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Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is one of several forms of pulmonary hypertension: a chronic disease of the pulmonary vasculature. The mean age at diagnosis is around 50 years old, with increasing prevalence in people over 70 years old (10% to 17%). The median survival to be approximately seven years with one-, three-, five-, and seven-year survival rates from time of diagnostic right-sided heart catheterization were 85%, 68%, 57%, and 49%, respectively. Several studies showed that calcium channel blockers (CCBs) reduce right ventricular hypertrophy and improve long-term haemodynamics in PAH. OBJECTIVES To evaluate the clinical efficacy and harms of CCBs for people with PAH. SEARCH METHODS The search strategy was provided by the Cochrane Airways Group Trials Search Co-ordinator. The following databases were searched from their inception until September 2014: the Cochrane Airways Group Register of Trials (CAGR); the Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library,Issue 8 2014); MEDLINE (1948 to September 2014); EMBASE (1974 to September 2014); ClinicalTrials.gov; WHO trial portal; the Chinese Biomedical Databases (1979 to September 2014); CNKI: the Chinese Journals Full Text Database (1979 to September 2014), the Chinese Journals Full Text Database Century Journals (1979 to September 2014), the Chinese Doctoral Degree Thesis Full Text Database (1979 to September 2014), the Chinese Outstanding Master Degree Thesis Full Text Database (1979 to September 2014); VIP Database (1989 to September 2014) and WANFANG Database (1993 to September 2014). No language restriction was applied. SELECTION CRITERIA Fully published randomized controlled trials (RCTs) comparing CCBs with placebo or other treatment, or comparing CCBs as an adjunct to other treatments with other treatments alone, in patients with PAH. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. MAIN RESULTS We found one RCT to include in this review but it was published only in abstract form with no data for evaluation. AUTHORS' CONCLUSIONS Currently, as there is lack of valid evidence, the efficacy and safety of CCBs is unproven in the treatment of PAH. However, the search strategy used for this review did identify four controlled clinical trials without randomization, three of which suggested treatment with CCBs may be beneficial in PAH. No adverse side effects of CCBs were reported. Confirmation of these findings by RCTs is recommended.
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Affiliation(s)
- Zhiyu Fan
- Singapore General HospitalDepartment of Family Medicine Continuing CareOutram Road, SingaporeSingaporeSingapore169608
| | - Yuanjing Chen
- Singapore General HospitalDepartment of AnesthesiologySingapore General Hospital, Outram RoadSingaporeSingapore169608
| | - Hanmin Liu
- West China Institute of Women’s and Children’s Health, West China Second University Hospital, Sichuan UniversityPulmonary Vascular Remodeling Research Unit, Department of PediatricsNo.20, 3rd Section, Renmin South RoadChengduSichuan ProvinceChina610041
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2
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Tuder RM. How do we measure pathology in PAH (lung and RV) and what does it tell us about the disease. Drug Discov Today 2014; 19:1257-63. [PMID: 24881780 DOI: 10.1016/j.drudis.2014.05.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/22/2014] [Indexed: 12/14/2022]
Abstract
The current understanding of the pathology that underlies pulmonary vascular and right ventricular remodeling in pulmonary hypertension is discussed. Although recent studies underscored the importance of intima and media remodeling and, for the first time, the relevance of perivascular inflammation, much is needed to move the field forward. Reassessment of distribution and extension of the different vascular lesions requires state-of-the-art stereological tools, allied to three-dimensional casting and integration with data concerning cellular and molecular pathobiological processes. This integrated approach is ever more pressing in the right ventricle, because our understanding of key structural alterations of the failing right ventricle in pulmonary hypertension is lacking. This enterprise will enable better translation of pathogenetic processes to the human disease and provide key data to guide diagnostic and prognostic imaging approaches.
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Affiliation(s)
- 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, 12700 East 18th Avenue, Research Complex 2, Room 9001, Aurora, CO 80045, USA.
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Twiss J, McKenna S, Ganderton L, Jenkins S, Ben-L'amri M, Gain K, Fowler R, Gabbay E. Psychometric performance of the CAMPHOR and SF-36 in pulmonary hypertension. BMC Pulm Med 2013; 13:45. [PMID: 23844640 PMCID: PMC3751055 DOI: 10.1186/1471-2466-13-45] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 07/03/2013] [Indexed: 12/23/2022] Open
Abstract
Background The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) and the Medical Outcomes Study Short Form 36 (SF-36) are widely used to assess patient-reported outcome in individuals with pulmonary hypertension (PH). The aim of the study was to compare the psychometric properties of the two measures. Methods Participants were recruited from specialist PH centres in Australia and New Zealand. Participants completed the CAMPHOR and SF-36 at two time points two weeks apart. The SF-36 is a generic health status questionnaire consisting of 36 items split into 8 sections. The CAMPHOR is a PH-specific measure consisting of 3 scales; symptoms, activity limitations and needs-based QoL. The questionnaires were assessed for distributional properties (floor and ceiling effects), internal consistency (Cronbach's alpha), test-retest reliability and construct validity (scores by World Health Organisation functional classification). Results The sample comprised 65 participants (mean (SD) age = 57.2 (14.5) years; n(%) male = 14 (21.5%)). Most of the patients were in WHO class 2 (27.7%) and 3 (61.5%). High ceiling effects were observed for the SF-36 bodily pain, social functioning and role emotional domains. Test-retest reliability was poor for six of the eight SF-36 domains, indicating high levels of random measurement error. Three of the SF-36 domains did not distinguish between WHO classes. In contrast, all CAMPHOR scales exhibited good distributional properties, test retest reliability and distinguished between WHO functional classes. Conclusions The CAMPHOR exhibited superior psychometric properties, compared with the SF-36, in the assessment of PH patient-reported outcome.
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Affiliation(s)
- James Twiss
- Galen Research Ltd, Manchester, United Kingdom.
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PGC-1α induction in pulmonary arterial hypertension. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2012; 2012:236572. [PMID: 22973467 PMCID: PMC3437671 DOI: 10.1155/2012/236572] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 06/13/2012] [Accepted: 07/10/2012] [Indexed: 12/19/2022]
Abstract
Idiopathic Pulmonary arterial hypertension (IPAH) is characterized by the obstructive remodelling of pulmonary arteries, and a progressive elevation in pulmonary arterial pressure (PAP) with subsequent right-sided heart failure and dead. Hypoxia induces the expression of peroxisome proliferator activated receptor γ coactivator-1α (PGC-1α) which regulates oxidative metabolism and mitochondrial biogenesis. We have analysed the expression of PGC-1α, cytochrome C (CYTC), superoxide dismutase (SOD), the total antioxidant status (TAS) and the activity of glutathione peroxidase (GPX) in blood samples of IPAH patients. Expression of PGC-1α was detected in IPAH patients but not in healthy volunteers. The mRNA levels of SOD were lower in IPAH patients compared to controls (3.93 ± 0.89 fold change). TAS and GPX activity were lower too in patients compared to healthy donors, (0.13 ± 0.027 versus 0.484 ± 0.048 mM and 56.034 ± 10.37 versus 165.46 ± 11.38 nmol/min/mL, resp.). We found a negative correlation between expression levels of PGC-1α and age, PAP and PVR, as well as a positive correlation with CI, PaO2, mRNA levels of CYTC and SOD, TAS and GPX activity. These results taken together are indicative of the possible role of PGC-1α as a potential biomarker of the progression of IPAH.
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Wang K, Gong J, Pei L, Shan S, Tan W. The effect of rhBMP-2 on pulmonary arterioles remodeling in endotoxin-induced acute lung injury in rats. Clin Exp Med 2012; 13:187-92. [DOI: 10.1007/s10238-012-0197-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
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MEDI CAROLINE, KALMAN JONATHANM, LING LIANGHAN, TEH ANDREWW, LEE GEOFFREY, LEE GERALDINE, SPENCE STEVENJ, KAYE DAVIDM, KISTLER PETERM. Atrial Electrical and Structural Remodeling Associated with Longstanding Pulmonary Hypertension and Right Ventricular Hypertrophy in Humans. J Cardiovasc Electrophysiol 2012; 23:614-20. [DOI: 10.1111/j.1540-8167.2011.02255.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jiang Y, Nohe A, Bragdon B, Tian C, Rudarakanchana N, Morrell NW, Petersen NO. Trapping of BMP receptors in distinct membrane domains inhibits their function in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2011; 301:L218-27. [PMID: 21622843 DOI: 10.1152/ajplung.00300.2010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Bone morphogenetic proteins (BMPs) are pleiotrophic growth factors that influence diverse processes such as skeletal development, hematopoiesis, and neurogenesis. They play crucial roles in diseases such as pulmonary arterial hypertension (PAH). In PAH, mutants of the BMP type II receptors (BMPR2) were detected, and their functions were impaired during BMP signaling. It is thought that expression levels of these receptors determine the fate of BMP signaling, with low levels of expression leading to decreased Smad activation in PAH. However, our studies demonstrate, for the first time, that the localization of receptors on the plasma membrane, in this case BMPR2, was misdirected. Three BMPR2 mutants, D485G, N519K, and R899X, which are known to be involved in PAH, were chosen as our model system. Our results show that all three BMPR2 mutants decreased BMP-dependent Smad phosphorylation and Smad signaling. Although the three mutants reached the cell membrane and their expression was lower than that of BMPR2, they formed smaller clusters and associated differently with membrane domains, such as caveolae and clathrin-coated pits. The disruption of these domains restored the Smad signaling of D485G and N519K to the level of wild-type BMPR2, showing that these mutants were trapped in the domains, rather than just expressed at a lower level on the surface. Therefore, new treatment options for PAH should also target receptor localization, rather than just expression level.
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Affiliation(s)
- Yaxin Jiang
- National Institute for Nanotechnology, National Research Council, Edmonton, Alberta, Canada
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Case of the Month. JAAPA 2011; 24:65. [DOI: 10.1097/01720610-201101000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ochiai E, Kamei K, Watanabe A, Nagayoshi M, Tada Y, Nagaoka T, Sato K, Sato A, Shibuya K. Inhalation of Stachybotrys chartarum causes pulmonary arterial hypertension in mice. Int J Exp Pathol 2008; 89:201-8. [PMID: 18460072 DOI: 10.1111/j.1365-2613.2008.00585.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Inhalation of Stachybotrys chartarum, a ubiquitous fungus in our living environment, has been suspected as a cause of acute idiopathic pulmonary haemorrhage in infants, but its relation to human diseases is not yet known. The aim of present study was to investigate the effect of repeated intratracheal injection of the fungus into mice, paying special attention to the pulmonary vascular system. Spores of S. chartarum were injected into the trachea of mice from 6 to 18 times over 4-12 weeks, and the lungs were examined by histopathology, morphometrics and haemodynamics. When 1 x 10(4) spores/mouse were injected, histopathological examination showed the development of pulmonary arterial hypertension (PAH). Symmetrical thickening of the intima and media of the pulmonary arterial walls was seen after six injections over 4 weeks. Right ventricular hypertrophy was also evident after 12 injections. PAH was confirmed by the elevation of right ventricular systolic pressure (20.1 +/- 5.7 mmHg in the injected group vs. 12.0 +/- 2.4 mmHg in the control group, P < 0.01). This study showed that the inhalation of S. chartarum caused PAH in mice, suggesting a potential of S. chartarum as a cause of human health problem such as PAH.
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Affiliation(s)
- Eri Ochiai
- Department of Pathogenic Fungi, Medical Mycology Research Center, Chiba University, Chiba, Japan
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West J, Fagan K, Steudel W, Fouty B, Lane K, Harral J, Hoedt-Miller M, Tada Y, Ozimek J, Tuder R, Rodman DM. Pulmonary Hypertension in Transgenic Mice Expressing a Dominant-Negative BMPRII Gene in Smooth Muscle. Circ Res 2004; 94:1109-14. [PMID: 15031260 DOI: 10.1161/01.res.0000126047.82846.20] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bone morphogenetic peptides (BMPs), a family of cytokines critical to normal development, were recently implicated in the pathogenesis of familial pulmonary arterial hypertension. The type-II receptor (BMPRII) is required for recognition of all BMPs, and targeted deletion of BMPRII in mice results in fetal lethality before gastrulation. To overcome this limitation and study the role of BMP signaling in postnatal vascular disease, we constructed a smooth muscle–specific transgenic mouse expressing a dominant-negative BMPRII under control of the tetracycline gene switch (SM22-tet-BMPRII
delx4+
mice). When the mutation was activated after birth, mice developed increased pulmonary artery pressure, RV/LV+S ratio, and pulmonary arterial muscularization with no increase in systemic arterial pressure. Studies with SM22-tet-BMPRII
delx4+
mice support the hypothesis that loss of BMPRII signaling in smooth muscle is sufficient to produce the pulmonary hypertensive phenotype.
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MESH Headings
- Animals
- Blood Pressure
- Bone Morphogenetic Protein Receptors, Type II
- Doxycycline/pharmacology
- Genes, Dominant
- Genetic Predisposition to Disease
- Genotype
- Humans
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/pathology
- Lung/pathology
- Mice
- Mice, Transgenic
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Organ Specificity
- Phenotype
- Promoter Regions, Genetic/drug effects
- Protein Serine-Threonine Kinases/deficiency
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/physiology
- Pulmonary Artery/physiopathology
- Pulmonary Artery/ultrastructure
- Transfection
- Transgenes
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Affiliation(s)
- James West
- University of Colorado Health Sciences Center, Division of Pulmonary Sciences and Critical Care Medicine and Department of Anesthesia, Denver, Colo 80262, USA
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Abstract
Pulmonary hypertension, as a result of adverse drug reactions, must be considered as a rare occurrence. With good medicinal chemistry and screening of compounds before entry into man, it should be almost totally avoidable. Life and medicine are a continuing challenge as our exploration of the regions of unknown biology throw up new targets and new mechanisms and may catch us again as the anorectic (anorectic) drug caught our predecessors.
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Affiliation(s)
- Tim Higenbottam
- Division of Clinical Science (South), Medical School, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2RX, UK.
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Steward CG, Pellier I, Mahajan A, Ashworth MT, Stuart AG, Fasth A, Lang D, Fischer A, Friedrich W, Schulz AS. Severe pulmonary hypertension: a frequent complication of stem cell transplantation for malignant infantile osteopetrosis. Br J Haematol 2004; 124:63-71. [PMID: 14675409 DOI: 10.1046/j.1365-2141.2003.04739.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This report describes eight infants who developed acute severe pulmonary arterial hypertension (PAH) at days -2 to +89 after allogeneic stem cell transplantation (SCT) for malignant infantile osteopetrosis (MIOP). They were taken from a total of 28 children (frequency 29%) transplanted for this disease at three institutions between 1996 and 2002. Typical presentations were acute dyspnoea, hypoxia and brady/tachycardia usually in the absence of fever, crepitations or other evidence of infection. Six patients (75%) required assisted ventilation and five (62%) died. There was clinical or pathological evidence of veno-occlusive disease (VOD) in three children, but absence of VOD in the remaining five suggests that a separate disease process may be responsible for the PAH. Responses to nitric oxide (NO), defibrotide (DF), nicardipine and steroids in varying combinations were disappointing. Three children showed sustained improvement after administration of epoprostenol (EP, prostacyclin) in conjunction with NO and/or DF and remain well and free of PAH 25, 31 and 32 months post-transplant. PAH must therefore be excluded in any child who becomes acutely breathless after SCT for osteopetrosis.
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Affiliation(s)
- C G Steward
- Bone Marrow Transplant Unit, Royal Hospital for Children, Bristol, UK.
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Abstract
Primary pulmonary hypertension (PPH) is a rare disorder characterised by raised pulmonary-artery pressure in the absence of secondary causes. Precapillary pulmonary arteries are affected by medial hypertrophy, intimal fibrosis, microthrombosis, and plexiform lesions. Most individuals present with dyspnoea or evidence of right heart failure. Echocardiography is the best non-invasive test to screen for suspected pulmonary hypertension. The discovery of mutations in the coding region of the gene for bone morphogenetic protein receptor 2 in patients with familial and sporadic PPH may help not only to elucidate pathogenesis but also to direct future treatment options. The pathogenesis is not completely understood, but recent investigations have revealed many possible candidate modifier genes. Without treatment, the disorder progresses in most cases to right heart failure and death. With current therapies such as epoprostenol, progression of disease is slowed, but not halted. Many promising new therapeutic options, including prostacyclin analogues, endothelin-1-receptor antagonists, and phosphodiesterase inhibitors, improve clinical function and haemodynamic measures and may prolong survival.
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Affiliation(s)
- James R Runo
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, T-1217 Medical Center North, Nashville, TN 37232-2650, USA
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Jeffery TK, Morrell NW. Molecular and cellular basis of pulmonary vascular remodeling in pulmonary hypertension. Prog Cardiovasc Dis 2002; 45:173-202. [PMID: 12525995 DOI: 10.1053/pcad.2002.130041] [Citation(s) in RCA: 221] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Clinical pulmonary hypertension is characterized by a sustained elevation in pulmonary arterial pressure. Pulmonary vascular remodeling involves structural changes in the normal architecture of the walls of pulmonary arteries. The process of vascular remodeling can occur as a primary response to injury, or stimulus such as hypoxia, within the resistance vessels of the lung. Alternatively, the changes seen in more proximal vessels may arise secondary to a sustained increase in intravascular pressure. To withstand the chronic increase in intraluminal pressure, the vessel wall becomes thickened and stronger. This "armouring" of the vessel wall with extra-smooth muscle and extracellular matrix leads to a decrease in lumen diameter and reduced capacity for vasodilatation. This maladaptive response results in increased pulmonary vascular resistance and consequently, sustained pulmonary hypertension. The process of pulmonary vascular remodeling involves all layers of the vessel wall and is complicated by the finding that cellular heterogeneity exists within the traditional compartments of the vascular wall: intima, media, and adventitia. In addition, the developmental stage of the organism greatly modifies the response of the pulmonary circulation to injury. This review focuses on the latest advances in our knowledge of these processes as they relate to specific forms of pulmonary hypertension and particularly in the light of recent genetic studies that have identified specific pathways involved in the pathogenesis of severe pulmonary hypertension.
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Affiliation(s)
- T K Jeffery
- Respiratory Medicine Unit, Department of Medicine, Addenbrooke's Hospital, University of Cambridge School of Clinical Medicine, Cambridge, UK
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