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Kiko T, Asano R, Endo H, Nishi N, Hayashi H, Ueda J, Aoki T, Tsuji A, Ogo T. Clinical outcomes of upfront combination therapy for portopulmonary hypertension. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200294. [PMID: 38872733 PMCID: PMC11168483 DOI: 10.1016/j.ijcrp.2024.200294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
Background Limited data exists on upfront combination therapy for portopulmonary hypertension. We evaluated the clinical efficacy, long-term outcomes, and safety of upfront combination therapy in patients with portopulmonary hypertension. Methods We performed a retrospective, single-center cohort study involving a final analysis of 33 consecutive patients diagnosed with portopulmonary hypertension who were taking pulmonary arterial hypertension-specific medication. We compared hemodynamic parameters, risk profiles, composite clinical worsening events, and safety between monotherapy (n = 23) and upfront combination therapy (n = 10). Results Twenty-seven patients (82 %) were classified into the Child-Pugh A stage. The change ratios of pulmonary vascular resistance (-32 % vs. -57 %, P = 0.006) were significantly better with upfront combination therapy. Upfront combination therapy also showed significant improvement in risk profiles. Kaplan-Meier analysis showed that the composite event-free rate was significantly lower in patients who received upfront combination therapy than in those who received monotherapy (P = 0.016), although no statistical differences were observed in all-cause death. In the univariate Cox proportional hazards analysis, upfront combination therapy was a factor for decreasing composite clinical worsening outcomes (hazard ratio 0.190, 95 % confidence interval 0.042-0.854; P = 0.030). No significant hepatic impairments were observed over 2 years of follow-up in the upfront combination group. Conclusions In patients with portopulmonary hypertension, upfront combination therapy significantly improved symptoms and short-term hemodynamics, and reduced long-term clinical worsening events without serious adverse effects. This study's findings suggest that patients with portopulmonary hypertension presenting with mild hepatic impairment benefit from upfront combination therapy.
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Affiliation(s)
- Takatoyo Kiko
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Ryotaro Asano
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Japan
| | - Hiroyuki Endo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Naruhiro Nishi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroya Hayashi
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Jin Ueda
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Tatsuo Aoki
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Akihiro Tsuji
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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Dardi F, Guarino D, Ballerini A, Bertozzi R, Donato F, Cennerazzo F, Salvi M, Nardi E, Magnani I, Manes A, Galiè N, Palazzini M. Prognostic role of haemodynamics at follow-up in patients with pulmonary arterial hypertension: a challenge to current European Society of Cardiology/European Respiratory Society risk tools. ERJ Open Res 2024; 10:00225-2024. [PMID: 39104950 PMCID: PMC11298999 DOI: 10.1183/23120541.00225-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/08/2024] [Indexed: 08/07/2024] Open
Abstract
Background Haemodynamic variables like right atrial pressure (RAP), cardiac index (CI), stroke volume index (SVI) and mixed venous oxygen saturation (S vO2 ) predict survival in patients with pulmonary arterial hypertension (PAH). However, there is the need to identify further prognostic haemodynamic parameters as well as to redefine their role in PAH risk stratification compared to current risk tools and non-invasive parameters. Methods This cohort study includes treatment-naïve patients assessed at baseline and after first-line PAH therapy with clinical, functional, exercise, laboratory and haemodynamic evaluations. Using a stepwise multivariate Cox regression analysis, independent prognostic haemodynamic parameters were identified and stratified according to cut-offs already defined in the European Society of Cardiology (ESC)/European Respiratory Society (ERS) risk table or defined based on the highest Chi-squared of the log-rank test. Their discriminatory power was tested for all-cause death and a combined end-point of death, hospitalisation and need of treatment escalation. Results 794 patients with PAH were enrolled. At first follow-up, RAP and pulmonary artery elastance were independently associated with death. Because of high correlations between haemodynamic parameters, different multivariable analyses were done identifying six other variables (pulmonary arterial compliance, cardiac efficiency, pulmonary vascular resistance, S vO2 , CI and SVI). Haemodynamic parameters were of no added prognostic value compared to ESC/ERS risk tools for the all-cause death end-point but they showed additional value to non-invasive parameters for the combined end-point and, when taken alone, had a discriminatory capacity comparable to ESC/ERS risk tools. Conclusion Haemodynamics' discriminative ability for clinical worsening is comparable to current ESC/ERS risk tools and is of added value to non-invasive parameters.
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Affiliation(s)
- Fabio Dardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Guarino
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Alberto Ballerini
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Riccardo Bertozzi
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Federico Donato
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Francesco Cennerazzo
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Monica Salvi
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Elena Nardi
- Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ilenia Magnani
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Bologna, Italy
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Waxman AB, Systrom DM, Manimaran S, de Oliveira Pena J, Lu J, Rischard FP. SPECTRA Phase 2b Study: Impact of Sotatercept on Exercise Tolerance and Right Ventricular Function in Pulmonary Arterial Hypertension. Circ Heart Fail 2024; 17:e011227. [PMID: 38572639 DOI: 10.1161/circheartfailure.123.011227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND This study aims to assess the impact of sotatercept on exercise tolerance, exercise capacity, and right ventricular function in pulmonary arterial hypertension. METHODS SPECTRA (Sotatercept Phase 2 Exploratory Clinical Trial in PAH) was a phase 2a, single-arm, open-label, multicenter exploratory study that evaluated the effects of sotatercept by invasive cardiopulmonary exercise testing in participants with pulmonary arterial hypertension and World Health Organization functional class III on combination background therapy. The primary end point was the change in peak oxygen uptake from baseline to week 24. Cardiac magnetic resonance imaging was performed to assess right ventricular function. RESULTS Among the 21 participants completing 24 weeks of treatment, there was a significant improvement from baseline in peak oxygen uptake, with a mean change of 102.74 mL/min ([95% CIs, 27.72-177.76]; P=0.0097). Sotatercept demonstrated improvements in secondary end points, including resting and peak exercise hemodynamics, and 6-minute walk distance versus baseline measures. Cardiac magnetic resonance imaging showed improvements from baseline at week 24 in right ventricular function. CONCLUSIONS The clinical efficacy and safety of sotatercept demonstrated in the SPECTRA study emphasize the potential of this therapy as a new treatment option for patients with pulmonary arterial hypertension. Improvements in right ventricular structure and function underscore the potential for sotatercept as a disease-modifying agent with reverse-remodeling capabilities. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03738150.
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Affiliation(s)
- Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - Solaiappan Manimaran
- Acceleron Pharma, a wholly owned subsidiary of Merck & Co Inc, Rahway, NJ (S.M.)
| | | | | | - Franz P Rischard
- Department of Medicine, Division of Pulmonary and Critical Care (F.P.R.), University of Arizona, Tucson
- Sarver Heart Center (F.R.), University of Arizona, Tucson
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Grünig E, Jansa P, Fan F, Hauser JA, Pannaux M, Morganti A, Rofael H, Chin KM. Randomized Trial of Macitentan/Tadalafil Single-Tablet Combination Therapy for Pulmonary Arterial Hypertension. J Am Coll Cardiol 2024; 83:473-484. [PMID: 38267108 DOI: 10.1016/j.jacc.2023.10.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Endothelin receptor antagonist (ERA) and phosphodiesterase 5 inhibitor (PDE5i) combination therapy is recommended for low-/intermediate-risk pulmonary arterial hypertension (PAH) patients. A fixed-dose combination of the ERA macitentan and PDE5i tadalafil (M/T FDC) in a once-daily, single tablet would simplify treatment. OBJECTIVES The multicenter, double-blind, adaptive phase 3 A DUE study investigated the efficacy and safety of M/T FDC vs macitentan 10 mg and vs tadalafil 40 mg monotherapies in PAH patients, including treatment-naïve and prior ERA or PDE5i monotherapy-treated patients. METHODS World Health Organization functional class II-III patients were randomized to M/T FDC, macitentan, or tadalafil depending on their PAH treatment (treatment-naïve, ERA, or PDE5i monotherapy) at baseline. The primary endpoint was change in pulmonary vascular resistance (PVR) at week 16. RESULTS In total, 187 patients were randomized to single-tablet M/T FDC (n = 108), macitentan (n = 35), or tadalafil (n = 44). PVR reduction with M/T FDC was significantly greater vs macitentan (29%; geometric mean ratio 0.71; 95% CL: 0.61-0.82; P < 0.0001) and vs tadalafil (28%; geometric mean ratio 0.72; 95% CL: 0.64-0.80; P < 0.0001). Three patients died in the M/T FDC arm (judged unrelated to treatment). Adverse events (AEs) leading to discontinuation, serious AEs, and those of special interest (anemia, hypotension, and edema) were more frequent with M/T FDC. CONCLUSIONS Macitentan and tadalafil FDC significantly improved PVR vs monotherapies in PAH patients, with a safety and tolerability profile consistent with the individual components. The A DUE study supports M/T FDC as a once-daily, single-tablet combination for initial therapy and escalation to double combination therapy in patients with PAH. (Clinical Study to Compare the Efficacy and Safety of Macitentan and Tadalafil Monotherapies With the Corresponding Fixed-dose Combination Therapy in Subjects With Pulmonary Arterial Hypertension [PAH]) [A DUE]; NCT03904693).
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Affiliation(s)
- Ekkehard Grünig
- Thoraxklinik at Heidelberg University Hospital and Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany
| | - Pavel Jansa
- Charles University and General University Hospital, Prague, Czech Republic
| | - Fenling Fan
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jakob A Hauser
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Clinical Science, Allschwil, Switzerland
| | | | - Adele Morganti
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Statistical Decision Science, Allschwil, Switzerland
| | - Hany Rofael
- Janssen Research and Development, LLC, Clinical Science, Titusville, New Jersey, USA
| | - Kelly M Chin
- UT Southwestern Medical Center, Dallas, Texas, USA.
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Kusunose K, Ikemiyagi H. Prognostic implications of pulmonary vascular resistance in transcatheter aortic valve implantation. Heart 2023; 110:5-6. [PMID: 37553140 DOI: 10.1136/heartjnl-2023-323094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus, Okinawa, Japan
| | - Hidekazu Ikemiyagi
- Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus, Okinawa, Japan
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Barkhane Z, Nimerta F, Zulfiqar S, Dar S, Afzal MS, Zaree A, Adwani R, Palleti SK. Independent Predictors of Mortality in Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e39730. [PMID: 37398831 PMCID: PMC10310541 DOI: 10.7759/cureus.39730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
The aim of this study is to determine the predictors of mortality in patients with systemic sclerosis-induced pulmonary arterial hypertension (SSc-PAH). This systematic review and meta-analysis were carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement guidelines. We searched the PubMed, EMBASE, and Web of Science databases from January 2010 to April 2023 using the following keywords: "systemic sclerosis," "pulmonary arterial hypertension," "death," and "predictors," along with medical subject headings (MeSH), to identify relevant studies. A total of eight studies with a total of 530 patients were included in the present systematic review and meta-analysis. The pooled one-year, three-year, and five-year survival was 90% (95% CI: 86-93%), 66% (95% CI: 59-72%), and 44% (95% CI: 23-65%), respectively. Factors associated with mortality in SSc-PAH included age (p-value: 0.02), male gender (p-value: 0.008), pericardial effusion (p-value: 0.003), cardiac index (p-value: 0.0001), six-minute walking distance (p-value: 0.04), pulmonary arterial pressure (PAP) (p-value: 0.01), and New York Heart Association (NYHA) classification (p-value: 0.0002). The findings of this study have important clinical implications. Assessing and managing the identified predictors, such as age, gender, pericardial effusion, PAP, cardiac index, and NYHA class, could help identify individuals at higher risk of mortality and guide treatment strategies.
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Affiliation(s)
- Zineb Barkhane
- Department of Neurology, Université Hassan II de Casablanca, Casablanca, MAR
| | - Fnu Nimerta
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Sualeha Zulfiqar
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Saleha Dar
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Muhammad Sohaib Afzal
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Amna Zaree
- Department of Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | - Rahul Adwani
- Department of Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Sujith K Palleti
- Department of Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, USA
- Department of Nephrology, Loyola University Medical Center, Maywood, USA
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