Pulmonary hypertension and right heart dysfunction in chronic lung disease

Multi-omics reveals bufadienolide Q-markers of Bufonis Venenum based on antitumor activity and cardiovascular toxicity in zebrafish

BACKGROUND

Bufonis Venenum (BV) is a traditional animal-based Chinese medicine with therapeutic effects against cancer. However, its clinical use is significantly restricted due to associated cardiovascular risks. BV's value in China's market is typically assessed based on "content priority," focusing on indicator components. However, these components of BV possess both antitumor activity and toxicity, and the correlation between the antitumor activity and toxicity of BV has not yet been elucidated.

PURPOSE

This study employs an integrated multi-omics approach to identify bufadienolide Q-markers and explore the correlation between BV's antitumor activity and toxicity. The aim is to establish a more comprehensive method for BV's quality.

METHODS

Normal zebrafish and HepG2 xenograft zebrafish were chosen as activity and toxicity evaluation models. Ultra-high performance liquid chromatography (UHPLC) coupled with a linear ion trap orbitrap (LTQ-Orbitrap) mass spectrometry was used to quantify eight batches of BV and key "toxic and effective" components were screened out. Transcriptomic and metabolomic analyses were performed to elucidate the regulatory mechanisms underlying the antitumor activity and cardiovascular toxicity of the key components in BV.

RESULTS

Eight key "toxic and effective" compounds were identified: resibufogenin, cinobufagin, arenobufagin, bufotalin, bufalin, gamabufotalin, desacetylcinobufagin, and telocinobufagin. The findings showed that bufalin and cinobufagin interfered with calcium homeostasis through CaV and CaSR, induced cardiotoxicity, and upregulated CASP9 to activate myocardial cell apoptosis. However, desacetylcinobufagin exhibited greater potential in terms of anti-tumor effects. Combining the results of untargeted and targeted metabolomics revealed that desacetylcinobufagin could have a callback effect on differential lipids and correct abnormal energy and amino acid metabolism caused by cancer, similar to cinobufagin and bufalin. Microscale thermophoresis (MST) ligand binding measurements also showed that the binding of desacetylcinobufagin to GPX4 has a more potent ability to induce ferroptosis in tumor cells compared to cinobufagin.

CONCLUSION

An innovative evaluation method based on the zebrafish was developed to investigate the relationship between the toxicity and efficacy of BV. This study identified toxicity and activity Q-markers and explored the mechanism between the two effects of BV. The research data could offer valuable insights into the efficacy of BV. Additionally, desacetylcinobufagin, an active ingredient with low toxicity, was found to enhance the quality of BV.

The Application of Point of Care Ultrasound to Screen for Pulmonary Hypertension: A Narrative Review

BACKGROUND

Pulmonary Hypertension (PH) is a condition with several cardiopulmonary etiologies that has the potential of progressing to right heart failure without proper intervention. After a history, physical exam, and investigations, cases of suspected PH typically undergo imaging via a transthoracic echocardiogram (TTE). This is a resource-intensive procedure that is less accessible in remote communities. However, point of care ultrasound (POCUS), a portable ultrasound administered at the bedside, has potential to aid in the diagnostic process of PH.

METHODS

The MEDLINE, Embase, and CENTRAL databases were searched to screen the intersection of POCUS and PH. Studies involved adult patients, and only English articles were accepted. Reviews, case reports, unfinished research, and conference abstracts were excluded. Our aim was to identify primary studies that correlated POCUS scan results and additional clinical findings related to PH.

RESULTS

Nine studies were included after our search. In these studies, POCUS was effective in identifying dilatation of inferior vena cava (IVC); internal jugular vein (IJV); and hepatic, portal, and intrarenal veins in patients with PH. The presence of pericardial effusion, pleural effusion, or b-lines on POCUS are also associated with PH.

CONCLUSIONS

This review suggests important potential for the use of POCUS in the initial screening of PH. IVC and basic cardiopulmonary POCUS exams are key for PH screening in patients with dyspnea. Right-heart dilatation can be visualized, and peripheral veins may be scanned based on clinical suspicion. POCUS offers screening as an extension of a physical exam, with direct visualization of cardiac morphology. However, more studies are required to develop a statistically validated POCUS exam for PH diagnosis. More studies should also be conducted at the primary-care level to evaluate the value of screening using POCUS for PH in less-differentiated patients.

Sudden death due to spontaneous rupture of the right atrium in the setting of chronic lung disease: A case report and review

Sudden death from haemopericardium as a result of a right atrial rupture is uncommon, most particularly when this occurs spontaneously without any prior trauma or evidence of atrial wall pathology. The deceased was a 32-year-old man. At lunchtime his symptoms of unease, giddiness and unconsciousness began and within 45 minutes he arrived at the hospital. His vitals could not be recorded in the emergency department, and after CPR, he was pronounced dead. At autopsy, an isolated right atrial rupture, without any disease of the heart wall, was discovered. The right atrium has the weakest wall and is frequently the site of spontaneous rupture brought on by increased intraluminal pressure. Both liquid blood and clotted blood were found in the pericardial cavity. Low atrial pressure encourages clot formation because it causes considerably slower blood entry into the pericardium at the time of atrial rupture compared with entry at the time of ventricular rupture. Evidence of chronic lung disease was found which explains the raised intraluminal pressure of the heart chambers. Even with no history of trauma or myocardial infarction, the Beck triad - an engorged neck vein, a muffled heart sound, and low blood pressure - should alert the emergency room staff to the possibility of cardiac tamponade because, in a very unlikely scenario, spontaneous cardial wall rupture might occur.

The alveolus: Our current knowledge of how the gas exchange unit of the lung is constructed and repaired

The mammalian lung completes its last step of development, alveologenesis, to generate sufficient surface area for gas exchange. In this process, multiple cell types that include alveolar epithelial cells, endothelial cells, and fibroblasts undergo coordinated cell proliferation, cell migration and/or contraction, cell shape changes, and cell-cell and cell-matrix interactions to produce the gas exchange unit: the alveolus. Full functioning of alveoli also involves immune cells and the lymphatic and autonomic nervous system. With the advent of lineage tracing, conditional gene inactivation, transcriptome analysis, live imaging, and lung organoids, our molecular understanding of alveologenesis has advanced significantly. In this review, we summarize the current knowledge of the constituents of the alveolus and the molecular pathways that control alveolar formation. We also discuss how insight into alveolar formation may inform us of alveolar repair/regeneration mechanisms following lung injury and the pathogenic processes that lead to loss of alveoli or tissue fibrosis.

Echocardiography and pulmonary hypertension in patients with chronic obstructive pulmonary disease undergoing lung transplantation evaluation

BACKGROUND

The use of echocardiography in pulmonary hypertension (PH) in advanced chronic obstructive pulmonary disease (COPD) is understudied. We aimed to compare the performance of echocardiography with right heart catheterization (RHC) in the diagnosis of PH in COPD patients undergoing lung transplant evaluation.

METHODS

We included 111 patients with severe COPD who underwent RHC in a single center as part of lung transplantation evaluation. COPD-PH and severe COPD-PH were defined based on RHC per the 6th world symposium on pulmonary hypertension. Echocardiographic probability of PH was described according to the European Society of Cardiology guidelines. Summary and univariate analyses were performed.

RESULTS

The mean age (±SD) was 62 (8) and 47% (n=52) were men. A total of 82 patients (74 %) had COPD-PH. The sensitivity, specificity, positive predictive, and negative predictive values of echocardiography in diagnosing COPD-PH were 43 %, 83 %, 88 %, and 34 % respectively and for severe COPD-PH were 67 %, 75 %, 50 %, and 86 % respectively. Echocardiography was consistent with RHC in ruling in/out PH in 53% (n=59) of patients. After controlling for age, sex. BMI, pack year, echocardiography-RHC time difference, GOLD class, FVC, and CT finding of emphysema, higher TLC decreased consistency (parameter estimate=-0.031; odds ratio: 0.97, 95%CI 0.94-0.99; p=0.037) and higher DLCO increased consistency (parameter estimate=0.070; odds ratio: 1.07, 95%CI 0.94-0.99; p=0.026).

CONCLUSIONS

Echocardiography has high specificity but low sensitivity for the diagnosis of PH in advanced COPD. Its performance improves when ruling out severe COPD-PH. This performance correlates inversely with lung hyperinflation.

Jagged 2 inhibition attenuates hypoxia-induced mitochondrial damage and pulmonary hypertension through Sirtuin 1 signaling

Notch pathway has played a significant role in the pathophysiology of pulmonary hypertension (PH). However, the role of Jagged 2 (Jag2), one ligand of Notch, remains to be elucidated.Therefore, determining the contribution of Jag2 to PH and its impact on pulmonary artery smooth muscle cells (PASMCs) was the aim of this investigation. Adeno-associated virus-mediated Jag2 inhibition was used to explore the role of Jag2 in peripheral pulmonary vascular remodeling assessed in a rat model of chronic hypoxia (10% O2, 4 weeks) induced pulmonary hypertension. In vitro, the effect of Jag2 silencing on hypoxia (1% O2, 24h) induced rat PASMCs was determined. Group differences were assessed using a 2-sided unpaired Student's t-test for two groups and one-way ANOVA for multiple groups. Jag2 upregulation was first confirmed in rats with sustained hypoxia-induced PH using publicly available gene expression data, experimental PH rat models and hypoxia induced rat PASMCs. Jag2 deficiency decreased oxidative stress injury, peripheral pulmonary vascular remodeling (0.276±0.020 vs. 0.451±0.033 μm, P<0.001, <50μm), and right ventricular systolic pressure (36.8±3.033 vs. 51.8±4.245 mmHg, P<0.001) in the chronic hypoxia-induced rat model of PH. Moreover, Jag2 knockdown decreased proliferation (1.227±0.051 vs. 1.45±0.07, P = 0.012), increased apoptosis (16.733%±0.724% vs. 6.56%±0.668%, P<0.001), and suppressed mitochondrial injury in hypoxia-treated rat PASMCs. Jag2 inhibition restored the activity of the Nrf2/HO-1 pathway, which was abolished by Sirtuin 1 deficiency. These findings show that Jag2 is essential for modulating pulmonary vascular dysfunction and accelerating PH, and that inhibition of Jag2 expression suppresses the progression and development of PH.

Effects of Ivabradine on Right Ventricular Systolic Function in Patients With Chronic Obstructive Pulmonary Disease and Cor Pulmonale

Cor pulmonale is a clinical syndrome associated with pulmonary hypertension, frequently complicated by congestive heart failure, commonly caused by chronic obstructive pulmonary disease (COPD). Most patients with cor pulmonale have tachycardia. However, heart rate (HR) reduction represents a primary treatment goal to improve the survival and quality of life in these patients. Ivabradine can selectively slow HR at rest and during exercise. In this prospective study, we tested the hemodynamic effects, invasively determined using right-sided cardiac catheterization, of reducing HR with ivabradine. We selected 18 patients (13 men [72.2%], mean age 67 ± 10 years) with COPD and cor pulmonale, presenting with sinus tachycardia. All patients performed clinical evaluation, electrocardiogram, spirometry, echocardiogram, 6-minute walking distance, and right-sided cardiac catheterization within 1 month of enrollment. All tests were repeated after 6 months of ivabradine treatment (median assumed dose 11.9 mg/die). We noticed a significant decrease of HR (from 98 ± 7 to 77 ± 8 beats/min, p = 0.0001), with a concomitant reduction of the congestion index (from 25.9 ± 5.1 to 19.4 ± 5.7 mm Hg, p = 0.001), and the consequent improvement of the right ventricular systolic performance (right ventricular stroke volume augmented from 56.7 ± 7.9 to 75.2 ± 8.6 ml/beat, p = 0.0001). This allows an improvement in clinical status and exercise tolerance (Borg scale score decreased from 5.2 ± 1.4 to 4.1 ± 1.3, p = 0.01 and the 6-minute walking distance increased to 252 ± 65 to 377 ± 59 m, p = 0.001). In conclusion, HR reduction significantly improves hemodynamic and clinical status of patients with tachycardia affected by COPD and cor pulmonale.

Pulmonary Arterial Hypertension in the Elderly: Peculiar Features and Challenges for a Proper Phenotyping Approach

(1) Introduction. Although pulmonary arterial hypertension (PAH) usually affects young people with a low cardiovascular risk profile, progressive epidemiologic changes have been providing a codified phenotype of elderly subjects with PAH and increased risk predictors for left heart disease. We therefore conducted a systematic review to describe the current knowledge and characteristics of elderly individuals with PAH and further insights concerning their prognostic outcomes and therapeutic response. (2) Methods. A search was conducted in PubMed, Embase, and Cochrane Library for publications evaluating the epidemiology, diagnostic work-up, and treatment of PAH in elderly subjects. (3) Among the 74 publications initially retrieved, 16 full-text articles were selected for the present systematic review. Compared to their younger counterparts, elderly individuals with PAH showed greater clinical deterioration, reduced exercise capacity, and worse prognostic outcomes, as well as less response to PAH-targeted therapy and higher rates of PAH drug discontinuation. (4) Conclusions. Demographic changes over time contributed to define a peculiar PAH phenotype in elderly patients, with an increased burden of cardiovascular comorbidities and distinctive features compared to young patients. Further investigations are needed in order to better clarify the nosologic criteria, and management in this subset population.

Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management

Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.

Cardiovascular Diseases in COPD: From Diagnosis and Prevalence to Therapy

Chronic obstructive pulmonary disease (COPD) is considered one of the leading causes of mortality. Cardiovascular comorbidities are diagnosed often in COPD patients, not only because of the common risk factors these two diseases share, but also because of the systemic inflammation which characterizes COPD and has deleterious effects in the cardiovascular system. The comorbid cardiovascular diseases in COPD result in several difficulties in the holistic treatment of these patients and affect outcomes such as morbidity and mortality. Several studies have reported that mortality from cardiovascular causes is common among COPD patients, while the risk for acute cardiovascular events increases during COPD exacerbations and remains high for a long time even after recovery. In this review, we focus on the prevalence of cardiovascular comorbidities in COPD patients, presenting the evidence regarding the interaction of the pathophysiological pathways which characterize each disease. Furthermore, we summarize information regarding the effects of cardiovascular treatment on COPD outcomes and vice versa. Finally, we present the current evidence regarding the impact of cardiovascular comorbidities on exacerbations, quality of life and survival of COPD patients.

Natural Products for the Treatment of Pulmonary Hypertension: Mechanism, Progress, and Future Opportunities

Pulmonary hypertension (PH) is a lethal disease due to the remodeling of pulmonary vessels. Its pathophysiological characteristics include increased pulmonary arterial pressure and pulmonary vascular resistance, leading to right heart failure and death. The pathological mechanism of PH is complex and includes inflammation, oxidative stress, vasoconstriction/diastolic imbalance, genetic factors, and ion channel abnormalities. Currently, many clinical drugs for the treatment of PH mainly play their role by relaxing pulmonary arteries, and the treatment effect is limited. Recent studies have shown that various natural products have unique therapeutic advantages for PH with complex pathological mechanisms owing to their multitarget characteristics and low toxicity. This review summarizes the main natural products and their pharmacological mechanisms in PH treatment to provide a useful reference for future research and development of new anti-PH drugs and their mechanisms.

Right ventricular-pulmonary arterial uncoupling in mild-to-moderate asthma

OBJECTIVE

Persistent pulmonary hypertension and resulting right ventricular (RV) failure are highly encountered phenomenon in severe pulmonary diseases. However, in this study, we aimed to examine the effects of mild-to-moderate asthma on RV functions, pulmonary arterial stiffness (PAS), and coupling of RV to the pulmonary artery (PA) in the absence of overt pulmonary hypertension.

METHODS

We enrolled 53 patients with mild-to-moderate asthma, and 50 healthy control subjects. A comprehensive two dimensional transthoracic echocardiography was performed on each individual. The parameters measuring RV function were all examined. PAS was calculated by dividing maximal frequency shift of pulmonary flow by pulmonary acceleration time. RV-PA coupling was estimated by the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio (TAPSE/PASP).

RESULTS

Baseline demographics, clinical and laboratory parameters of both groups were similar (p > 0.05). Most of conventional echocardiographic parameters measuring RV function were impaired in patients with asthma compared to control subjects. PAS values were significantly higher in the asthma group [24 (21-26) vs. 20 (18-22), p < 0.001], and TAPSE/PASP ratio was significantly lower in the asthma group versus the control group [0.81 ± 0.08 vs. 0.96 ± 0.11, p < 0.001]. Multilinear regression analysis revealed PAS, TAPSE, and PASP as independent predictors of TAPSE/PASP ratio.

CONCLUSION

Mild-to-moderate asthma was shown to be associated with both subclinical RV dysfunction and increased PAS values. TAPSE/PASP ratio was also markedly decreased, suggesting RV-PA uncoupling even in the absence of overt pulmonary hypertension. PAS referring RV afterload was shown to be an independent predictor of TAPSE/PASP ratio.

Diagnosis and management of pulmonary hypertension related to chronic respiratory disease

Pulmonary hypertension (PH) is a recognised and significant complication of chronic lung disease (CLD) and hypoxia (referred to as group 3 PH) that is associated with increased morbidity, decreased quality of life and worse survival. The prevalence and severity of group 3 PH varies within the current literature, with the majority of CLD-PH patients tending to have non-severe disease. The aetiology of this condition is multifactorial and complex, while the prevailing pathogenetic mechanisms include hypoxic vasoconstriction, parenchymal lung (and vascular bed) destruction, vascular remodelling and inflammation. Comorbidities such as left heart dysfunction and thromboembolic disease can further confound the clinical picture. Noninvasive assessment is initially undertaken in suspected cases (e.g. cardiac biomarkers, lung function, echocardiogram), while haemodynamic evaluation with right heart catheterisation remains the diagnostic gold standard. For patients with suspected severe PH, those with a pulmonary vascular phenotype or when there is uncertainty regarding further management, referral to specialist PH centres for further investigation and definitive management is mandated. No disease-specific therapy is currently available for group 3 PH and the focus of management remains optimisation of the underlying lung therapy, along with treating hypoventilation syndromes as indicated.

Regression of Tricuspid Valve Regurgitation After Lung Transplant: A Single-Center Experience

BACKGROUND

Although tricuspid regurgitation (TR) is common in candidates for lung transplant, no data or established guidelines exist regarding the need for surgical repair at the time of transplant. We aimed to evaluate the natural course of TR by assessing the incidence and extent of TR regression among patients who did not undergo tricuspid valve repair (TVR) concomitantly with lung transplant.

METHODS

We retrospectively identified adult patients who underwent lung transplant without TVR at our institution from 2001 through 2017. Pretransplant and posttransplant echocardiograms were reviewed to assess severity of TR, tricuspid annular plane systolic excursion, central venous pressure, mean pulmonary arterial pressure, and right ventricular size and function.

RESULTS

Among 553 included patients, 324 (58.7%) were men, the mean (SD) age was 61.9 years (12.7), and 417 (75.4%) had a double lung transplant. TR before transplant was reported as trivial in 265 patients (47.9%), mild in 235 (42.5%), moderate in 40 (7.2%), and severe in 13 (2.4%). After transplant, TR improved significantly overall (P < .001). TR improved in 193 patients: 158 patients (81.9%) by 1 grade and 35 patients (18.1%) by 2 or more grades. Additionally, of 53 patients with pretransplant moderate or severe TR, 44 (83%) had improvement to mild, trivial, or no TR. After transplant, 12 patients (2.2%) had no remaining TR.

CONCLUSION

The severity of TR improved or showed no change in most patients after lung transplant, which obviates the need for TVR among most lung transplant recipients.

Association of right ventricle diastolic diameter with pulmonary function, exercise tolerance and exacerbation period in patients with chronic obstructive pulmonary disease: A prospective study

BACKGROUND

The echocardiogram is a useful method for monitoring the cardiovascular complications of chronic obstructive pulmonary disease (COPD), but it is not clear if morphological and functional cardiac variables are able to identify patients with unfavorable COPD progression.

OBJECTIVE

The aim of this study was to investigate morphological and functional echocardiographic variables associated with exacerbation of the disease, pulmonary function parameters and functional capacity evaluation in COPD patients.

METHOD

A longitudinal observational study including 91 patients diagnosed with COPD, who were stratified in two groups according to their basal right ventricle diastolic diameter (RVDD) measuring greater and less than 35 mm. They underwent clinical evaluation, echocardiography, spirometry and 6-minute walking-test (6MWT).

RESULTS

The study found that patients with RVDD greater than 35 mm showed worse functional capacity in the 6MWT (p = 0.05) and more exacerbation of the disease during the one-year follow-up (p = 0.05). There were correlations of greater RVDD vs forced vital capacity (R = -0.27; p = 0.02) and distance in the 6MWT (R = 0.55; p = 0.03) in patients with exacerbation. In the univariate regression analysis, the RVDD was responsible for 55% of the variation in distance in the 6MWT (-0.75 m) in COPD patients.

CONCLUSION

The RV dilation is associated with unfavorable prognostic markers in COPD, such as the worsening of the functional capacity and more frequent exacerbations. The echocardiogram may be a useful tool to identify patients who need more aggressive strategies to control the evolution of the disease with potential impact in pulmonary rehabilitation.

The frequency of pulmonary hypertension in chronic obstructive pulmonary disease of geriatric patients: a narrative literature review

Background

Pulmonary hypertension (PH) is a serious complication with complex pathogenesis in the natural history of chronic obstructive pulmonary disease COPD, with a progressively increasing frequency with a meanwhile decreasing in functional capacity.

Purpose

Assessment of the incidence, pathogenesis, peculiarities, and complications of PH in COPD in geriatric population worldwide.

Methods

We performed an analysis of randomized, retrospective, and prospective clinical, case-control and observational studies, published at the international level, according to the subject studied and target population. Four hundred ninety-seven full articles were identified after the search through engine Google Search and databases PubMed, Hinari, SpringerLink, and Scopus (Elsevier) according to the keywords and subsequent filters.

Results

Depending on various factors, like the population examined, the definition used for mPAP (mPAP> 20 mm Hg or ≥25 mm Hg), the severity of the lung disease, and the method of measuring PAP, a varied incidence of COPD patients with PH complication was discovered, namely 10–91%. PH prevalence increases with the COPD severity. The presence of PH is associated with acute exacerbations of COPD, reduced survival, and increasing expenses for healthcare programs. Mild to moderate levels of PH (mPAP 25–34 mm Hg) are relatively common in COPD and usually are associated with severe airflow obstruction or parenchymal destruction. Only a minority of patients (1–5%) have severe PH (mPAP ≥35 mm Hg).

Conclusions

Diagnosis of PH in COPD is difficult, especially in a mild form, and requires a clinical approach associated with a comprehensive set of investigations for confirming the etiology, evaluation of the functional and hemodynamical impairment severity, and important factors in the appropriate treatment election.

The alterations of retinal vasculature detected on optical coherence tomography angiography associated with chronic obstructive pulmonary disease

OBJECTIVES

This study aimed to evaluate the retinal vasculature of the macula and optic disc in patients with chronic obstructive pulmonary disease (COPD) by optical coherence tomography angiography (OCTA).

METHODS

The right eyes of 70 COPD patients and 71 healthy individuals were evaluated. These patients had moderate airflow limitation and mean PO2 of 60 mmHg, and their average age was less than 60 years. Superficial and deep capillary plexus vascular densities, foveal avascular zone (FAZ) width, and optic disc parameters were measured with OCTA. In addition, the correlation between the PO2 level in COPD patients and superficial, deep, and peripapillary vascular densities and FAZ was examined in the study.

RESULTS

The COPD group had a significant decrease in the vascular density in the superficial (fovea [p = 0.019]; parafovea [p = 0.013]; and perifovea [p = 0.001]) and deep capillary plexus (fovea [p = 0.028]; parafovea [p = 0.005]; and perifovea [p = 0.002]). Also, the enlargement of the FAZ (p = 0.002) and a decrease in the peripapillary vascular density (p = 0.006) were observed in the COPD group. There was a positive correlation between PO2 level and superficial, deep, and peripapillary vascular densities in COPD patients and a negative correlation with FAZ (r = 0.559-0.900).

CONCLUSION

Hypercapnia, respiratory acidosis, and chronic hypoxia associated with COPD may affect the macula and optic nerve, resulting in a serious decrease in vascular density, and OCTA can be a very important tool in the follow-up and treatment of these patients.

Triple Therapy in COPD: Can We Welcome the Reduction in Cardiovascular Risk and Mortality?

Chronic obstructive pulmonary disease (COPD) is a complex disease which consists in the reduction of the airflow and leads to the disruption of the pulmonary tissue due to a chronic inflammation. The progression of the disease is characterized by an exacerbation of the symptoms and the presence of life-threatening systemic complications, such as stroke and ischemic heart disease, with a progressive decline in lung function which can deeply impact the quality of life. Mortality represents the most important COPD outcome, with an increased risk in patients with cardiovascular comorbidities. The efficacy and safety of triple inhaled therapy were demonstrated by numerous controlled trials. Above all, many robust data are now available on the effectiveness of the triple therapy to reduce mortality in COPD patients.

Xinmai 'an extract enhances the efficacy of sildenafil in the treatment of pulmonary arterial hypertension via inhibiting MAPK signalling pathway

CONTEXT

Xinmai 'an tablet has been used to improve myocardial blood supply. Recently, some compounds from its formula have shown that they can treat pulmonary arterial hypertension (PAH).

OBJECTIVE

This study investigates the effects of Xinmai 'an extract (XMA) on PAH and further tests the co-therapeutic enhancement with sildenafil (SIL).

MATERIALS AND METHODS

Pulmonary artery smooth muscle cells were subjected to stimulation with SIL (12.5 μM) and XMA (250 μg/mL) for 48 h. Sprague-Dawley rats were randomly grouped into eight groups (n = 8 per group): (I) control group received saline; (II) MCT group received MCT (60 mg/kg); (III) SIL-Low group received MCT + SIL at 10 mg/kg/day; (IV) SIL-high group received MCT + SIL at 30 mg/kg/day; (V) XMA-High group received MCT + XMA at 251.6 mg/kg/day; (VI) SIL (Low)+XMA (Low) group received SIL (10 mg/kg) + XMA at 62.9 mg/kg/day; (VII) SIL (Low)+XMA (Medium) group received SIL (10 mg/kg) + XMA at 125.8 mg/kg/day; (VIII) SIL (Low)+XMA (High) group received SIL (10 mg/kg) + XMA at 251.6 mg/kg/day. Both XMA and SIL were given by gavage and were maintained daily for 2 weeks.

RESULTS

XMA could improve SIL's efficacy in the treatment of PAH by decreasing cell viability more effectively at non-cytotoxic concentrations (250 μg/mL) and reducing Right Ventricular Systolic Pressure (RVSP) in PAH rat. Potential mechanisms might at least in part be through activating the MAPK signalling pathway.

DISCUSSION AND CONCLUSIONS

The combination of XMA and SIL can improve the efficacy of pulmonary hypertension and reduce the dosage of SIL.

Influenza Vaccination and the Risk of Ventricular Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease: A Population-Based Longitudinal Study

Backgrounds: Influenza vaccination could decrease the risk of major cardiac events in patients with chronic obstructive pulmonary disease (COPD). However, the effects of the vaccine on decreasing the risk of ventricular arrhythmia (VA) development in such patients remain unclear. Methods: We retrospectively analyzed the data of 18,658 patients with COPD (≥55 years old) from the National Health Insurance Research Database from January 1, 2001, to December 31, 2012. After a 1:1 propensity score matching by the year of diagnosis, we divided the patients into vaccinated and unvaccinated groups. Time-varying Cox proportional hazards regression was applied to assess the time to event hazards of influenza vaccination exposure. Results: The risk of VA occurrence was significantly lower in the vaccinated group during influenza season and all seasons [adjusted hazard ratio (aHR): 0.62, 95% CI: 0.41-0.95; aHR: 0.69, 95% CI: 0.44-1.08; and aHR: 0.65, 95% CI: 0.48-0.89, in the influenza season, non-influenza season, and all seasons, respectively]. Among patients with CHA₂DS₂-VASc scores (conditions and characteristics included congestive heart failure, hypertension, diabetes, stroke, vascular disease, age, and sex) of 2-3, receiving one time and two to three times of influenza vaccination were associated with lower risk of VA occurrence in all seasons (aHR: 0.28, 95% CI: 0.10-0.80; aHR: 0.27, 95% CI: 0.10-0.68, respectively). Among patients without stroke, peripheral vascular disease, and diabetes, a lower risk of VA occurrence after receiving one and two to three times vaccination was observed in all seasons. Among patients with a history of asthma and patients without a history of heart failure, ischemic heart disease, angina hypertension, or renal failure, a significantly lower risk of VA occurrence was observed after the first time of vaccination in all seasons. Conclusions: Influenza vaccination may be associated with lower risks of VA among patients with COPD aged 55-74. Further investigation is still needed to resolve this clinical question.

Safety of diuretic administration during the early management of dyspnea patients who are not finally diagnosed with acute heart failure

OBJECTIVES

Investigating whether it is safe or not to administrate diuretics to patients arriving at emergency departments in a stage of acute dyspnea but without a final diagnosis of acute heart failure.

METHODS

We analyzed an unselected multinational sample of patients with dyspnea without a final diagnosis of acute heart failure from Global Research on Acute Conditions Team (France, Lithuania, Tunisia) and Basics in Acute Shortness of Breath Evaluation (Switzerland) registries. Thirty-day all-cause mortality and 30-day postdischarge all-cause readmission rate of treated patients with diuretics at emergency departments were compared with untreated patients by unadjusted and adjusted hazard and odds ratios. Interaction and stratified analyses were performed.

RESULTS

We included 2505 patients. Among them, 365 (14.6%) received diuretics in emergency departments. Thirty-day mortality was 4.5% (treated/untreated = 5.2%/4.3%, hazard ratio: 1.22; 95% confidence interval, 0.75-2.00) and 30-day readmission rate was 11.3% (14.7%/10.8%, odds ratio: 1.41; 95% confidence interval, 0.95-2.11). After adjustment, no differences were found between two groups in mortality (hazard ratio: 0.86; 95% confidence interval, 0.51-1.44) and readmission (odds ratio: 1.15; 95% confidence interval, 0.72-1.82). Age significantly interacted with the use of diuretics and readmission (P = 0.03), with better prognosis when used in patients >80 years (odds ratio: 0.27; 95% confidence interval, 0.07-1.03) than in patients ≤80 years (odds ratio: 1.56; 95% confidence interval, 0.94-2.63).

CONCLUSIONS

Diuretic administration to patients presenting to emergency departments with dyspnea while they were undiagnosed and in whom acute heart failure was finally excluded was not associated with 30-day all-cause mortality and 30-day postdischarge all-cause readmission rate.

Comorbidity in chronic obstructive pulmonary disease and cardiovascular disease

Comorbidity is one of the most significant problems of modern healthcare. Numerous studies have analyzed the possible pathogenetic mechanisms and relationships between a wide variety of diseases. Cardiovascular (CVD) and pulmonary diseases, in particular chronic obstructive pulmonary disease (COPD), have a number of the same risk factors and pathogenetic links, which aggravate each other's course. Moreover, CVD and COPD are among the most common diseases in the world. This review provides up-to-date information on the prevalence, risk factors and pathophysiological mechanisms underlying this unfavorable combination of diseases. Some problems of diagnosis and treatment of patients with COPD and CVD are also discussed.

Chronic Obstructive Pulmonary Disease and the Cardiovascular System: Vascular Repair and Regeneration as a Therapeutic Target

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide and encompasses chronic bronchitis and emphysema. It has been shown that vascular wall remodeling and pulmonary hypertension (PH) can occur not only in patients with COPD but also in smokers with normal lung function, suggesting a causal role for vascular alterations in the development of emphysema. Mechanistically, abnormalities in the vasculature, such as inflammation, endothelial dysfunction, imbalances in cellular apoptosis/proliferation, and increased oxidative/nitrosative stress promote development of PH, cor pulmonale, and most probably pulmonary emphysema. Hypoxemia in the pulmonary chamber modulates the activation of key transcription factors and signaling cascades, which propagates inflammation and infiltration of neutrophils, resulting in vascular remodeling. Endothelial progenitor cells have angiogenesis capabilities, resulting in transdifferentiation of the smooth muscle cells via aberrant activation of several cytokines, growth factors, and chemokines. The vascular endothelium influences the balance between vaso-constriction and -dilation in the heart. Targeting key players affecting the vasculature might help in the development of new treatment strategies for both PH and COPD. The present review aims to summarize current knowledge about vascular alterations and production of reactive oxygen species in COPD. The present review emphasizes on the importance of the vasculature for the usually parenchyma-focused view of the pathobiology of COPD.

Chronic Hypoxia Decreases Endothelial Connexin 40, Attenuates Endothelium-Dependent Hyperpolarization-Mediated Relaxation in Small Distal Pulmonary Arteries, and Leads to Pulmonary Hypertension

Background Abnormal endothelial function in the lungs is implicated in the development of pulmonary hypertension; however, there is little information about the difference of endothelial function between small distal pulmonary artery (PA) and large proximal PA and their contribution to the development of pulmonary hypertension. Herein, we investigate endothelium-dependent relaxation in different orders of PAs and examine the molecular mechanisms by which chronic hypoxia attenuates endothelium-dependent pulmonary vasodilation, leading to pulmonary hypertension. Methods and Results Endothelium-dependent relaxation in large proximal PAs (second order) was primarily caused by releasing NO from the endothelium, whereas endothelium-dependent hyperpolarization (EDH)-mediated vasodilation was prominent in small distal PAs (fourth-fifth order). Chronic hypoxia abolished EDH-mediated relaxation in small distal PAs without affecting smooth muscle-dependent relaxation. RNA-sequencing data revealed that, among genes related to EDH, the levels of Cx37, Cx40, Cx43, and IK were altered in mouse pulmonary endothelial cells isolated from chronically hypoxic mice in comparison to mouse pulmonary endothelial cells from normoxic control mice. The protein levels were significantly lower for connexin 40 (Cx40) and higher for connexin 37 in mouse pulmonary endothelial cells from hypoxic mice than normoxic mice. Cx40 knockout mice exhibited significant attenuation of EDH-mediated relaxation and marked increase in right ventricular systolic pressure. Interestingly, chronic hypoxia led to a further increase in right ventricular systolic pressure in Cx40 knockout mice without altering EDH-mediated relaxation. Furthermore, overexpression of Cx40 significantly decreased right ventricular systolic pressure in chronically hypoxic mice. Conclusions These data suggest that chronic hypoxia-induced downregulation of endothelial Cx40 results in impaired EDH-mediated relaxation in small distal PAs and contributes to the development of pulmonary hypertension.

Sleep disordered breathing and chronic obstructive pulmonary disease: a narrative review on classification, pathophysiology and clinical outcomes

Chronic obstructive pulmonary disease (COPD) causes load-capacity-drive imbalance in both wakefulness and sleep, principally driven by expiratory flow limitation and hyperinflation. Sleep imposes additional burdens to the respiratory muscle pump, driven by changes in respiratory muscle tone, neural respiratory drive and consequences of the supine position. COPD patients are therefore at higher risk of decompensation during sleep, which may manifest as altered sleep architecture, isolated nocturnal desaturation, sleep hypoventilation and restless legs. Each form of sleep disordered breathing in COPD is associated with adverse clinical and patient-reported outcomes, including increased risk of exacerbations, hospitalisation, cardiovascular events, reduced survival and poorer quality of life. COPD-obstructive sleep apnoea (OSA) overlap syndrome represents a distinct clinical diagnosis, in which clinical outcomes are significantly worse than in either disease alone, including increased mortality, risk of cardiovascular events, hospitalisation and exacerbation frequency. Sleep disordered breathing is under-recognised by COPD patients and their clinicians, however early diagnosis and management is crucial to reduce the risk of adverse clinical outcomes. In this narrative review, we describe the pathophysiology of COPD and physiological changes that occur during sleep, manifestations and diagnosis of sleep disordered breathing in COPD and associated clinical outcomes.

Advances in understanding of mechanisms related to increased cardiovascular risk in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) represents a serious global health issue that is commonly associated with cardiovascular (CV) disease (CVD). The close relationship between COPD and CVD could be explained by different factors, first and foremost a chronic low-grade systemic inflammation implicated in the pathogenesis of both diseases and several stimuli enhancing the inflammatory processes and causing a mixed condition with worse outcomes than either disorder alone.

AREAS COVERED

The present narrative review considers the mechanisms underlying the increased CV risk in COPD, and it provides insights on biomarkers and predictive models to predict CVD in COPD patients.

EXPERT OPINION

COPD patients often remain asymptomatic of CVD, with respiratory symptoms generally attributed to the preexisting pulmonary disease. It is fundamental to understand the mechanistic pathways that underpin the intimate relationship between the two disorders. However, it is still not clear what is the origin of the common background of low-grade systemic inflammation, it could be a 'spillover' or a general inflammatory state. Primary prevention, cross-collaboration between specialists and early detection via predictive biomarkers and validated models are fundamental to stratify COPD patients according to CV risk.

Risk factors for right ventricular dysfunction in patients with lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare disease characterized by diffuse cystic lesions of the lung. The present study was designed to evaluate the right ventricular (RV) function in LAM patients via single-beat real-time three-dimensional echocardiography (RT-3DE) and to investigate the factors affecting RV function in LAM patients. According to tricuspid regurgitation velocity (TRV), forty-five female LAM patients [(44.07 ± 10.22) years old] were divided into TRV ≤ 2.8 m/s group (n = 29) and TRV > 2.8 m/s group (n = 16). Relative echocardiography parameters were assessed by conventional transthoracic echocardiography, Doppler tissue imaging (DTI) and RT-3DE, respectively. Pulmonary function tests and the six-minute walk tests (SMWT) were also performed for LAM patients. We found that most of RV functional parameters in LAM patients were worse than that in control patients, although left ventricular dysfunction was not significantly observed. Correlation analysis showed that 3D echocardiographic RV ejection fraction (RVEF) was negatively correlated with pulmonary vascular resistance (PVR), TRV, and the decrease of oxygen saturation (SpO₂) post SMWT, and positively correlated with Forced expiratory volume in the first second/forced vital capacity, carbon monoxide diffusion predicted value, SMWT distance, and resting SpO₂ in LAM patients. Multivariate stepwise linear regression analysis showed that PVR and SpO2 before SMWT were independent influence factors of RVEF in LAM patients. In this study, we found that RV dysfunction was presented in LAM patients, although left ventricular dysfunction was not significantly obvious. The main influence factors of RVEF were PVR and hypoxia. RT-3DE is a low-cost and noninvasive way to evaluate RV function in LAM patients.

[Cardiovascular and chronic obstructive pulmonary diseases: pathophysiological processes and treatment tactics]

Due to the global aging of the population, the deteriorating ecology and lifestyle changes, patients with isolated cardiovascular diseases (CVD) are becoming less common, and the portrait of a comorbid patient comes first in the structure of patients with CVD. Among a number of diseases complicating and concomitant with cardiovascular, a special place is occupied by chronic obstructive pulmonary disease (COPD). The prevalence of COPD among CVD patients can reach 60%. Many of the pathophysiological mechanisms underlying COPD can increase the risk of cardiovascular disease and vice versa. The most common cases of COPD are arterial hypertension, coronary heart disease, heart failure, and atrial fibrillation. Given the close relationship between COPD and CVD, it is clear that treatment for one condition can affect another. This review discusses current positions about the influence of both groups of diseases on each other, and also observes the effects of drug therapy of both diseases.

Exercise Pathophysiology in Interstitial Lung Disease

Interstitial lung disease (ILD) is a heterogeneous group of disorders that primarily affect the lung parenchyma. Patients with ILD have reduced lung volumes, impaired pulmonary gas exchange, and decreased cardiovascular function. These pathologic features of ILD become exacerbated during physical exertion, leading to exercise intolerance and abnormally high levels of exertional dyspnea. In this review, the authors summarize the primary pathophysiologic features of patients with ILD and their effect on the integrative response to exercise.

Lung function and cardiovascular disease: A link

The relationship between lung and heart diseases has long been recognized, with necropsy studies demonstrating silent myocardial infarctions or coronary artery calcification in patients with advanced emphysema as the death cause. Improvements in non-invasive techniques and epidemiologic approaches established that lung and cardiovascular diseases frequently coexist in mid and late life. Even among those without diagnosed lung disease, lower than expected forced vital capacity, forced expiratory volume in 1 s, and their ratio each portend greater risk of developing cardiovascular risk factors including hypertension, obesity, and metabolic syndrome, and for incident cardiovascular diseases including left heart failure, atrial fibrillation and stroke. Greater longitudinal declines in these spirometric measures are further associated with cardiovascular morbidity and mortality. While obstructive ventilatory patterns are more common, restrictive ventilatory patterns seem to demonstrate an independent and more robust association with cardiovascular diseases such as heart failure. These subclinical alterations in pulmonary function also relate to subclinical abnormalities of cardiac structure and function. Although the biologic pathways linking pulmonary and cardiovascular dysfunction are not clear, chronic systemic inflammation appears to be one important underlying pathophysiologic link. Despite the growing evidence of lung dysfunction as a cardiovascular risk factor, spirometric evaluation is still underutilized in clinical practice, particularly among cardiac patients, and optimal therapeutic and preventive strategies are still unclear. In this review, we address the current knowledge and controversies regarding the links between lung function and cardiovascular disease.

Aquaporin-2 expression in the kidney and urine is elevated in rats with monocrotaline-induced pulmonary heart disease

Objective

Little is known about how renal aquaporin-2 (AQP2) expression is affected by right heart failure caused by pulmonary heart disease (PHD). Therefore, we examined the expression of AQP2 in a rat model of PHD induced by monocrotaline (MCT).

Methods

After 4 weeks of treatment, urine and blood samples were collected from sham-treated and MCT-treated rats. Plasma arginine vasopressin (AVP) levels were measured by radioimmunoassay, and kidney Aqp2 mRNA expression was detected by reverse transcription (RT)-PCR. Kidney AQP2 protein expression was quantified by immunohistochemistry and western blotting assays. The concentration of urine AQP2 was determined by indirect enzyme-linked immunosorbent assay.

Results

We successfully established an animal model of MCT-induced PHD in rats. MCT-treated rats had significantly higher mRNA and protein levels of AQP2 in their kidney tissue. Following MCT treatment, rats also had markedly increased concentrations of both urine AQP2 and plasma AVP.

Conclusions

AQP2 expression was significantly increased in the kidney tissues and urine of rats with PHD induced by MCT. Our findings suggest that the evaluation of AQP2 expression contributes to an early diagnosis of PHD, and may also be an important reference to improve PHD therapeutics.

An association between right ventricular dysfunction and sudden cardiac death

BACKGROUND

The effectiveness of severely reduced left ventricular ejection fraction (LVEF <35%) as a predictor of sudden cardiac death (SCD) has diminished, and improvements in risk stratification await discovery of novel markers. Right ventricular (RV) abnormalities can be observed in conditions such as chronic obstructive pulmonary disease and sleep apnea, which have been linked to SCD.

OBJECTIVE

The purpose of this study was to evaluate whether RV abnormalities were associated with SCD after accounting for LVEF and other patient characteristics.

METHODS

In a large, prospective ongoing community-based study of SCD in the Portland, Oregon, metropolitan area, SCD cases (age ≥18 years; 2002-2014) were compared to controls with coronary artery disease but no SCD. Using a novel archive of digital echocardiograms, a standardized approach was used to evaluate RV basal diameter, RV end-diastolic area, and right ventricular fractional area change (RVFAC).

RESULTS

A total of 350 subjects were studied, including 81 SCD cases (age 68.7 ± 13.6 years; 73% male) and 269 controls (age 66.5 ± 10.2 years; 69% male). In multivariate analysis, RVFAC was significantly associated with SCD (odds ratio 1.14 for each 5% decrease; 95% confidence interval 1.03-1.25; P = .01). When modeled with LVEF ≤35%, RVFAC ≤35% was significantly associated with increased risk of SCD. Individuals with both left ventricular and RV dysfunction had a 3× higher odds of SCD than those with neither (odds ratio 3.19; 95% confidence interval 1.33-7.68; P = .01).

CONCLUSION

RV dysfunction was associated with a significantly increased risk of SCD independent of LVEF and, when combined with LVEF, had additive effects on SCD risk.

DHT deteriorates the progression of monocrotaline-induced pulmonary arterial hypertension: effects of endogenous and exogenous androgen

Pulmonary arterial hypertension (PAH) is more popular among females than males. However, female patients exhibit better prognosis than men, sex hormones may partly explain such sex paradox. Estrogens are disease modifiers in PAH, androgen effects on PAH are yet incompletely characterized. In this study, we sought to determine the effect of androgen depletion and dihydrotestoterone (DHT) repletion on a rat model of monocrotaline-induced PAH (MCT-PH) and to further clarify the possible mechanisms. MCT-PH was induced in male Sprague-Dawley (SD) rats as well as castrated rats with or without concomitant DHT repletion. Our research showed that rats with PAH exhibited cardiopulmonary alterations including induction of right ventricular systolic pressure (RVSP), pulmonary vascular remodeling, right ventricular hypertrophy (RVH) and fibrosis. Moreover, MCT upregulated expression of vascular cell proliferative proteins (PCNA and Ki67), matrix metalloproteinase-2 (MMP-2) and apoptotic proteins (Bax and Bcl-2) in pulmonary artery, and promoted pro-inflammatory cytokines expression (IL-6, TNF-α and IL-1β) and oxidative stress level (SOD activity and MDA level) in perivascular lung tissue. The magnitude of these PAH-induced changes was significantly partly inhibited by castration. DHT replacement reversed castration-action on MCT-related cardiopulmonary alteration. We studied the detrimental effect of endogenous androgen and exogenous DHT in MCT-PH rats, which may be through stimulation of vascular cell proliferation, gelatinolytic activity, apoptosis, perivascular inflammation and oxidative stress.

Secondary pulmonary arterial hypertension: to treat or not to treat?

PURPOSE OF REVIEW

The purpose of this review is to review recent literature related to mechanisms and treatment options for 'secondary' (i.e., WHO Groups 3 and 5) pulmonary arterial hypertension (PAH).

RECENT FINDINGS

Published randomized controlled trials, in general, do not support the use of approved therapies for 'primary' (i.e., WHO Group 1) PAH patients in patients with Group 3 PAH because of the small numbers of patients and inconsistent benefit. Therefore, we currently recommend against the use of these medications for Group 3 PAH. Similarly, there is limited evidence supporting the use of Group 1 PAH medications in Group 5 patients. In most patients with Group 5 PAH, treatment should be directed to the underlying disease.

SUMMARY

The utility of PAH-specific therapy in WHO Group 3 PAH is unclear because of the small numbers of patients evaluated and inconsistent beneficial effects observed. There is limited evidence supporting the use of PAH medications in Group 5 patients, and they may be harmful in some cases.

Alterations in cardiovascular function in an experimental model of lung fibrosis and pulmonary hypertension

NEW FINDINGS

What is the central question of this study? We have evaluated changes in cardiovascular physiology using echocardiography in an experimental model of lung fibrosis. What is the main finding and its importance? Remarkably, we report changes in cardiovascular function as early as day 7, concomitant with evidence of vascular remodelling. We also report that isolated pulmonary arteries were hypercontractile in response to a thromboxane A2 agonist. These findings are significant because the development of pulmonary hypertension is one of the most significant predictors of mortality in patients with lung fibrosis, where there are no available therapies and a lack of animal models.

ABSTRACT

Group III pulmonary hypertension is observed in patients with chronic lung diseases such as chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) develops as a result of extensive pulmonary vascular remodelling and resultant changes in vascular tone that can lead to right ventricle hypertrophy. This eventually leads to right heart failure, which is the leading indicator of mortality in patients with idiopathic pulmonary fibrosis. Treatments for group III PH are not available, in part owing to a lack of viable animal models. Here, we have evaluated the cardiovascular changes in a model of lung fibrosis and PH. Data obtained from this study indicated that structural alterations in the right heart, such as right ventricular wall hypertrophy, occurred as early as day 14, and similar increases in right ventricle chamber size were seen between days 21 and 28. These structural changes were correlated with decreases in the systolic function of the right ventricle and right ventricular cardiac output, which also occurred between the same time points. Characterization of pulmonary artery dynamics also highlighted that PH might be occurring as early as day 21, indicated by reductions in the velocity-time integral; however, evidence for PH is apparent as early as day 7, indicated by the significant reduction in pulmonary acceleration time values. These changes are consistent with evidence of vascular remodelling observed histologically starting on day 7. In addition, we report hyperactivity of bleomycin-exposed pulmonary arteries to a thromboxane A2 receptor (Tbxa2r) agonist.

The pulmonary artery-aorta ratio: Is it related to quality of life in chronic obstructive pulmonary disease?

INTRODUCTION

Little is known about the relationship between health status and pulmonary artery diameter in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to evaluate correlation between pulmonary artery-aorta ratio (P-A ratio) and health status of the individuals, using COPD assessment test (CAT).

MATERIALS AND METHODS

In a cross-sectional study, 112 COPD patients were recruited. The severity of COPD was determined by global initiative for obstructive lung disease (GOLD). After digital chest CT scan, the P-A ratio was measured at the level of bifurcation and compared with CAT score, GOLD stage, exacerbation rate and Modified Medical Research Council (MMRC) score.

RESULTS

The average P-A ratio was 0.89 ± 0.16 and 62.5% of patients had ratio less than one. The P-A ratio correlates significantly with different GOLD stages, CAT score and MMRC score (P < .001, P < .001, P < .001, respectively). Compared patients with low P-A ratio (<1), those with high P-A ratio (≥ 1) showed higher CAT score [11.94 ± 5.94 vs 25.17 ± 5.84] (P < .001). The P-A ratio was significantly higher in frequent (≥2) comparing low (<2) exacerbations [1.07 ± 0.07 vs 0.77 ± 0.06] (P < .001).

CONCLUSION

Significant correlations were found between P-A ratio and GOLD, exacerbation rate and health status, using CAT of patients with COPD. These findings also may suggest the potential role of P-A ratio, in the management of COPD patients.

High prevalence of echocardiographic abnormalities in older HIV-infected children taking antiretroviral therapy

Background:

Antiretroviral therapy (ART) has decreased mortality so that increasing numbers of children with HIV are reaching adolescence. However, longstanding HIV infection and/or its treatment in children is associated with noninfectious complications including cardiac disease. We investigated the prevalence, spectrum and risk factors for echocardiographic abnormalities among children established on ART.

Methods:

HIV-infected children aged 6–16 years, on ART at least 6 months were enrolled into a cross-sectional study from a public-sector paediatric HIV clinic in Harare, Zimbabwe. A standardized examination including transthoracic echocardiography was performed. Local echocardiographic reference ranges were used to define cardiac abnormalities. Logistic regression was used to examine the association between cardiac abnormalities and risk factors.

Results:

Of the 201participants recruited, 92 (46%) were girls and median age was 11 (IQR 9–12) years; CD4⁺ cell count was 727 cells/μl (IQR 473–935) and 154 (78%) had viral load less than 400 copies/ml. Echocardiographic abnormalities were found in 83 (42%); left ventricular (LV) diastolic dysfunction was the most common abnormality 45 (23%) and LV hypertrophy in 22 (11%). LV and left atrial dilatation were found in 9 (5%) and 16 (8%), respectively. Right ventricular dilatation and systolic dysfunction were found in 13 (7%) and 4 (2%), respectively, of whom 60% had concurrent left heart abnormalities. Current use of nevirapine was associated with LVH [aOR 3.14 (1.13–8.72; P = 0.03)] and hypertension was associated with LV diastolic dysfunction [aOR 3.12 (1.48–6.57; P < 0.01)].

Conclusion:

HIV-infected children established on ART have a high burden of echocardiographic abnormalities. Right heart disease was predominantly associated with left heart abnormalities and may be part of a global cardiomyopathic process. Further studies are needed to investigate the natural history, aetiology, and pathogenesis of these abnormalities, so that appropriate monitoring and treatment strategies can be developed.

Associations between diabetes mellitus and pulmonary hypertension in chronic respiratory disease patients

Background

Pulmonary hypertension (PH) is a common complication of chronic respiratory disease. Recent studies have reported diabetes mellitus (DM) to be a poor prognostic factor in patients with chronic respiratory disease, including chronic obstructive pulmonary disease or interstitial pneumoniae. However, the association between DM and PH in chronic respiratory disease remains unclear. In this study, we aimed to investigate whether DM is a predictor of PH in patients with chronic respiratory disease.

Methods

We prospectively analyzed 386 patients in our hospital with chronic respiratory disease. An echocardiographic pressure gradient between the right atrium and the right ventricle of ≥ 40 mmHg was defined as PH. We compared the clinical characteristics and impact of DM between chronic respiratory disease patients with and those without PH.

Results

Of the 386 patients, 42 (10.9%) were diagnosed as having PH. The PH group had higher modified medical research council (mMRC) grade and complication rate of DM, but not hypertension and hyperlipidemia, when compared to the non-PH group. Multivariable logistic regression analysis revealed that mMRC scale (odds ratio 1.702, 95% confidence interval, 1.297 to 2.232, P < 0.001) and presence of DM (odd ratio 2.935, 95% confidence interval, 1.505 to 5.725, P = 0.002) were associated with PH in chronic respiratory disease patients.

Conclusion

DM is potentially associated with PH and is an independent factor for prediction of PH in patients with chronic respiratory disease.

Cardiovascular disease and COPD: dangerous liaisons?

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β₂-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.

Prevalence and etiologies of pulmonary hypertension in Africa: a systematic review and meta-analysis

BACKGROUND

Despite the recent increasing worldwide attention towards pulmonary hypertension (PH), its epidemiology remains poorly described in Africa. Accordingly, we performed a systematic review and meta-analysis of PH prevalence, incidence and etiologies in Africa.

METHODS

We searched PubMed, EMBASE, African Journals Online, and Africa Index Medicus. Published observational studies until September 20, 2017, including adult participants residing in Africa were considered. Two review authors independently selected studies, assessed included studies for methodological quality, and extracted data. A random-effects model was used for meta-analysis. Heterogeneity was evaluated by the χ 2 test on Cochrane's Q statistic which is quantified by I2 values. Using Newcastle-Ottawa Scale, we considered a score of 0-4, 5-7, and 8-10 as indicative of high, moderate, and low risk of bias in included studies, respectively.

RESULTS

Of 1611 entries, 25 studies were retained. Twelve (48%), seven (28%), and six (24%) papers had respectively a low, moderate and high risk of bias. The prevalence of PH widely varied across different populations: 9.8% (95% confidence interval: 3.2-19.3; I2 = 99.4%; 6 studies) in 11,163 people presenting with cardiac complaints; 10.6% (4.3-19.1; I2 = 90.3%; 4 studies) in 937 HIV-infected people; 32.9% (17.6-50.4; I2 = 97.2%; 3 studies) in 2077 patients with heart failure; 23.2% (15.2-32.2; I2 = 59.4%; 3 studies) in 248 patients on hemodialysis; 12.9% (11.8-14.0; I2 = 79.7%; 2 studies) in 3750 patients with rheumatic heart disease; 36.9% (29.7-44.3; I2 = 79.7; 2 studies) in 79 patients with sickle cell disease; 62.7% (49.0-74.7; 1 study) in 51 patients with chronic obstructive pulmonary disease; 25.4% (16.3-37.3; 1 study) in 63 patients with systemic lupus erythematous; 68.7% (62.8-74.1; 1 study) in 259 patients with cardiac surgery; and 7.4% (4.6-11.9; 1 study) in 202 patients with systemic sclerosis. No study reported PH incidence. From one international study (n = 209), PH etiologies were: left heart disease (68.9%), pulmonary arterial hypertension (15.8%), lung disease and/or hypoxia (12.0%), chronic thromboembolic PH (1.9%) and unclear/multifactorial PH (15.8%).

CONCLUSION

The prevalence of PH is relatively high in some populations in Africa, perhaps mainly driven by left heart diseases, highlighting the need for context-specific interventions.

Baicalein attenuates monocrotaline-induced pulmonary arterial hypertension by inhibiting vascular remodeling in rats

BACKGROUND

Pulmonary arterial hypertension (PAH) is a devastating cardiopulmonary disorder characterized by elevated pulmonary arterial pressure (PAP) and right ventricular hypertrophy (RVH) driven by progressive vascular remodeling. Reversing adverse vascular remodeling is an important concept in the treatment of PAH. Endothelial injury, inflammation, and oxidative stress are three main contributors to pulmonary vascular remodeling. Baicalein is a natural flavonoid that has been shown to possess anti-proliferative, anti-inflammatory, anti-oxidative, and cardioprotective properties. We hypothesized that baicalein may prevent the progression of PAH and preserve the right heart function by inhibiting pulmonary arterial remodeling.

METHODS

Male Sprague-Dawley rats were distributed randomly into 4 groups: control, monocrotaline (MCT)-exposed, and MCT-exposed plus baicalein treated rats (50 and 100 mg/kg/day for 2 weeks). Hemodynamic changes, RVH, and lung morphological features were examined on day 28. Apoptosis was determined by TUNEL staining, and the mRNA levels of tumor necrosis factor alpha (TNF-α), interleukin-1β (IL-1β), and IL-6 were detected by qRT-PCR. The changes in oxidative indicators, including malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were measured using corresponding commercial kits. The levels of Bax, Bcl-2, and cleaved caspase-3, and the activation of mitogen-activated protein kinase (MAPK) and NF-κB were assessed by western blotting.

RESULTS

MCT induced an increase in hemodynamic parameters and RVH, which were attenuated by baicalein treatment. Baicalein also blocked MCT-induced pulmonary arterial remodeling. The levels of apoptotic (Bax/Bcl-2 ratio and cleaved caspase-3) and inflammatory (IL-6, TNF-α, and IL-1β) biomarkers in lung tissue were lower in baicalein-treated groups. Baicalein also decreased MDA level, and increased SOD and GSH-Px activity in rat pulmonary tissue. Furthermore, baicalein inhibited MCT-induced activation of the MAPK and NF-κB pathways.

CONCLUSION

Baicalein ameliorates MCT-induced PAH by inhibiting pulmonary arterial remodeling at least partially via the MAPK and NF-κB pathways in rats.

Risk factors for pulmonary arterial hypertension in patients with tuberculosis-destroyed lungs and their clinical characteristics compared with patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

There are limited data on pulmonary arterial hypertension (PAH) in patients with tuberculosis-destroyed lung (TDL), a sequela of pulmonary tuberculosis. We identified the risk factors for PAH and their effects on acute exacerbation and mortality in patients with TDL, as well as the clinical differences in patients with chronic obstructive pulmonary disease (COPD) and PAH.

METHODS

A retrospective cohort study was conducted from 2010 through 2015 in a municipal referral hospital in South Korea. PAH was defined when echocardiographic pulmonary arterial pressure (PAP) was >40 mmHg. The clinical features and course of TDL patients with or without PAH were evaluated and differences between patients with COPD and PAH were analyzed.

RESULTS

Among the 195 patients with TDL, echocardiographic data were available in 53 patients, and their mean PAP was 50.72±23.99 mmHg. The PAH group (n=37) had a smaller lung volume (forced vital capacity % predicted, 51.55% vs 72.37%, P<0.001) and more extensively destroyed lungs (3.27 lobes vs 2 lobes, P<0.001) than those in the non-PAH group (n=16). A higher PAP was significantly correlated with a higher frequency of acute exacerbation (r=0.32, P=0.02). Multivariate analyses did not reveal any significant risk factors contributing to PAH in patients with TDL. Compared to COPD patients with PAH, TDL patients with PAH have smaller lung volume but a less severe airflow limitation. Tricuspid regurgitation and a D-shaped left ventricle during diastole were more frequently observed in TDL patients. The risk of exacerbation was not different between patients with PAH in COPD and TDL.

CONCLUSION

PAH in patients with TDL was associated with severity of lung destruction but risk of exacerbation and mortality did not significantly differ between patients with PAH and without PAH.

Protein kinase C isozyme expression in right ventricular hypertrophy induced by pulmonary hypertension in chronically hypoxic rats

In chronic hypoxia, pulmonary hypertension (PH) induces right ventricular hypertrophy (RVH). Evidence indicates that protein kinase C (PKC) serves a crucial role in hypoxia-induced RVH. The present study investigated PKC isoform-specific expression and its involvement in RVH. Rats were exposed to normobaric hypoxia for a number of days to induce PH. PKC isoform-specific membrane translocation and protein expression in the myocardium were evaluated by western blotting and immunostaining. A total of six isoforms of conventional PKC (cPKC; α, βI and βII) and of novel PKC (nPKC; δ, ε and η), were detected in the rat myocardium. Hypoxic exposure (1–21 days) induced PH with RVH and vascular remodeling. nPKCδ membrane translocation at 3–7 days and cPKCβI expression at 1–21 days in the RV following hypoxic exposure were significantly decreased as compared with the normoxia control group. Membrane translocation of cPKCβII at 14–21 days and of nPKCη at 7–21 days in the left ventricle following hypoxic exposure was significantly increased when compared with the control. The results of the present study suggested that the alterations in membrane translocation, and nPKCδ and cPKCβI expression, are associated with RVH following PH, and the upregulation of cPKCβII membrane translocation is involved in left-sided heart failure.

Ambient Coarse Particulate Matter and the Right Ventricle: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Coarse particulate matter (P10-2.5) is primarily mechanically generated and includes crustal material, brake and tire wear, and biological particles. PM10-2.5 is associated with pulmonary disease, which can lead to right ventricular (RV) dysfunction. Although RV characteristics have been associated with combustion-related pollutants, relationships with PM10-2.5 remain unknown.

OBJECTIVES

To quantify cross-sectional associations between RV dysfunction and PM10-2.5 mass and components among older adults and susceptible populations.

METHODS

We used baseline cardiac magnetic resonance images from 1,490 participants (45-84 y old) from the Multi-Ethnic Study of Atherosclerosis and assigned 5-y residential concentrations of PM10-2.5 mass, copper, zinc, phosphorus, silicon, and endotoxin, using land-use regression models. We quantified associations with RV mass, end-diastolic volume, and ejection fraction after control for risk factors and copollutants using linear regression. We further examined personal susceptibility.

RESULTS

We found positive associations of RV mass and, to a lesser extent, end diastolic volume with PM10-2.5 mass among susceptible populations including smokers and persons with emphysema. After adjustment for copollutants, an interquartile range increase in PM10-2.5 mass (2.2 μg/m3) was associated with 0.5 g (95% CI: 0.0, 1.0), 0.9 g (95% CI: 0.1, 1.7), and 1.4 g (95% CI: 0.4, 2.5) larger RV mass among former smokers, current smokers, and persons with emphysema, respectively. No associations were found with healthy individuals or with ejection fraction.

CONCLUSIONS

Alterations to RV structure may represent a mechanism by which long-term PM10-2.5 exposure increases risks for adverse respiratory and cardiovascular outcomes, especially among certain susceptible populations. https://doi.org/10.1289/EHP658.

Impact of High-Intensity-NIV on the heart in stable COPD: a randomised cross-over pilot study

BACKGROUND

Although high-intensity non-invasive ventilation has been shown to improve outcomes in stable COPD, it may adversely affect cardiac performance. Therefore, the aims of the present pilot study were to compare cardiac and pulmonary effects of 6 weeks of low-intensity non-invasive ventilation and 6 weeks of high-intensity non-invasive ventilation in stable COPD patients.

METHODS

In a randomised crossover pilot feasibility study, the change in cardiac output after 6 weeks of each NIV mode compared to baseline was assessed with echocardiography in 14 severe stable COPD patients. Furthermore, CO during NIV, gas exchange, lung function, and health-related quality of life were investigated.

RESULTS

Three patients dropped out: two deteriorated on low-intensity non-invasive ventilation, and one presented with decompensated heart failure while on high-intensity non-invasive ventilation. Eleven patients were included in the analysis. In general, cardiac output and NTproBNP did not change, although individual effects were noticed, depending on the pressures applied and/or the co-existence of heart failure. High-intensity non-invasive ventilation tended to be more effective in improving gas exchange, but both modes improved lung function and the health-related quality of life.

CONCLUSIONS

Long-term non-invasive ventilation with adequate pressure to improve gas exchange and health-related quality of life did not have an overall adverse effect on cardiac performance. Nevertheless, in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output.

TRIAL REGISTRATION

The trial was registered in the Deutsches Register Klinischer Studien (DRKS-ID: DRKS00007977 ).

Evaluation of choroidal thickness, retinal vascular caliber, and nerve fiber layer thickness in idiopathic interstitial pneumonia

Background: Idiopathic interstitial pneumonia (IIP) is a subtype of interstitial lung disease. Hypoxia and oxidative stress that take a role in IIP, are also thought to affect ocular structures. Objectives: In this study, our aim was to evaluate the retinal nerve fiber layer thickness, choroidal thickness and retinal vessel diameter using the Spectral-domain optical coherence tomography (SD-OCT) in participants with IIP. Material and method: A total of 35 subjects with IIP were evaluated. The ocular parameters of patients with IIP were compared with that of 35 age-sex matched healthy volunteers. All subjects underwent respiratory function testing and carbon monoxide diffusion test. Arterial blood gas analysis was performed to determine the hypoxic state. In addition to SD-OCT measurements, all participants underwent a standard ophthalmic examination including visual acuity assessment, biomicroscopy, air-puff tonometry and retinal examination. Results: The mean retinal arteriolar caliber (RAC) was 89.5±5.5 μm in the IIP group and 94.3±6.9 μm in the control group (p=0.002). The mean retinal venular caliber (RVC) was 131.5±11.2 μm in the IIP group and 125.2±9.2 μm in the control group (p=0.01). The mean inferior quadrant retinal nerve fiber layer (RNFL) thickness was 127.5±19.4 μm in the IIP group and 140.1±13.8 μm in the control group (p=0.003). Conclusion: The IIP may affect retinal vessels and nerve fiber layer. The diameter of the retinal venules was larger and the diameter of the retinal arterioles was smaller in the IIP patients when compared to the healthy controls. The inferior quadrant RNFL was significantly thinner in the IIPgroup. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 68-73).