypertension are often subtle and nonspecific. As a result, a significant delay between the onset of symptoms and the diagnosis of pulmonary hypertension is common. Echocardiography with Doppler flow is the most useful study to evaluate patients suspected of having pulmonary hypertension. The suspected diagnosis of pulmonary hypertension should then be confirmed by right heart catheterization. If present, further evaluation may include oxygen assessment, pulmonary function testing, high resolution computed tomography of the chest, and ventilation-perfusion lung scanning. Treatment of pulmonary hypertension requires uncommon expertise. General measures include correction of the underlying cause, reversal of hypoxemia and judicious use of diuretics. Advances in vasodilator therapy have increased treatment options beyond calcium channel blockers and intravenous epoprostenol. Lung transplantation remains an option for select patients with pulmonary hypertension not responding to medical management.
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Affiliation(s)
- Trenton D Nauser
- Division of Pulmonary and Critical Care Medicine, Department of Veterans Affairs Medical Center, Kansas City, MO 64128-2295, USA.
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32
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Abstract
BACKGROUND Primary pulmonary hypertension (PPH) is progressive, resulting in right ventricular failure. Survival seldom exceeds five years. Pulmonary hypertension can be idiopathic or associated with other conditions. It is common in patients with diffuse scleroderma and the CREST syndrome where it is clinically, haemodynamically and prognostically indistinguishable from idiopathic primary pulmonary hypertension. Prostacyclin is a potent vasodilator and inhibitor of platelet aggregation. Iloprost is a chemically stable derivative of prostacyclin with similar biologic properties and can be given orally, by infusion or nebulised. OBJECTIVES To determine the efficacy of prostacyclin or one of its analogues in idiopathic primary pulmonary hypertension. SEARCH STRATEGY A search was carried out using the Cochrane controlled clinical trial register. An update search was conducted on 12th August 2002. Four new trials met the inclusion criteria of the review. SELECTION CRITERIA Randomised controlled trials (RCTs) involving patients with primary pulmonary hypertension or pulmonary hypertension secondary to connective tissue disorders were selected by two reviewers. DATA COLLECTION AND ANALYSIS Study quality was assessed and data extracted independently by two reviewers. Outcomes were analysed as continuous and dichotomous outcomes, using standard statistical techniques. MAIN RESULTS Seven RCTs of short duration (8-12 weeks) were included. Three compared intravenous epoprostenol with conventional therapy. One compared intravenous Iloprost with placebo. One RCT compared oral prostacyclin with placebo, another compared subcutaneous infusion of treprostinil with placebo and a further RCT studied the effects of inhaled iloprost. All the trials showed an improvement in exercise capacity. Cardiopulmonary haemodynamics, dyspnoea scores and symptoms also improved in some of the studies. Side effects and adverse events related to the indwelling catheter (sepsis and thrombosis) were common in intravenous trials. The other routes of administration had less severe side effects. REVIEWER'S CONCLUSIONS Intravenous prostacyclin or one of its analogues in addition to conventional therapy over 12 weeks appears to improve exercise capacity, NYHA functional class and several cardiopulmonary haemodynamic variables. There is some evidence that other routes of administration of the drug may also be effective with fewer side effects, which were mainly related to the indwelling catheter.
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Affiliation(s)
- N S Paramothayan
- Division of Physiological Medicine, St George's Hospital Medical School, Cranmer Terrace, London, UK, SW17 0RE
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33
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Abstract
There have been remarkable advances in our understanding of the pathobiology of pulmonary hypertension. A region on chromosome 2 encoding bone morphogenetic receptor type 2 has been identified to underlie familial and many cases of sporadic primary pulmonary arterial hypertension. The vasoactive mediators, discovered and defined by vascular biologists, have been translated into promising treatments of human disease. Prostacyclin, endothelin receptor blockers, sildenafil, and nitric oxide have been applied therapeutically to limit, and occasionally reverse, the inexorable damage to the pulmonary circulation initiated by recently identified genetic and environmental triggers of pulmonary arterial hypertension.
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Affiliation(s)
- Ian Adatia
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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34
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Abstract
Pulmonary hypertension is a common complication of chronic obstructive pulmonary disease (COPD). The increase in pulmonary artery pressures is often mild to moderate, but some patients may suffer from severe pulmonary hypertension, and present with a progressively downhill clinical course because of right-sided heart failure added to ventilatory handicap. The cause of pulmonary hypertension in COPD is generally assumed to be hypoxic pulmonary vasoconstriction leading to permanent medial hypertrophy. However, recent pathological studies point, rather, to extensive remodeling of the pulmonary arterial walls, with prominent intimal changes. These aspects account for minimal reversibility with supplemental oxygen. There may be a case for pharmacological treatment of pulmonary hypertension in selected patients with advanced COPD and right-sided heart failure. Candidate drugs include prostacyclin derivatives, endothelin antagonists and inhaled nitric oxide, all of which have been reported of clinical benefit in primary pulmonary hypertension. However, it will be a challenge for randomized controlled trials to overcome the difficulties of the diagnosis of right ventricular failure and the definition of a relevant primary endpoint in pulmonary hypertensive COPD patients.
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Affiliation(s)
- R Naeije
- Department of Pathophysiology, Erasme Campus of the Free University of Brussels, Belgium.
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