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Gierhardt M, Pak O, Walmrath D, Seeger W, Grimminger F, Ghofrani HA, Weissmann N, Hecker M, Sommer N. Impairment of hypoxic pulmonary vasoconstriction in acute respiratory distress syndrome. Eur Respir Rev 2021; 30:30/161/210059. [PMID: 34526314 DOI: 10.1183/16000617.0059-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/05/2021] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious complication of severe systemic or local pulmonary inflammation, such as caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ARDS is characterised by diffuse alveolar damage that leads to protein-rich pulmonary oedema, local alveolar hypoventilation and atelectasis. Inadequate perfusion of these areas is the main cause of hypoxaemia in ARDS. High perfusion in relation to ventilation (V/Q<1) and shunting (V/Q=0) is not only caused by impaired hypoxic pulmonary vasoconstriction but also redistribution of perfusion from obstructed lung vessels. Rebalancing the pulmonary vascular tone is a therapeutic challenge. Previous clinical trials on inhaled vasodilators (nitric oxide and prostacyclin) to enhance perfusion to high V/Q areas showed beneficial effects on hypoxaemia but not on mortality. However, specific patient populations with pulmonary hypertension may profit from treatment with inhaled vasodilators. Novel treatment targets to decrease perfusion in low V/Q areas include epoxyeicosatrienoic acids and specific leukotriene receptors. Still, lung protective ventilation and prone positioning are the best available standard of care. This review focuses on disturbed perfusion in ARDS and aims to provide basic scientists and clinicians with an overview of the vascular alterations and mechanisms of V/Q mismatch, current therapeutic strategies, and experimental approaches.
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Affiliation(s)
- Mareike Gierhardt
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Member of the German Center for Lung Research (DZL), Member of the Cardio-Pulmonary Institute (CPI) Bad Nauheim, Germany
| | - Oleg Pak
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Dieter Walmrath
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Institute for Lung Health (ILH), Giessen, Germany
| | - Friedrich Grimminger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Hossein A Ghofrani
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Norbert Weissmann
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Matthias Hecker
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Both authors contributed equally
| | - Natascha Sommer
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Both authors contributed equally
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2
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Methods to improve the yield of right heart catheterization in pulmonary hypertension. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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3
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Asadi AK, Sá RC, Kim NH, Theilmann RJ, Hopkins SR, Buxton RB, Prisk GK. Inhaled nitric oxide alters the distribution of blood flow in the healthy human lung, suggesting active hypoxic pulmonary vasoconstriction in normoxia. J Appl Physiol (1985) 2014; 118:331-43. [PMID: 25429099 DOI: 10.1152/japplphysiol.01354.2013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hypoxic pulmonary vasoconstriction (HPV) is thought to actively regulate ventilation-perfusion (V̇a/Q̇) matching, reducing perfusion in regions of alveolar hypoxia. We assessed the extent of HPV in the healthy human lung using inhaled nitric oxide (iNO) under inspired oxygen fractions (FiO2 ) of 0.125, 0.21, and 0.30 (a hyperoxic stimulus designed to abolish HPV without the development of atelectasis). Dynamic measures of blood flow were made in a single sagittal slice of the right lung of five healthy male subjects using an arterial spin labeling (ASL) MRI sequence, following a block stimulus pattern (3 × 60 breaths) with 40 ppm iNO administered in the central block. The overall spatial heterogeneity, spatiotemporal variability, and regional pattern of pulmonary blood flow was quantified as a function of condition (FiO2 × iNO state). While spatial heterogeneity did not change significantly with iNO administration or FiO2 , there were statistically significant increases in Global Fluctuation Dispersion, (a marker of spatiotemporal flow variability) when iNO was administered during hypoxia (5.4 percentage point increase, P = 0.003). iNO had an effect on regional blood flow that was FiO2 dependent (P = 0.02), with regional changes in the pattern of blood flow occurring in hypoxia (P = 0.007) and normoxia (P = 0.008) tending to increase flow to dependent lung at the expense of nondependent lung. These findings indicate that inhaled nitric oxide significantly alters the distribution of blood flow in both hypoxic and normoxic healthy subjects, and suggests that some baseline HPV may indeed be present in the normoxic lung.
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Affiliation(s)
- Amran K Asadi
- Department of Medicine, University of California, San Diego, La Jolla, California; and
| | - Rui Carlos Sá
- Department of Medicine, University of California, San Diego, La Jolla, California; and
| | - Nick H Kim
- Department of Medicine, University of California, San Diego, La Jolla, California; and
| | - Rebecca J Theilmann
- Department of Radiology, University of California, San Diego, La Jolla, California
| | - Susan R Hopkins
- Department of Medicine, University of California, San Diego, La Jolla, California; and Department of Radiology, University of California, San Diego, La Jolla, California
| | - Richard B Buxton
- Department of Radiology, University of California, San Diego, La Jolla, California
| | - G Kim Prisk
- Department of Medicine, University of California, San Diego, La Jolla, California; and Department of Radiology, University of California, San Diego, La Jolla, California
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Pulmonary vasodilator testing and use of calcium channel blockers in pulmonary arterial hypertension. Respir Med 2009; 104:481-96. [PMID: 20004088 DOI: 10.1016/j.rmed.2009.11.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 11/07/2009] [Accepted: 11/21/2009] [Indexed: 11/21/2022]
Abstract
Pulmonary arterial hypertension (PAH) encompasses a number of diseases responsible for a specific set of hemodynamic findings during right heart catheterization. During initial workup, pulmonary vasodilator testing is performed. A positive acute pulmonary vasodilator test predicts better survival and response to calcium channel blocker (CCB) therapy. There is lack of consensus on the preferred agent for determining acute pulmonary vasoreactivity. The ACCP guidelines and the 4(th) World Symposium on Pulmonary Hypertension support the use of intravenous epoprostenol or nitric oxide (NO) as the preferred agents for pulmonary vasodilator testing. A decrease in the mean pulmonary artery pressure by at least 10 mmHg to reach an absolute value of 40 mmHg or less without a decrease in cardiac output is currently considered a positive pulmonary vasodilator test. A positive test by the current recommended criteria is observed in about 10-15% of patients with idiopathic PAH. Approximately half of these patients will experience long-term benefits with CCBs. A positive test may select patients with an earlier or less aggressive form of disease, which may carry a better prognosis. A positive vasodilator test is observed very infrequently in patients with pulmonary arterial hypertension other than idiopathic PAH or anorexigen associated PAH. This article reviews the literature regarding pulmonary vasodilator testing and use of CCB therapy in patients with PAH, while identifying the gaps in knowledge concerning this diagnostic procedure.
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Skoro-Sajer N, Hack N, Sadushi-Koliçi R, Bonderman D, Jakowitsch J, Klepetko W, Hoda MAR, Kneussl MP, Fedullo P, Lang IM. Pulmonary Vascular Reactivity and Prognosis in Patients With Chronic Thromboembolic Pulmonary Hypertension. Circulation 2009; 119:298-305. [DOI: 10.1161/circulationaha.108.794610] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background—
Surgical pulmonary endarterectomy is the preferred treatment for chronic thromboembolic pulmonary hypertension. Persistent pulmonary hypertension after pulmonary endarterectomy has been recognized as a major determinant of poor outcome. We tested whether acute vasoreactivity identifies chronic thromboembolic pulmonary hypertension patients prone to develop persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and whether the degree of acute vasoreactivity affects survival or freedom from lung transplantation.
Methods and Results—
Right-sided heart catheterization at baseline and after inhalation of 40 ppm nitric oxide for 20 minutes was performed in 103 patients (56.3±15.3 years old, 53 women). Reductions in mean pulmonary arterial pressure (ΔmPAP; −8.8±12.6%;
P
<0.0001) and pulmonary vascular resistance (−16.1±18.1%;
P
<0.0001) and an increase in mixed venous saturation during inhaled nitric oxide (9.1±11.6%;
P
<0.0001) were observed. Sixty-two patients underwent pulmonary endarterectomy after a median of 49 days (25th and 75th percentiles: 24 and 123 days). Operated patients were followed up for a median of 70.9 months (25th and 75th percentiles: 14 and 97 months). Change in mPAP during inhaled NO was identified as a predictor of persistent/recurrent pulmonary hypertension after pulmonary endarterectomy. Patients experiencing a reduction in mPAP >10.4% with nitric oxide inhalation had a better postoperative outcome. A significant correlation was found between ΔmPAP and immediate postoperative pulmonary vascular resistance (
r
=0.5,
P
<0.0001).
Conclusions—
A total of 80 (77.7%) of 103 patients demonstrated acute pulmonary vascular reactivity of some degree. A decrease in mPAP >10.4% under inhaled nitric oxide is a predictor of long-term survival and freedom from lung transplantation in adult patients with chronic thromboembolic pulmonary hypertension who are undergoing pulmonary endarterectomy.
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Affiliation(s)
- Nika Skoro-Sajer
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Niklas Hack
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Roela Sadushi-Koliçi
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Diana Bonderman
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Johannes Jakowitsch
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Walter Klepetko
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Mir Ali Reza Hoda
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Meinhard P. Kneussl
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Peter Fedullo
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Irene M. Lang
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
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7
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Oliveira EC, Amaral CFS, Moura MA, Campos FTAF, Pauperio HM. Teste de vasorreatividade pulmonar. J Bras Pneumol 2008; 34:838-44. [DOI: 10.1590/s1806-37132008001000013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 01/24/2008] [Indexed: 11/22/2022] Open
Abstract
A hipertensão arterial pulmonar é classificada como idiopática ou secundária (associada a colagenoses, cardiopatias, hipertensão portal, tromboembolismo pulmonar e doenças da vasculatura pulmonar). O teste de vasorreatividade pulmonar é indicado para definir a melhor opção terapêutica. Muitas drogas têm sido utilizadas para a realização desse teste, sendo o óxido nítrico inalado a melhor opção, por apresentar ação específica pulmonar e meia vida muita curta (5-10 s). O resultado desse teste identifica candidatos à cirurgia cardíaca nas cardiopatias congênitas e candidatos ao uso de antagonista de cálcio nas outras formas de hipertensão pulmonar. A realização e interpretação do teste de vasorreatividade pulmonar exigem grande responsabilidade, e erros podem levar a decisões erradas e à ocorrência de óbitos.
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Ricci GL, Melgosa MT, Burgos F, Valera JL, Pizarro S, Roca J, Rodriguez-Roisin R, Barberà JA. Assessment of acute pulmonary vascular reactivity in portopulmonary hypertension. Liver Transpl 2007; 13:1506-14. [PMID: 17969197 DOI: 10.1002/lt.21173] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The role of acute pulmonary vasodilator testing in portopulmonary hypertension (PoPH), a current contraindication for orthotopic liver transplantation (OLT), has not been thoroughly elucidated. The purpose of this work was to analyze the results of acute vasodilator testing with inhaled nitric oxide (NO), to compare them with intravenous epoprostenol (PGI(2)), and to investigate the acute effects of the oral vasodilator isosorbide-5-mononitrate (Is-5-MN), in patients with PoPH. A total of 19 patients with PoPH (male/female = 9/10) were studied. Pulmonary hemodynamic measurements were performed at baseline and during NO inhalation (40 ppm); additionally, 15 patients were tested with PGI(2) (2-12 mug/kg/minute) and 8 were tested with Is-5-MN (20-40 mg). Inhaled NO reduced pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) by 5.7% and 11.0%, respectively. PGI(2) elicited greater reductions in PAP (11.8%) and PVR (-24.0%), and produced a 28% drop in systemic vascular resistance (SVR) and a 17% increase in the cardiac index (CI). Is-5-MN reduced PAP by 25.6% and PVR by 21.5%, without systemic changes. There was good agreement between the response to PGI(2) and Is-5-MN: 6 patients of the whole series (32%) decreased PAP >20% from baseline, reaching a final value < or = 35 mmHg, the current limit for OLT. In conclusion, acute vasodilator testing has a relevant role in PoPH, as it identifies one-third of patients able to reach a more favorable hemodynamic situation, which can be determinant for their management. For vasodilator testing, PGI(2) is more suitable than NO in PoPH. Is-5-MN exerts a selective effect on pulmonary circulation in patients who had already responded to PGI(2).
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Affiliation(s)
- Giovanni L Ricci
- Department of Clinical Sciences, Università; La Sapienza, Roma, Italy
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Abstract
This article briefly reviews the background of endothelium-dependent vasorelaxation, describes the nitric oxide/cGMP/protein kinase pathway and its role in modulating pulmonary vascular tone and remodeling, and describes three approaches that target the nitric oxide/cGMP pathway in the treatment of patients with pulmonary arterial hypertension.
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Affiliation(s)
- James R Klinger
- Division of Pulmonary Sleep and Critical Care Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
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Ulrich S, Fischler M, Speich R, Popov V, Maggiorini M. Chronic thromboembolic and pulmonary arterial hypertension share acute vasoreactivity properties. Chest 2006; 130:841-6. [PMID: 16963684 DOI: 10.1378/chest.130.3.841] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are the major classes of pulmonary hypertensive disorders according to the World Health Organization; both lead to right heart failure and death. A better understanding of disease mechanisms has led to the suggestion that the thromboembolic and nonthromboembolic types of pulmonary hypertension may share pathophysiologic features. We therefore compared acute vasoreactivity and proximal pulmonary artery compliance in patients with PAH and CTEPH during the initial diagnostic heart catheterization. METHODS Right heart catheterization using a flow-directed Swan-Ganz catheter was performed in patients with CTEPH (n = 22) and PAH (n = 35). Pulmonary hemodynamics were assessed at baseline, during the inhalation of 40 ppm of nitric oxide, and 30 min after the inhalation of 10 mug of iloprost. To assess the proximal pulmonary artery compliance, the pulse pressure (PP) [systolic-diastolic pressure] and the fractional PP (PPf) [divided by the mean pressure] were calculated. RESULTS Both vasodilators produced similar hemodynamic improvement, and the difference between CTEPH and PAH was not significant. The baseline PP and PPf did not vary between the two groups. CONCLUSION Patients with PAH and CTEPH show similar acute vasoreactivity to inhaled nitric oxide and iloprost, and have similar pulmonary artery compliance. These findings support the presence of some shared pathophysiologic pathways in both disorders and may lead to therapeutic implications in patients with inoperable CTEPH.
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Affiliation(s)
- Silvia Ulrich
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
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Sitbon O, Humbert M, Simonneau G. Les traitements de l’hypertension artérielle pulmonaire à l’heure de la T2A. Recommandations du groupe de travail “Maladies vasculaires pulmonaires” de la Société de pneumologie de langue française. Presse Med 2005; 34:1456-64. [PMID: 16301977 DOI: 10.1016/s0755-4982(05)84207-1] [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] [Indexed: 11/22/2022] Open
Abstract
Activity-based financing (that is, casemix-based hospital payments, known as T2A) is intended to harmonize and improve the fairness of remuneration of public and private hospitals. T2A will ultimately rely mainly on a flat rate per admission, set according to the diagnosis-related group (DRG). Although payment for drugs is usually included in the DRG price, some expensive drugs will be reimbursed on an additional cost basis after implementation of a "best practices" agreement. Four drugs used for treatment of pulmonary arterial hypertension are eligible for this additional reimbursement: 3 prostacyclin derivatives (intravenous epoprostenol, inhaled iloprost, and subcutaneous treprostinil), and oral bosentan, an endothelin receptor antagonist. The Pulmonary Vascular Diseases working group of the French Society of Pulmonary Medicine has developed guidelines for the best practices in use of these drugs.
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Affiliation(s)
- O Sitbon
- Centre de référence national sur l'HTAP, service de pneumologie et réanimation, UPRES EA2705, Université Paris-Sud, Hôpital Antoine Béclère, AP-HP, Clamart.
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Abstract
BACKGROUND AND OBJECTIVES Pulmonary arterial hypertension (PHT) is a potentially fatal disease. The purpose of this article is to review the current knowledge of the role played by endothelin (ET) in PHT and the relevant drug regimens used in the treatment of this condition. METHODS A detailed search via MEDLINE (PubMed) was performed by using PHT and ET as the key terms. RESULTS PHT could be a primary or a secondary diagnosis associated with various heart and lung diseases. PHT appears during the late stage of systemic sclerosis and may complicate other systemic diseases such as systemic lupus erythematosus. The vascular endothelium and activation of various mediators and growth factors such as the ET system are thought to play a crucial role in the development of this condition. The pathologic process progresses very rapidly from vasoconstriction to widespread pulmonary vascular obstruction. The use of high doses of calcium channel blockers is of limited value. Life-long anticoagulant therapy is recommended for the treatment of PHT. Currently, the drug being used in PHT therapy is continuous central-venous prostacyclin infusion. Prostacyclin is a strong vasodilator with antiaggregate and antifibrotic properties and has the potential to reduce endothelial injury and to induce vasculature remodeling. This treatment results in improved functional status and increased life span. Unfortunately, its use is accompanied by various side effects, technical difficulties, and high cost. The role of other therapeutic modalities (inhaled prostacyclin, subcutaneous treprostinil, oral beraprost, sildenafil) in vascular remodeling, and the improvement in functional capacity and survival of patients with PHT, are currently under investigation. Bosentan, administered orally, is a recently developed active ET receptor antagonist. It is a promising new therapeutic tool in the treatment of PHT because of its potent vasodilator, antiproliferative, and vascular remodeling activity. CONCLUSIONS The revolutionary conceptual shift in understanding the pathogenesis of PHT from a vasoconstrictive process to a vasoproliferative one, has led to a modification in the treatment of this disease from the use of vasodilators to the use of drugs with antiproliferative and vascular remodeling activity. Until now, prostacyclin was the only drug of this type available for the treatment of PHT. ET blockade seems to be a reasonable and potential therapeutic option.
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Morales-Blanhir J, Santos S, de Jover L, Sala E, Paré C, Roca J, Rodriguez-Roisin R, Barberà JA. Clinical value of vasodilator test with inhaled nitric oxide for predicting long-term response to oral vasodilators in pulmonary hypertension. Respir Med 2004; 98:225-34. [PMID: 15002758 DOI: 10.1016/j.rmed.2003.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute vasodilator tests with prostacyclin (PGI2) or inhaled nitric oxide (iNO) are used to select patients with pulmonary arterial hypertension (PAH) who should be treated with oral vasodilators. The haemodynamic effects of PGI2 and iNO are different, and the limits for considering a vasodilator response as significant are controversial. The study was aimed to investigate the diagnostic performance of acute vasodilator testing with iNO and PGI2 in predicting the clinical outcome after 1 year treatment with oral vasodilators. Twenty-seven patients with severe PAH were studied. Nineteen patients were treated with oral vasodilators and their outcome after 1 year was qualified as favourable or unfavourable. The diagnostic performance of vasodilator tests in predicting this outcome was evaluated using receiver operating characteristics (ROC) curves. The acute effects of iNO and PGI2 on pulmonary artery pressure (PAP) were similar. By contrast, PGI2 produced more marked changes on cardiac output and pulmonary vascular resistance than iNO (P<0.05). The evolution at 1 year was favourable in 11 patients and unfavourable in 8. Patients with favourable evolution showed greater decrease of PAP with iNO than with PGI2 (P<0.05). The decrease of PAP with iNO had the greatest predictive value on the clinical outcome (area under ROC curve, 0.83). We conclude that in patients with PAH, acute vasodilator testing with iNO is preferable to PGI2 because it reflects more consistently the changes in pulmonary vascular tone. The acute decrease of PAP with iNO is the best predictor of the long-term response to oral vasodilator treatment.
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Affiliation(s)
- Jaime Morales-Blanhir
- Department of Pulmonary Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Abstract
Because the causes of primary pulmonary hypertension (PPH) remains unknown, the therapeutic approach of the disease can be only empirical, based on the pathology and pathobiology of pulmonary circulation. Despite the inability to cure the disease, therapeutic advances over the past 20 years have contributed to an improvement of quality of life and prolonged survival in PPH patients. Current therapeutic approach of PPH mostly includes limitation of physical activity, long-term anticoagulation, and vasodilator therapy. Among all tested oral vasodilators, calcium-channel blockers are the most efficient long-term therapies by improving symptoms and hemodynamics in a subset of PPH patients (10% to 15%) who acutely respond to such drugs. Acute pulmonary vasodilator response to inhalation of nitric oxide can predict acute and chronic responses to oral calcium-channel blockers. A better understanding of the pathogenesis of PPH has changed the focus of medical treatments from purely chronic vasodilator therapy to the evaluation of agents, such as prostaglandins, that may reverse the proliferation of pulmonary vascular cells and result in regression of the pulmonary vascular hypertrophy and remodeling. Long-term treatment with intravenous epoprostenol (prostaglandin I(2) or prostacyclin) improves exercise capacity, hemodynamics and survival in most patients with PPH in functional class NYHA III or IV, and may be currently considered as the "gold standard" therapy for severe patients. However, response to long-term epoprostenol therapy may be incomplete, adverse effects are common, and survival remains unsatisfactory (55% at 5 years). In such patients with severe pulmonary hypertension refractory to medical therapy, atrioseptostomy and lung transplantation can be indicated.
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Affiliation(s)
- Olivier Sitbon
- Service de Pneumologie et Réanimation Respiratoire, Pulmonary Vascular Center, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Clamart, France
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16
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Budts W, Van Pelt N, Gillyns H, Gewillig M, Van De Werf F, Janssens S. Residual pulmonary vasoreactivity to inhaled nitric oxide in patients with severe obstructive pulmonary hypertension and Eisenmenger syndrome. Heart 2001; 86:553-8. [PMID: 11602551 PMCID: PMC1729989 DOI: 10.1136/heart.86.5.553] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine whether inhaled NO (iNO) can reduce pulmonary vascular resistance in adults with congenital heart disease and obstructive pulmonary hypertension or Eisenmenger syndrome. DESIGN 23 patients received graded doses of iNO. Pulmonary and systemic haemodynamic variables and circulating cyclic guanosine monophosphate (cGMP) concentrations were measured at baseline and after 20 and 80 ppm iNO. Patients were considered responders when total pulmonary resistance was reduced by at least 20%, and rebound was defined as a greater than 10% increase in total pulmonary resistance upon withdrawal from iNO. RESULTS In response to 20 ppm iNO, total pulmonary resistance decreased in four patients (18%, 95% confidence interval (CI), 2% to 34%), while in response to 80 ppm iNO it decreased in six patients (29%, 95% CI 10% to 38%). Systemic blood pressure did not change. Withdrawal resulted in rebound in three patients (16%, 95% CI 0% to 32%) after cessation of 20 ppm iNO, and in six patients (35%, 95% CI 12% to 58%) after cessation of 80 ppm iNO. Patients with predominant right to left shunting did not respond. In all patients cGMP increased from (mean (SD)) 28 (13) micromol/l at baseline to 55 (30) and 78 (44) micromol/l after 20 and 80 ppm iNO (p < 0.05 v baseline). CONCLUSIONS NO inhalation is safe and is associated with a dose dependent increase in circulating cGMP concentrations. Pulmonary vasodilatation in response to iNO was observed in 29% of patients and was influenced by baseline pulmonary haemodynamics. Responsiveness to acute iNO may identify patients with advanced obstructive pulmonary hypertension and Eisenmenger syndrome who could benefit from sustained vasodilator treatment.
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Affiliation(s)
- W Budts
- Department of Cardiology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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17
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Recommendations on the management of pulmonary hypertension in clinical practice. Heart 2001; 86 Suppl 1:I1-13. [PMID: 11473937 PMCID: PMC1766547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
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18
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Lee SD, Kim DS, Shim TS, Lim CM, Koh Y, Kim WS, Kim WD. Nitric oxide and molsidomine in the management of pulmonary hypertension in Takayasu's arteritis. Chest 2001; 119:302-7. [PMID: 11157624 DOI: 10.1378/chest.119.1.302] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
We present three patients with pulmonary hypertension in Takayasu's arteritis who showed long-term favorable response, clinically and hemodynamically, to nitric oxide donor molsidomine. In these patients, nitric oxide inhalation was effective in reducing pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). Molsidomine (single dose of 4 mg p.o.) was also effective in reducing PAP and PVR, but nifedipine was not. With molsidomine, 4 mg tid, dyspnea, exercise capacity, and hemodynamic parameters were improved. These favorable responses have lasted during the 3-month follow-up period in all patients.
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Affiliation(s)
- S D Lee
- Department of Internal Medicine, Asan Medical Center, College of Medicine, Ulsan University, Seoul, Korea.
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19
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Abstract
The goals of treatment of cor pulmonale are 1) to reduce pulmonary arterial hypertension; 2) to optimize gas-exchange efficiency; and 3) to improve survival. These goals are achieved through long-term oxygen therapy, bronchodilator and vasodilator therapy, aggressive treatment of pulmonary infection, and anticoagulation. Selected patients may benefit from available surgical options.
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Affiliation(s)
- ED Missov
- Division of Cardiology, University of California at San Francisco, 1180 Moffitt Hospital, 505 Parnassus Avenue, San Francisco, CA 94143-0124, USA.
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20
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Hoeper MM, Olschewski H, Ghofrani HA, Wilkens H, Winkler J, Borst MM, Niedermeyer J, Fabel H, Seeger W. A comparison of the acute hemodynamic effects of inhaled nitric oxide and aerosolized iloprost in primary pulmonary hypertension. German PPH study group. J Am Coll Cardiol 2000; 35:176-82. [PMID: 10636277 DOI: 10.1016/s0735-1097(99)00494-5] [Citation(s) in RCA: 198] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We sought to compare the acute hemodynamic effects of inhaled nitric oxide (NO) and aerosolized iloprost in primary pulmonary hypertension (PPH). BACKGROUND Inhalation of the stable prostacyclin analogue iloprost has recently been described as a novel therapeutic strategy for PPH and may offer an alternative to continuous intravenous infusion of prostacyclin or inhalation of NO. METHODS During right heart catheterization, 35 patients with PPH sequentially inhaled 40 ppm of NO and 14 to 17 microg of iloprost, and the effects on hemodynamics and blood gases were monitored. RESULTS Both NO and iloprost caused significant increases in cardiac output, mixed-venous oxygen saturation and stroke volume as well as significant decreases in pulmonary artery pressure and pulmonary vascular resistance, whereas only inhaled iloprost significantly increased the arterial PO2 (p = 0.01). Compared with inhaled NO, aerosolized iloprost was more effective in reducing pulmonary artery pressure (-8.3 +/- 7.5 mm Hg vs. -4.3 +/- 8.8 mm Hg; p = 0.0001) and the pulmonary vascular resistance (-447 +/- 340 dynes x s x cm(-5) vs. -183 +/- 305 dyne x s x cm(-5); p < 0.0001). Furthermore, aerosolized iloprost caused a significantly greater increase of the cardiac output compared with NO (+0.7 +/- 0.6 liter/min vs. +0.3 +/- 0.4 liter/min; p = 0.0002) and had a more pronounced effect on the mixed-venous oxygen saturation (p = 0.003). CONCLUSIONS During acute drug testing, aerosolized iloprost was more potent than inhaled NO as a pulmonary vasodilator in PPH at the doses used in this study.
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Affiliation(s)
- M M Hoeper
- Department of Pulmonary Medicine, Hannover Medical School, Germany.
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Affiliation(s)
- A J Peacock
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow G11 6NT, UK
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22
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Affiliation(s)
- S Brij
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, UK
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23
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Schenk P, Mittermayer C, Ratheiser K. Inhaled nitric oxide in a patient with severe pulmonary embolism. Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80011-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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24
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Affiliation(s)
- M K al-Ali
- University Medicine, Southampton General Hospital, U.K
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