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Frank BS, Niemiec S, Khailova L, Mancuso CA, Lehmann T, Mitchell MB, Morgan GJ, Twite M, DiMaria MV, Klawitter J, Davidson JA. Arginine-NO metabolites are associated with morbidity in single ventricle infants undergoing stage 2 palliation. Pediatr Res 2024; 96:347-355. [PMID: 38565916 DOI: 10.1038/s41390-024-03162-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/01/2024] [Accepted: 03/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Infants with single ventricle heart disease (SVHD) suffer morbidity from insufficient pulmonary blood flow, which may be related to impaired arginine metabolism. No prior study has reported quantitative mapping of arginine metabolites to evaluate the relationship between circulating metabolite levels and outcomes. METHODS Prospective cohort study of 75 SVHD cases peri-Stage 2 and 50 healthy controls. We targeted pre- and post-op absolute serum quantification of 9 key members of the arginine metabolism pathway by tandem mass spectrometry. Primary outcomes were length of stay (LOS) and post-Stage 2 hypoxemia. RESULTS Pre-op cases showed alteration in 6 metabolites including decreased arginine and increased asymmetric dimethyl arginine (ADMA) levels compared to controls. Post-op cases demonstrated decreased arginine and citrulline levels persisting through 48 h. Adjusting for clinical variables, lower pre-op and 2 h post-op concentrations of multiple metabolites, including arginine and citrulline, were associated with longer post-op LOS (p < 0.01). Increased ADMA at 24 h was associated with greater post-op hypoxemia burden (p < 0.05). CONCLUSION Arginine metabolism is impaired in interstage SVHD infants and is further deranged following Stage 2 palliation. Patients with greater metabolite alterations experience greater post-op morbidity. Decreased arginine metabolism may be an important driver of pathology in SVHD. IMPACT Interstage infants with SVHD have significantly altered arginine-nitric oxide metabolism compared to healthy children with deficiency of multiple pathway intermediates persisting through 48 h post-Stage 2 palliation. After controlling for clinical covariates and classic catheterization-derived predictors of Stage 2 readiness, both lower pre-operation and lower post-operation circulating metabolite levels were associated with longer post-Stage 2 LOS while increased post-Stage 2 ADMA concentration was associated with greater post-op hypoxemia. Arginine metabolism mapping offers potential for development using personalized medicine strategies as a biomarker of Stage 2 readiness and therapeutic target to improve pulmonary vascular health in infants with SVHD.
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Affiliation(s)
- Benjamin S Frank
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA.
| | - Sierra Niemiec
- University of Colorado Department of Biostatistics and Informatics, Denver, CO, USA
| | - Ludmila Khailova
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA
| | | | - Tanner Lehmann
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA
| | - Max B Mitchell
- University of Colorado Department of Surgery, Denver, CO, USA
| | - Gareth J Morgan
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA
| | - Mark Twite
- University of Colorado Department of Anesthesiology, Denver, CO, USA
| | - Michael V DiMaria
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA
| | - Jelena Klawitter
- University of Colorado Department of Anesthesiology, Denver, CO, USA
| | - Jesse A Davidson
- University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA
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Berber NK, Kurt O, Altıntop Geçkil A, Erdem M, Kıran TR, Otlu Ö, Ecin SM, İn E. Evaluation of Oxidative Stress and Endothelial Dysfunction in COVID-19 Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1041. [PMID: 39064471 PMCID: PMC11279166 DOI: 10.3390/medicina60071041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/01/2024] [Accepted: 06/05/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Heat shock proteins (HSPs) are stress proteins. The endogenous nitric oxide (NO) synthase inhibitor asymmetric dimethyl arginine (ADMA) is a mediator of endothelial dysfunction. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus causes endothelial dysfunction and coagulopathy through severe inflammation and oxidative stress. Using these markers, we analyzed the prognostic value of serum ADMA and HSP-90 levels for early prediction of severe coronavirus disease (COVID-19) patients. Materials and Methods: A total of 76 COVID-19 patients and 35 healthy control subjects were included in this case-control study. COVID-19 patients were divided into two groups: mild and severe. Results: Serum ADMA and HSP-90 levels were significantly higher in the COVID-19 patients compared to the control subjects (p < 0.001). Additionally, serum ADMA and HSP-90 levels were determined to be higher in a statistically significant way in severe COVID-19 compared to mild COVID-19 (p < 0.001). Univariable logistic regression analysis revealed that ADMA and HSP-90, respectively, were independent predictors of severe disease in COVID-19 patients (ADMA (OR = 1.099, 95% CI = 1.048-1.152, p < 0.001) and HSP-90 (OR = 5.296, 95% CI = 1.719-16.316, p = 0.004)). When the cut-off value for ADMA was determined as 208.94 for the prediction of the severity of COVID-19 patients, the sensitivity was 72.9% and the specificity was 100% (AUC = 0.938, 95%CI = 0.858-0.981, p < 0.001). When the cut-off value for HSP-90 was determined as 12.68 for the prediction of the severity of COVID-19 patients, the sensitivity was 88.1% and the specificity was 100% (AUC = 0.975, 95% CI= 0.910-0.997, p < 0.001). Conclusions: Increased levels of Heat shock proteins-90 (HSP-90) and ADMA were positively correlated with increased endothelial damage in COVID-19 patients, suggesting that treatments focused on preventing and improving endothelial dysfunction could significantly improve the outcomes and reduce the mortality rate of COVID-19. ADMA and HSP-90 might be simple, useful, and prognostic biomarkers that can be utilized to predict patients who are at high risk of severe disease due to COVID-19.
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Affiliation(s)
- Nurcan Kırıcı Berber
- Department of Chest Diseases, Malatya Turgut Özal University, Malatya 44210, Turkey;
| | - Osman Kurt
- Department of Public Health, Faculty of Medicine, Inonu University, Malatya 44210, Turkey;
| | | | - Mehmet Erdem
- Department of Medical Biochemistry, Malatya Turgut Özal University, Malatya 44210, Turkey; (M.E.); (T.R.K.); (Ö.O.)
| | - Tuğba Raika Kıran
- Department of Medical Biochemistry, Malatya Turgut Özal University, Malatya 44210, Turkey; (M.E.); (T.R.K.); (Ö.O.)
| | - Önder Otlu
- Department of Medical Biochemistry, Malatya Turgut Özal University, Malatya 44210, Turkey; (M.E.); (T.R.K.); (Ö.O.)
| | - Seval Müzeyyen Ecin
- Department of Occupational Medicine and Internal Medicine Clinic, Mersin City Training and Research Hospital, Mersin 33240, Turkey;
| | - Erdal İn
- Department of Pulmonary Diseases, Faculty of Medicine, İzmir University of Economics, İzmir 35330, Turkey;
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Shafran I, Probst V, Panzenböck A, Sadushi-Kolici R, Gerges C, Wolzt M, Segel MJ, Celermajer DS, Lang IM, Skoro-Sajer N. Asymmetric Dimethylarginine and NT-proBNP Levels Provide Synergistic Information in Pulmonary Arterial Hypertension. JACC. HEART FAILURE 2024; 12:1089-1097. [PMID: 38573264 DOI: 10.1016/j.jchf.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/24/2024] [Accepted: 02/06/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Plasma asymmetric dimethylarginine (ADMA) is elevated in pulmonary arterial hypertension (PAH) and is associated with unfavorable outcomes. OBJECTIVES The aim of this study was to assess changes in ADMA plasma levels for monitoring disease progression and outcomes during PAH-specific therapy. METHODS ADMA was measured at baseline and after at least 6 months of follow-up using enzyme-linked immunosorbent assay and high-performance liquid chromatography. Changes in ADMA were analyzed in relation to changes in established PAH markers, including hemodynamic status, N-terminal pro-brain natriuretic peptide (NT-proBNP) and risk assessment scores. Impact on survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. RESULTS Between 2008 and 2019, ADMA samples were collected prospectively from 215 patients with PAH. Change in ADMA plasma level was a predictor of disease progression and survival. ΔADMA (median -0.03 μmol/L; 95% CI: -0.145 to 0.0135) was correlated with change in mean pulmonary arterial pressure (P < 0.005; rS = 0.287) but was not significantly correlated with ΔNT-proBNP (P = 0.056; rS = 0.135). Patients with decreased ADMA plasma levels at follow-up had better 3-year and 5-year survival rates (88% and 80%, respectively, vs 72% and 53% in those without decreases in ADMA) (P < 0.005; pulmonary hypertension-related mortality or lung transplantation). Patients with decreases in both ADMA and NT-proBNP had better survival rates compared with patients in whom only 1 parameter improved (P < 0.005). ΔADMA was a significant predictor of survival in Cox regression analysis and also when corrected for ΔNT-proBNP (HRs: 1.27 and 1.35, respectively; P < 0.005). CONCLUSIONS ADMA and NT-proBNP provide synergistic prognostic information for patients with PAH. ADMA could be used as an objective and distinct biomarker for monitoring treatment response in PAH.
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Affiliation(s)
- Inbal Shafran
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; Pulmonary Institute, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Probst
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Adelheid Panzenböck
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Roela Sadushi-Kolici
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael J Segel
- Pulmonary Institute, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Irene Marthe Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.
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Thenappan T. Asymmetric Dimethylarginine in Pulmonary Arterial Hypertension: A Liquid Biopsy to Assess Pulmonary Vascular Endothelial Health. JACC. HEART FAILURE 2024; 12:1098-1100. [PMID: 38839153 DOI: 10.1016/j.jchf.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Thenappan Thenappan
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
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5
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Böger R, Hannemann J. Defining the role of exertional hypoxemia and pulmonary vasoconstriction on lung function decline, morbidity, and mortality in patients with chronic obstructive lung disease - the PROSA study: rationale and study design. BMC Pulm Med 2024; 24:262. [PMID: 38816826 PMCID: PMC11137990 DOI: 10.1186/s12890-024-03074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Chronic obstructive lung disease (COPD) has diverse molecular pathomechanisms and clinical courses which, however, are not fully mirrored by current therapy. Intermittent hypoxemia is a driver of lung function decline and poor outcome, e.g., in patients with concomitant obstructive sleep apnea. Transient hypoxemia during physical exercise has been suggested to act in a similar manner. The PROSA study is designed to prospectively assess whether the clinical course of COPD patients with or without exertional desaturation differs, and to address potential pathophysiological mechanisms and biomarkers. METHODS 148 COPD patients (GOLD stage 2-3, groups B or C) will undergo exercise testing with continuous pulse oximetry. They will be followed for 36 months by spirometry, echocardiography, endothelial function testing, and biomarker analyses. Exercise testing will be performed by comparing the 6-min walk test (6MWT), bicycle ergometry, and a 15-sec breath-hold test. Exertional desaturation will be defined as SpO2 < 90% or delta-SpO2 ≥ 4% during the 6MWT. The primary endpoint will be the rate of decline of FEV1(LLN) between COPD patients with and without exertional desaturation. DISCUSSION The PROSA Study is an investigator-initiated prospective study that was designed to prove or dismiss the hypothesis that COPD patients with exertional desaturation have a significantly more rapid rate of decline of lung function as compared to non-desaturators. A 20% difference in the primary endpoint was considered clinically significant; it can be detected with a power of 90%. If the primary endpoint will be met, exercise testing with continuous pulse oximetry can be used as a ubiquitously available, easy screening tool to prospectively assess the risk of rapid lung function decline in COPD patients at an early disease stage. This will allow to introduce personalized, risk-adapted therapy to improve COPD outcome in the long run. PROSA is exclusively funded by public funds provided by the European Research Council through an ERC Advanced Grant. Patient recruitment is ongoing; the PROSA results are expected to be available in 2028. TRIAL REGISTRATION The PROSA Study has been prospectively registered at clinicaltrials.gov (register no. NCT06265623, dated 09.02.2024).
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Affiliation(s)
- Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany.
| | - Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
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6
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Correale M, Tricarico L, Bevere EML, Chirivì F, Croella F, Severino P, Mercurio V, Magrì D, Dini F, Licordari R, Beltrami M, Dattilo G, Salzano A, Palazzuoli A. Circulating Biomarkers in Pulmonary Arterial Hypertension: An Update. Biomolecules 2024; 14:552. [PMID: 38785959 PMCID: PMC11117582 DOI: 10.3390/biom14050552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare subtype of group 1 pulmonary hypertension (PH) diseases, characterized by high pulmonary artery pressure leading to right ventricular dysfunction and potential life-threatening consequences. PAH involves complex mechanisms: vasoconstriction, vascular remodeling, endothelial dysfunction, inflammation, oxidative stress, fibrosis, RV remodeling, cellular hypoxia, metabolic imbalance, and thrombosis. These mechanisms are mediated by several pathways, involving molecules like nitric oxide and prostacyclin. PAH diagnosis requires clinical evaluation and right heart catheterization, confirming a value of mPAP ≥ 20 mmHg at rest and often elevated pulmonary vascular resistance (PVR). Even if an early and accurate diagnosis is crucial, PAH still lacks effective biomarkers to assist in its diagnosis and prognosis. Biomarkers could contribute to arousing clinical suspicion and serve for prognosis prediction, risk stratification, and dynamic monitoring in patients with PAH. The aim of the present review is to report the main novelties on new possible biomarkers for the diagnosis, prognosis, and treatment monitoring of PAH.
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Affiliation(s)
- Michele Correale
- Cardiothoracic Department, Ospedali Riuniti University Hospital, 71100 Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Ester Maria Lucia Bevere
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Francesco Chirivì
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Francesca Croella
- Cardiothoracic Vascular Department, Division of Provincial Cardiology, Santissima Annunziata Hospital and Delta Hospital, Azienda Unità Sanitaria Locale di Ferrara, 44121 Ferrara, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 00185 Rome, Italy;
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, 80138 Naples, Italy;
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant’Andrea, “Sapienza” Università degli Studi di Roma, 00161 Rome, Italy;
| | - Frank Dini
- Istituto Auxologico IRCCS, Centro Medico Sant’Agostino, Via Temperanza, 6, 20127 Milan, Italy;
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Roberto Licordari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy; (R.L.); (G.D.)
| | - Matteo Beltrami
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy; (R.L.); (G.D.)
| | - Andrea Salzano
- Cardiology Unit, AORN A Cardarelli, 80131 Naples, Italy;
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, S. Maria alle Scotte Hospital, University of Siena, 53100 Siena, Italy;
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7
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Xu J, Sun X, Cao Y, Zhu H, Yang W, Liu J, Guo J. Fractional exhaled nitric oxide in idiopathic pulmonary arterial hypertension and mixed connective tissue disease complicating pulmonary hypertension. BMC Pulm Med 2024; 24:199. [PMID: 38654208 PMCID: PMC11036718 DOI: 10.1186/s12890-024-03004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) has been extensively studied in various causes of pulmonary hypertension (PH), but its utility as a noninvasive marker remains highly debated. The objective of our study was to assess FeNO levels in patients with idiopathic pulmonary arterial hypertension (IPAH) and mixed connective tissue disease complicating pulmonary hypertension (MCTD-PH), and to correlate them with respiratory functional data, disease severity, and cardiopulmonary function. METHODS We collected data from 54 patients diagnosed with IPAH and 78 patients diagnosed with MCTD-PH at the Shanghai Pulmonary Hospital Affiliated to Tongji University. Our data collection included measurements of brain natriuretic peptide (pro-BNP), cardiopulmonary exercise test (CPET), pulmonary function test (PFT), impulse oscillometry (IOS), and FeNO levels. Additionally, we assessed World Health Organization functional class (WHO-FC) of each patient. RESULTS (1) The fractional exhaled concentration of nitric oxide was notably higher in patients with IPAH compared to those with MCTD-PH. Furthermore, within the IPAH group, FeNO levels were found to be lower in cases of severe IPAH compared to mild IPAH (P = 0.024); (2) In severe pulmonary hypertension as per the WHO-FC classification, FeNO levels in IPAH exhibited negative correlations with FEV1/FVC (Forced Expiratory Velocity at one second /Forced Vital Capacity), MEF50% (Maximum Expiratory Flow at 50%), MEF25%, and MMEF75/25% (Maximum Mid-expiratory Flow between 75% and 25%), while in severe MCTD-PH, FeNO levels were negatively correlated with R20% (Resistance at 20 Hz); (3) ROC (Receiving operator characteristic curve) analysis indicated that the optimal cutoff value of FeNO for diagnosing severe IPAH was 23ppb; (4) While FeNO levels tend to be negatively correlated with peakPETO2(peak end-tidal partial pressure for oxygen) in severe IPAH, in mild IPAH they had a positive correlation to peakO2/Heart rate (HR). An interesting find was observed in cases of severe MCTD-PH, where FeNO levels were negatively correlated with HR and respiratory exchange ratio (RER), while positively correlated with O2/HR throughout the cardiopulmonary exercise test. CONCLUSION FeNO levels serve as a non-invasive measure of IPAH severity. Although FeNO levels may not assess the severity of MCTD-PH, their significant makes them a valuable tool when assessing severe MCTD-PH.
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Affiliation(s)
- Jianhua Xu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Xingxing Sun
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Yuan Cao
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Hanqing Zhu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Wenlan Yang
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Jinming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200092, Shanghai, China.
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8
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Favoino E, Prete M, Liakouli V, Leone P, Sisto A, Navarini L, Vomero M, Ciccia F, Ruscitti P, Racanelli V, Giacomelli R, Perosa F. Idiopathic and connective tissue disease-associated pulmonary arterial hypertension (PAH): Similarities, differences and the role of autoimmunity. Autoimmun Rev 2024; 23:103514. [PMID: 38181859 DOI: 10.1016/j.autrev.2024.103514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024]
Abstract
Pre-capillary pulmonary arterial hypertension (PAH) is hemodynamically characterized by a mean pulmonary arterial pressure (mPAP) ≥ 20 mmHg, pulmonary capillary wedge pressure (PAWP) ≤15 mmHg and pulmonary vascular resistance (PVR) > 2. PAH is classified in six clinical subgroups, including idiopathic PAH (IPAH) and PAH associated to connective tissue diseases (CTD-PAH), that will be the main object of this review. The aim is to compare these two PAH subgroups in terms of epidemiology, histological and pathogenic findings in an attempt to define disease-specific features, including autoimmunity, that may explain the heterogeneity of response to therapy between IPAH and CTD-PAH.
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Affiliation(s)
- Elvira Favoino
- Laboratory of Cellular and Molecular Immunology, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy.
| | - Marcella Prete
- Internal Medicine Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Vasiliki Liakouli
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Patrizia Leone
- Internal Medicine Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Adriana Sisto
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Luca Navarini
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Marta Vomero
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Francesco Ciccia
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Vito Racanelli
- Centre for Medical Sciences, University of Trento and Internal Medicine Division, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy
| | - Roberto Giacomelli
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Federico Perosa
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy.
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9
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Lammi MR, Kolstad KD, Saketkoo LA, Khatri A, Utz PJ, Steen VD, Chung L. Endothelial Biomarkers of Systemic Sclerosis-Associated Pulmonary Hypertension. Arthritis Care Res (Hoboken) 2023. [PMID: 37365746 DOI: 10.1002/acr.25180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/23/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Despite efforts at early detection, patients with systemic sclerosis (SSc) pulmonary hypertension (PH) present with advanced disease. We sought to determine whether endothelial biomarkers (asymmetric dimethylarginine [ADMA], soluble endoglin [sEng], and pentraxin-3 [PTX-3]) can determine SSc-PH risk or differentiate between SSc-PH subgroups. METHODS ADMA, sEng, and PTX-3 were measured by enzyme-linked immunosorbent assay in four groups: 1) 18 healthy controls, 2) 74 patients with SSc-PH, 3) 44 patients at high risk for PH features, and 4) 10 patients with low risk for PH features. High-risk features included a diffusion capacity (DLco) less than 55% with a forced vital capacity (FVC) greater than 70%, an FVC/DLco ratio of >1.6, or a right ventricular systolic pressure on an echocardiogram greater than or equal to 40 mm Hg. ADMA, sEng, and PTX-3 were compared between these four groups as well as stratified based on the three SSc-PH clinical classification groups (pulmonary arterial hypertension [PAH], left-heart disease, and interstitial lung disease [ILD]). RESULTS PTX-3 was significantly lower in subjects with SSc at low risk for PH (median 27.0 pg/ml [interquartile range (IQR) 19.0-47.3]; P < 0.003) than the other groups. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval 0.76-0.98, P = 0.0002) to differentiate low risk from high risk for patients with PH. PTX-3 was significantly lower in SSc-PH from disease of the left side of the heart (57.5 pg/ml [IQR 39.8-79.0]; P < 0.01) compared to SSc-PH from either PAH (85.5 pg/ml [IQR 56.3-104.5]) or ILD (90.3 pg/ml [IQR 74.9-111.0]). Neither ADMA nor sEng differed between the four groups. CONCLUSION PTX-3 is a promising biomarker of PH risk status in patients with SSc as well as a possible marker of precapillary PH, which should be validated in an external cohort.
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Affiliation(s)
- Matthew R Lammi
- Louisiana State University Health Sciences Center, University Medical Center-New Orleans, and New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, Louisiana
| | | | - Lesley Ann Saketkoo
- University Medical Center-New Orleans, New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, and Tulane University School of Medicine, New Orleans, Louisiana
| | - Avani Khatri
- Stanford University School of Medicine, Palo Alto, California
| | - Paul J Utz
- Stanford University School of Medicine, Palo Alto, California
| | | | - Lorinda Chung
- Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, California
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10
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Hojda SE, Chis IC, Clichici S. Biomarkers in Pulmonary Arterial Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12123033. [PMID: 36553040 PMCID: PMC9776459 DOI: 10.3390/diagnostics12123033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe medical condition characterized by elevated pulmonary vascular resistance (PVR), right ventricular (RV) failure, and death in the absence of appropriate treatment. The progression and prognosis are strictly related to the etiology, biochemical parameters, and treatment response. The gold-standard test remains right-sided heart catheterization, but dynamic monitoring of systolic pressure in the pulmonary artery is performed using echocardiography. However, simple and easily accessible non-invasive assays are also required in order to monitor this pathology. In addition, research in this area is in continuous development. In recent years, more and more biomarkers have been studied and included in clinical guidelines. These biomarkers can be categorized based on their associations with inflammation, endothelial cell dysfunction, cardiac fibrosis, oxidative stress, and metabolic disorders. Moreover, biomarkers can be easily detected in blood and urine and correlated with disease severity, playing an important role in diagnosis, prognosis, and disease progression.
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11
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Santos-Gomes J, Gandra I, Adão R, Perros F, Brás-Silva C. An Overview of Circulating Pulmonary Arterial Hypertension Biomarkers. Front Cardiovasc Med 2022; 9:924873. [PMID: 35911521 PMCID: PMC9333554 DOI: 10.3389/fcvm.2022.924873] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH), also known as Group 1 Pulmonary Hypertension (PH), is a PH subset characterized by pulmonary vascular remodeling and pulmonary arterial obstruction. PAH has an estimated incidence of 15-50 people per million in the United States and Europe, and is associated with high mortality and morbidity, with patients' survival time after diagnosis being only 2.8 years. According to current guidelines, right heart catheterization is the gold standard for diagnostic and prognostic evaluation of PAH patients. However, this technique is highly invasive, so it is not used in routine clinical practice or patient follow-up. Thereby, it is essential to find new non-invasive strategies for evaluating disease progression. Biomarkers can be an effective solution for determining PAH patient prognosis and response to therapy, and aiding in diagnostic efforts, so long as their detection is non-invasive, easy, and objective. This review aims to clarify and describe some of the potential new candidates as circulating biomarkers of PAH.
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Affiliation(s)
- Joana Santos-Gomes
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Gandra
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Adão
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Frédéric Perros
- Paris-Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERM, Université Paris-Saclay, Paris, France
- Université Paris–Saclay, AP-HP, INSERM UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Carmen Brás-Silva
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
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12
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Hannemann J, Böger R. Dysregulation of the Nitric Oxide/Dimethylarginine Pathway in Hypoxic Pulmonary Vasoconstriction—Molecular Mechanisms and Clinical Significance. Front Med (Lausanne) 2022; 9:835481. [PMID: 35252268 PMCID: PMC8891573 DOI: 10.3389/fmed.2022.835481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/27/2022] [Indexed: 12/21/2022] Open
Abstract
The pulmonary circulation responds to hypoxia with vasoconstriction, a mechanism that helps to adapt to short-lived hypoxic episodes. When sustained, hypoxic pulmonary vasoconstriction (HPV) may become deleterious, causing right ventricular hypertrophy and failure, and contributing to morbidity and mortality in the late stages of several chronic pulmonary diseases. Nitric oxide (NO) is an important endothelial vasodilator. Its release is regulated, amongst other mechanisms, by the presence of endogenous inhibitors like asymmetric dimethylarginine (ADMA). Evidence has accumulated in recent years that elevated ADMA may be implicated in the pathogenesis of HPV and in its clinical sequelae, like pulmonary arterial hypertension (PAH). PAH is one phenotypic trait in experimental models with disrupted ADMA metabolism. In high altitude, elevation of ADMA occurs during long-term exposure to chronic or chronic intermittent hypobaric hypoxia; ADMA is significantly associated with high altitude pulmonary hypertension. High ADMA concentration was also reported in patients with chronic obstructive lung disease, obstructive sleep apnoea syndrome, and overlap syndrome, suggesting a pathophysiological role for ADMA-mediated impairment of endothelium-dependent, NO-mediated pulmonary vasodilation in these clinically relevant conditions. Improved understanding of the molecular (dys-)regulation of pathways controlling ADMA concentration may help to dissect the pathophysiology and find novel therapeutic options for these diseases.
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Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
- *Correspondence: Rainer Böger
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13
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Banaszkiewicz M, Gąsecka A, Darocha S, Florczyk M, Pietrasik A, Kędzierski P, Piłka M, Torbicki A, Kurzyna M. Circulating Blood-Based Biomarkers in Pulmonary Hypertension. J Clin Med 2022; 11:jcm11020383. [PMID: 35054082 PMCID: PMC8779219 DOI: 10.3390/jcm11020383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/01/2022] [Accepted: 01/09/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary hypertension (PH) is a serious hemodynamic condition, characterized by increased pulmonary vascular resistance (PVR), leading to right heart failure (HF) and death when not properly treated. The prognosis of PH depends on etiology, hemodynamic and biochemical parameters, as well as on response to specific treatment. Biomarkers appear to be useful noninvasive tools, providing information about the disease severity, treatment response, and prognosis. However, given the complexity of PH, it is impossible for a single biomarker to be adequate for the broad assessment of patients with different types of PH. The search for novel emerging biomarkers is still ongoing, resulting in a few potential biomarkers mirroring numerous pathophysiological courses. In this review, markers related to HF, myocardial remodeling, inflammation, hypoxia and tissue damage, and endothelial and pulmonary smooth muscle cell dysfunction are discussed in terms of diagnosis and prognosis. Extracellular vesicles and other markers with complex backgrounds are also reviewed. In conclusion, although many promising biomarkers have been identified and studied in recent years, there are still insufficient data on the application of multimarker strategies for monitoring and risk stratification in PH patients.
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Affiliation(s)
- Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
- Correspondence:
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.G.); (A.P.)
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.G.); (A.P.)
| | - Piotr Kędzierski
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Michał Piłka
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
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14
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Tettey A, Jiang Y, Li X, Li Y. Therapy for Pulmonary Arterial Hypertension: Glance on Nitric Oxide Pathway. Front Pharmacol 2021; 12:767002. [PMID: 34867394 PMCID: PMC8633825 DOI: 10.3389/fphar.2021.767002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/25/2021] [Indexed: 01/11/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe disease with a resultant increase of the mean pulmonary arterial pressure, right ventricular hypertrophy and eventual death. Research in recent years has produced various therapeutic options for its clinical management but the high mortality even under treatment remains a big challenge attributed to the complex pathophysiology. Studies from clinical and non-clinical experiments have revealed that the nitric oxide (NO) pathway is one of the key pathways underlying the pathophysiology of PAH. Many of the essential drugs used in the management of PAH act on this pathway highlighting its significant role in PAH. Meanwhile, several novel compounds targeting on NO pathway exhibits great potential to become future therapy medications. Furthermore, the NO pathway is found to interact with other crucial pathways. Understanding such interactions could be helpful in the discovery of new drug that provide better clinical outcomes.
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Affiliation(s)
- Abraham Tettey
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
| | - Yujie Jiang
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
| | - Xiaohui Li
- Department of Pharmacology, School of Pharmaceutical Science, Central South University, Changsha, China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha, China
| | - Ying Li
- Department of Health Management, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha, China
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15
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Martynyuk TV, Shmalts AA, Gorbachevsky SV, Chazova IE. Optimization of specific therapy for pulmonary hypertension: the possibilities of riociguat. TERAPEVT ARKH 2021; 93:1117-1124. [DOI: 10.26442/00403660.2021.09.201014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
Pulmonary hypertension (PH) is a severe and often rapidly progressive disease with fatal outcome. Endothelial dysfunction in PH is associated with decreased nitric oxide production. After reviewing the mechanisms of action and the evidence base for specific therapy with phosphodiesterase 5 inhibitors (PDE-5) and soluble guanylate cyclase stimulators, a reseach review on switching from PDE-5 to riociguat is conducted. A potential advantage of riociguat is its independence from endogenous nitric oxide and from the other (besides PDE-5) isoenzymes of phosphodiesterases. The favorable efficacy profile of sildenafil has been proven for the main forms of pulmonary arterial hypertension, of riociguat for the main forms of pulmonary arterial hypertension and chronic thromboembolic PH. The clinical efficacy of replacing PDE-5 with riociguat has been demonstrated in uncontrolled trials and in the randomized controlled study REPLACE. The possibility of therapy optimization by switching from IFDE-5 to riociguat is fixed in the Russian (class and level of evidence B-3) and Eurasian (class and level of evidence IIb-B) clinical guidelines, as well as in the materials of the Cologne Expert Consensus. An additional argument for switching is the lower cost as compared to combination therapy in the Russian Federation. According to the Russian and Eurasian guidelines for PH and the Russian instructions for the use of riociguat, the drug should be taken at least 24 hours after sildenafil discontinuation.
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16
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Sweatt AJ, Reddy R, Rahaghi FN, Al-Naamani N. What's new in pulmonary hypertension clinical research: lessons from the best abstracts at the 2020 American Thoracic Society International Conference. Pulm Circ 2021; 11:20458940211040713. [PMID: 34471517 PMCID: PMC8404658 DOI: 10.1177/20458940211040713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
In this conference paper, we review the 2020 American Thoracic Society International Conference session titled, "What's New in Pulmonary Hypertension Clinical Research: Lessons from the Best Abstracts". This virtual mini-symposium took place on 21 October 2020, in lieu of the annual in-person ATS International Conference which was cancelled due to the COVID-19 pandemic. Seven clinical research abstracts were selected for presentation in the session, which encompassed five major themes: (1) standardizing diagnosis and management of pulmonary hypertension, (2) improving risk assessment in pulmonary arterial hypertension, (3) evaluating biomarkers of disease activity, (4) understanding metabolic dysregulation across the spectrum of pulmonary hypertension, and (5) advancing knowledge in chronic thromboembolic pulmonary hypertension. Focusing on these five thematic contexts, we review the current state of knowledge, summarize presented research abstracts, appraise their significance and limitations, and then discuss relevant future directions in pulmonary hypertension clinical research.
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Affiliation(s)
- Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Raju Reddy
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - on behalf of the American Thoracic Society Pulmonary Circulation Assembly Early Career Working Group
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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17
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Türer Cabbar A, Değertekin MM, Şimşek MA, Özveren O, Güleç S, Yanartaş M, Gezer Taş S, Olgun Yıldızeli Ş, Mutlu B, İşbir T, Yıldızeli B. Evaluation of Asymmetric Dimethylarginine Levels in Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy. Heart Lung Circ 2021; 31:110-118. [PMID: 34130918 DOI: 10.1016/j.hlc.2021.05.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary embolism, and pulmonary endarterectomy (PEA) is the surgical treatment. Asymmetric dimethylarginine (ADMA) levels are increased in pulmonary hypertension. This study aimed to investigate serum ADMA levels in patients with CTEPH, the effect of PEA on ADMA, and its prognostic value in long-term mortality. METHOD Eighty (80) patients with CTEPH and 32 healthy controls were included. Preoperative serum ADMA levels, determined using an enzyme-linked immunosorbent assay, were compared between patients with CTEPH and controls. Of 80 patients, 64 had PEA. Pre- and 6-month postoperative serum ADMA levels, 6-minute walk distance (6MWD), and haemodynamic parameters were collected from patients undergoing PEA. Patients were followed-up for survival analysis. RESULTS Mean ± standard deviation serum ADMA levels were significantly higher in patients with CTEPH compared with controls (0.79±0.32 μmol/L vs 0.52±0.12 μmol/L; p=0.0001). Statistically significant differences were observed between preoperative and postoperative serum ADMA levels (0.78±0.30 μmol/L vs 0.62±0.22 μmol/L; p=0.0001), 6MWD (p=0.0001), and pulmonary vascular resistance (p=0.0001) in 60 patients who underwent and survived PEA. The decrease in serum ADMA levels and increase in 6MWD were significantly correlated (r=-0.286, p=0.027). No other correlation was found. Perioperative mortality was 6.3%, and the survival rate with a mean follow-up of 34.57±8.20 months was 93.3%. Patients with serum ADMA levels >0.8 μmol/L had a significantly lower survival rate (logrank: 5.86; p=0.015). CONCLUSIONS Levels of circulating ADMA might add diagnostic and prognostic information in CTEPH. Pulmonary endarterectomy is associated with an improvement in serum ADMA levels. Preoperative serum ADMA levels may be useful for estimating the outcome of PEA.
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Affiliation(s)
- Ayça Türer Cabbar
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey.
| | | | - Mustafa A Şimşek
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Olcay Özveren
- Department of Cardiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Seda Güleç
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Mehmed Yanartaş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Serpil Gezer Taş
- Department of Cardiovascular Surgery, Kartal Koşuyolu High Specialty Educational and Research Hospital, Istanbul, Turkey
| | - Şehnaz Olgun Yıldızeli
- Department of Pulmonary and Intensive Care, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Turgay İşbir
- Department of Medical Biology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Marmara University Istanbul Pendik Educational and Research Hospital, Istanbul, Turkey
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18
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Walsh TP, Baird GL, Atalay MK, Agarwal S, Arcuri D, Klinger JR, Mullin CJ, Morreo H, Normandin B, Shiva S, Whittenhall M, Ventetuolo CE. Experimental design of the Effects of Dehydroepiandrosterone in Pulmonary Hypertension (EDIPHY) trial. Pulm Circ 2021; 11:2045894021989554. [PMID: 34094503 PMCID: PMC8142004 DOI: 10.1177/2045894021989554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/15/2020] [Indexed: 12/02/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) remains life-limiting despite numerous approved vasodilator therapies. Right ventricular (RV) function determines outcome in PAH but no treatments directly target RV adaptation. PAH is more common in women, yet women have better RV function and survival as compared to men with PAH. Lower levels of the adrenal steroid dehydroepiandrosterone (DHEA) and its sulfate ester are associated with more severe pulmonary vascular disease, worse RV function, and mortality independent of other sex hormones in men and women with PAH. DHEA has direct effects on nitric oxide (NO) and endothelin-1 (ET-1) synthesis and signaling, direct antihypertrophic effects on cardiomyocytes, and mitigates oxidative stress. Effects of Dehydroepiandrosterone in Pulmonary Hypertension (EDIPHY) is an on-going randomized double-blind placebo-controlled crossover trial of DHEA in men (n = 13) and pre- and post-menopausal women (n = 13) with Group 1 PAH funded by the National Heart, Lung and Blood Institute. We will determine whether orally administered DHEA 50 mg daily for 18 weeks affects RV longitudinal strain measured by cardiac magnetic resonance imaging, markers of RV remodeling and oxidative stress, NO and ET-1 signaling, sex hormone levels, other PAH intermediate end points, side effects, and safety. The crossover design will elucidate sex-based phenotypes in PAH and whether active treatment with DHEA impacts NO and ET-1 biosynthesis. EDIPHY is the first clinical trial of an endogenous sex hormone in PAH. Herein we present the study’s rationale and experimental design.
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Affiliation(s)
| | - Grayson L Baird
- Lifespan Health System, Providence, RI, USA.,Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael K Atalay
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Saurabh Agarwal
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Daniel Arcuri
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - James R Klinger
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher J Mullin
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Sruti Shiva
- Department of Pharmacology and Chemical Biology, Vascular Medicine Institute, NO Metabolomics Core Facility, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Whittenhall
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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19
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Bening C, Sales VL, Alhussini K, Radakovic D, Benitez RC, Madrahimov N, Keller D, Leyh R. Clinically inapparent right heart dysfunction is associated with reduced myofilament force development in coronary artery disease. BMC Cardiovasc Disord 2021; 21:125. [PMID: 33663396 PMCID: PMC7934411 DOI: 10.1186/s12872-021-01926-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background Right ventricular dysfunction after CABG is associated with poor peri- and postoperative outcomes. We aimed to identify clinical and experimental predictors for preoperative inapparent right ventricular dysfunction and therefore hypothesized that reduced myofilament force development as well as altered levels of biomarkers might predict inapparent right ventricular dysfunction. Methods From 08/2016 to 02/2018, 218 patients scheduled for CABG were divided into two groups (TAPSE ≥ 20 mm, n = 178; TAPSE < 20 mm, n = 40). Baseline serum samples for biomarkers (Galectin, TGFß1, N Acyl-SDMA, Arginine, ADMA and Pentraxin-3), clinical laboratory and transthoracic echocardiographic parameters were evaluated. To examine the myocardial apparatus of the right ventricle intraoperative right auricular tissue was harvested for stepwise skinned fiber force measurements. Results Patients with TAPSE < 20 mm had a higher incidence of DM (55 vs. 34%, p = 0.018), preoperative AFib (43 vs. 16%, p < 0.001), reduced GFR (67 ± 18 vs. 77 ± 24 ml/min/1.73 m2, p = 0.013), larger LA area (22 ± 6 vs. 20 ± 5 cm2, p = 0.005) and reduced LVEF (50 vs. 55%, p = 0.008). Furthermore, higher serum ADMA (0.70 ± 0.13 vs. 0.65 ± 0.15 µmol/l, p = 0.046) and higher serum Pentraxin-3 levels (3371 ± 1068 vs. 2681 ± 1353 pg/dl, p = 0.004) were observed in these patients. Skinned fiber force measurements showed significant lower values at almost every step of calcium concentration (pCa 4.52 to pCa 5.5, p < 0.01 and pCa 5.75–6.0, p < 0.05). Multivariable analysis revealed DM (OR 2.53, CI 1.12–5.73, Euro Score II (OR 1.34, CI 1.02–1.78), preoperative AF (OR 4.86, CI 2.06–11.47), GFR (OR 7.72, CI 1.87–31.96), albumin (OR 1.56, CI 0.52–2.60), Pentraxin-3 (OR 19.68, CI 14.13–25.24), depressed LVEF (OR 8.61, CI 6.37–10.86), lower force values: (pCa 5.4; OR 2.34, CI 0.40–4.29 and pCa 5.2; OR 2.00, CI 0.39–3.60) as predictors for clinical inapparent right heart dysfunction. Conclusions These preliminary data showed that inapparent right heart dysfunction in CAD is already associated with reduced force development of the contractile apparatus.
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Affiliation(s)
- C Bening
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany. .,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany.
| | - V L Sales
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - K Alhussini
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany
| | - D Radakovic
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - R Cris Benitez
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - N Madrahimov
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - D Keller
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - R Leyh
- Department of Thoracic and Cardiovascular Surgery, Zentrum Operative Medizin, University of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.,Comprehensive Heart Failure Centre (CHFC) Würzburg, University of Wuerzburg, Wuerzburg, Germany
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Dara A, Arvanitaki A, Theodorakopoulou M, Athanasiou C, Pagkopoulou E, Boutou A. Non-Invasive Assessment of Endothelial Dysfunction in Pulmonary Arterial Hypertension. Mediterr J Rheumatol 2021; 32:6-14. [PMID: 34386697 PMCID: PMC8314877 DOI: 10.31138/mjr.32.1.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/01/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterised by an increased pressure in the pulmonary arterial circulation, resulting in the elevation of pulmonary vascular resistance. Pulmonary endothelial dysfunction and inflammation, triggered by shear stress and hypoxia, constitute the hallmarks of pulmonary vasculopathy by promoting endothelial and smooth muscle cells proliferation, vasoconstriction, and thrombosis. While research was predominantly focused on pulmonary vasculature, the investigation of peripheral endothelial damage in different vascular beds has attracted the interest over the last years. As a result, effective non-invasive methods that can assess the endothelial function and the architectural integrity have been utilized for the evaluation of pulmonary and peripheral vasculature. Non-invasive plethysmography, pulmonary flow reserve, nailfold videocapillaroscopy, near-infrared spectroscopy, and imaging techniques such as magnetic resonance angiography and perfusion imaging coupled by a number of biomarkers can be used for the assessment of peripheral vascular function in PAH individuals. In this review, we summarise and critically approach the current evidence of more systemic derangement of vascular function in PAH defined by novel, non-invasive methods employed for functional and morphological assessment of endothelium and microcirculation.
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Affiliation(s)
- Athanasia Dara
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.,First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Adult Congenital Heart Centre and National Centre for Pulmonary Arterial Hypertension, Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, Imperial College, London, UK
| | | | - Christos Athanasiou
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Afroditi Boutou
- Department of Respiratory Medicine, G. Papanikolaou Hospital, Thessaloniki, Greece
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21
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Lázár Z, Mészáros M, Bikov A. The Nitric Oxide Pathway in Pulmonary Arterial Hypertension: Pathomechanism, Biomarkers and Drug Targets. Curr Med Chem 2021; 27:7168-7188. [PMID: 32442078 DOI: 10.2174/0929867327666200522215047] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 02/20/2020] [Indexed: 11/22/2022]
Abstract
The altered Nitric Oxide (NO) pathway in the pulmonary endothelium leads to increased vascular smooth muscle tone and vascular remodelling, and thus contributes to the development and progression of pulmonary arterial hypertension (PAH). The pulmonary NO signalling is abrogated by the decreased expression and dysfunction of the endothelial NO synthase (eNOS) and the accumulation of factors blocking eNOS functionality. The NO deficiency of the pulmonary vasculature can be assessed by detecting nitric oxide in the exhaled breath or measuring the degradation products of NO (nitrite, nitrate, S-nitrosothiol) in blood or urine. These non-invasive biomarkers might show the potential to correlate with changes in pulmonary haemodynamics and predict response to therapies. Current pharmacological therapies aim to stimulate pulmonary NO signalling by suppressing the degradation of NO (phosphodiesterase- 5 inhibitors) or increasing the formation of the endothelial cyclic guanosine monophosphate, which mediates the downstream effects of the pathway (soluble guanylate cyclase sensitizers). Recent data support that nitrite compounds and dietary supplements rich in nitrate might increase pulmonary NO availability and lessen vascular resistance. This review summarizes current knowledge on the involvement of the NO pathway in the pathomechanism of PAH, explores novel and easy-to-detect biomarkers of the pulmonary NO.
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Affiliation(s)
- Zsófia Lázár
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Martina Mészáros
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Andras Bikov
- Department of Pulmonology, Semmelweis University, Budapest, Hungary,Manchester University NHS Foundation Trust, Manchester, United Kingdom
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22
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Treatment-related biomarkers in pulmonary hypertension patients on oral therapies. Respir Res 2020; 21:304. [PMID: 33213478 PMCID: PMC7678114 DOI: 10.1186/s12931-020-01566-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Multiple classes of oral therapy are available for the treatment of pulmonary arterial hypertension (PAH), but there is little to guide clinicians in choosing a specific regimen or therapeutic class. We aimed to investigate whether treatment-relevant blood biomarkers can predict therapy response in prevalent PAH patients. Methods This prospective cohort study longitudinally assessed biomarkers along the endothelin-1 (ET-1) and nitric oxide (cGMP, ADMA, SDMA, nitrite, and S-nitrosohemoglobin) pathways along with the cGMP/NT-proBNP ratio over 12 months in patients with WHO Group 1 PAH on oral PAH-specific therapies. The relationship between biomarkers and 6MWD at the same and future visits was examined using mixed linear regression models adjusted for age. As cGMP can be elevated when NT-proBNP is elevated, we also tested the relationship between 6MWD and the cGMP/NT-pro BNP ratio. Patients with PAH with concomitant heart or lung disease or chronic thromboembolic pulmonary hypertension (CTEPH) were included in a sensitivity analysis. Results The study cohort included 58 patients with PAH treated with either an endothelin receptor antagonist (27.6%), phosphodiesterase-5 inhibitor (25.9%) or a combination of the two (43.1%). Among biomarkers along the current therapeutic pathways, ET-1 and the cGMP/NT-proBNP ratio associated with same visit 6MWD (p = 0.02 and p = 0.03 respectively), and ET-1 predicted future 6MWD (p = 0.02). ET-1 (p = 0.01) and cGMP/NT-proBNP ratio (p = 0.04) also predicted future 6MWD in the larger cohort (n = 108) of PAH patients with concomitant left heart disease (n = 17), lung disease (n = 20), or CTEPH (n = 13). Finally, in the larger cohort, SDMA associated with 6MWD at the same visit (p = 0.01) in all subgroups and ADMA associated with 6MWD in PAH patients with concomitant lung disease (p = 0.03) and PAH patients on ERA therapy (p = 0.01). Conclusions ET-1, cGMP/NTproBNP ratio, and dimethylarginines ADMA and SDMA are mediators along pathways targeted by oral PAH therapies that associate with or predict 6MWD.
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23
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Shostak NA, Klimenko AA, Demidova NA. [The place of riociguat in the treatment of patients with pulmonary arterial hypertension associated with systemic connective tissue diseases]. ACTA ACUST UNITED AC 2020; 60:92-101. [PMID: 33131480 DOI: 10.18087/cardio.2020.9.n1189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/14/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension (PH) can develop in different systemic autoimmune rheumatic diseases (SARD), such as systemic scleroderma (SSD), systemic lupus erythematosus, rheumatoid arthritis, and mixed connective tissue disease In most cases, patients with SARD develop WHO group I PH (pulmonary arterial hypertension associated with systemic connective tissue diseases, PAH-SCTD). General prevalence of this pathology reaches 15 cases per million adults. Most cases of PAH-SCTD are induced by SSD. Survival of PAH-SCTD patients is generally lower than survival of patients with other forms of LAH. Treatment of any SARD, including in LAH, implies a complex approach using glucocorticoids, disease-modifying anti-rheumatic drugs (cyclophosphamide, methotrexate, azathioprine, and others), and genetically engineered biologics. Specific targeted therapy is indicated for most patients with PAH-SCTD. The representative of a new class (soluble guanylate cyclase (sGC) stimulators), riociguat, has been approved for the treatment of PAH. This drug has a unique double mechanism of action: (i) sGC sensibilization to endogenous nitric oxide (NO) by stabilizing the NO-sGC bond; and (ii) direct, NO-independent sGC stimulation. For patients with PAH-SCTD, riociguat is the major alternative to phosphodiesterase-5 inhibitors both as monotherapy and combination therapy.
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Affiliation(s)
- N A Shostak
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - A A Klimenko
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - N A Demidova
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
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24
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Hannemann J, Zummack J, Hillig J, Böger R. Metabolism of asymmetric dimethylarginine in hypoxia: from bench to bedside. Pulm Circ 2020; 10:2045894020918846. [PMID: 32313644 PMCID: PMC7158260 DOI: 10.1177/2045894020918846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022] Open
Abstract
Acute hypoxia and chronic hypoxia induce pulmonary vasoconstriction. While hypoxic pulmonary vasoconstriction is a physiological response if parts of the lung are affected, global exposure to hypoxic conditions may lead to clinical conditions like high-altitude pulmonary hypertension. Nitric oxide is the major vasodilator released from the vascular endothelium. Nitric oxide-dependent vasodilation is impaired in hypoxic conditions. Inhibition of nitric oxide synthesis is the most rapid and easily reversible molecular mechanism to regulate nitric oxide-dependent vascular function in response to physiological and pathophysiological stimuli. Asymmetric dimethylarginine is an endogenous, competitive inhibitor of nitric oxide synthase and a risk marker for major cardiovascular events and mortality. Elevated asymmetric dimethylarginine has been observed in animal models of hypoxia as well as in human cohorts under chronic and chronic intermittent hypoxia at high altitude. In lowlanders, asymmetric dimethylarginine is high in patients with pulmonary hypertension. We have recently shown that high asymmetric dimethylarginine at sea level is a predictor for high-altitude pulmonary hypertension. Asymmetric dimethylarginine is a highly regulated molecule, both by its biosynthesis and metabolism. Methylation of L-arginine by protein arginine methyltransferases was shown to be increased in hypoxia. Furthermore, the metabolism of asymmetric dimethylarginine by dimethylarginine dimethylaminohydrolases (DDAH1 and DDAH2) is decreased in animal models of hypoxia. Whether these changes are caused by transcriptional or posttranslational modifications remains to be elucidated. Current data suggest a major role of asymmetric dimethylarginine in regulating pulmonary arterial nitric oxide production in hypoxia. Further studies are needed to decipher the molecular mechanisms regulating asymmetric dimethylarginine in hypoxia and to understand their clinical significance.
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Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Julia Zummack
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Jonas Hillig
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
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25
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Abstract
Objective: The use of the radial approach in coronary angiography or percutaneous coronary intervention has increased owing to its advantages over the femoral approach such as rapid patient mobilization and improved patient comfort. However, radial artery spasm (RAS) that occurs during the procedure is a crucial factor in transradial approach failure and access site switch. Asymmetric dimethylarginine (ADMA) is a naturally occurring, modified amino acid that inhibits nitric oxide (NO) production. High ADMA levels may reduce arterial elasticity especially in small arteries like the radial artery. This study aimed to evaluate the relationship between ADMA levels and RAS in radial artery access. Methods: This study included 155 patients (89 males and 66 females) who underwent transradial coronary angiography between January 2016 and June 2016. The ADMA level in the plasma was determined using a quantitative sandwich enzyme immunoassay technique. Results: RAS was observed in 16 of the 155 patients (10.1%). The RAS was found to be more frequent in female patients (17.9% for women vs. 4.4% for men, p=0.019). The plasma concentration of ADMA in the RAS group was significantly higher than that in the control group [22.1 ng/mL (12.1–37.8) vs. 9.2 ng/mL (5.9–14.8), p<0.001]. Moreover, the plasma concentration of ADMA was significantly higher in patients with RAS among female patients [20.4 ng/mL (12.1–44.9) vs. 9.9 ng/mL (6.2–16.6); p=0.002] and among male patients [25.2 ng/mL (13.7–35.4) vs. 8.2 ng/mL (5.9–12.8); p=0.007]. Binary logistic regression analysis of all patients showed that ADMA concentration was the only predictor for RAS (odds ratio=1.142; 95% confidence interval=1.061–1.228; p<0.001). Conclusion: It was found that the ADMA concentration of the patients in the RAS group was elevated compared to that of controls. The findings indicated that elevated ADMA concentrations could predict RAS that may occur. (Anatol J Cardiol 2020; 23: 228-32)
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26
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Abstract
BACKGROUND The aim of the study was to provide a theoretical basis for the early diagnosis and prediction of acute altitude sickness, to provide a better entry mode for healthy people from plain areas to plateau areas, and to preliminarily clarify the possible mechanism of this approach. METHODS We measured endothelin-1 (ET-1), asymmetric dimethylarginine (ADMA), vascular endothelial growth factor (VEGF), nitric oxide (NO), and hypoxia-inducible factor 1 (HIF-1) levels in each sample and determined flow-mediated dilation (FMD) values using a portable OMRON color Doppler with a 7.0- to 12.0-MHz linear array probe. We used the Lewis Lake score to diagnose acute mountain sickness (AMS) and to stratify the disease severity. RESULTS We found no cases of AMS at any of the studied elevation gradients. We found significant differences in FMD values between individuals when at 400 m above sea level and when at 2200, 3200, and 4200 m above sea level (P < .05) but found no significant differences among those at 2200, 3200, and 4200 m. Our variance analysis showed that serum ET-1, VEGF, ADMA, NO, and HIF-1 levels in individuals at ≥3000 m and those at subplateau and plain areas (<3000 m) significantly differed (P < .05). The level of these factors also significantly differed between individuals at elevation gradients of plateau areas (3260 m vs 4270 m) (P < .05). We found no significant differences in serum ET-1, VEGF, and ADMA levels between individuals at the plateau (2260 m) and plain (400 m) areas (P > .05). NO and HIF-1 levels were significantly different in serum samples from individuals between the plateau (2260 m) and plain (400 m) areas (P < .05). However, with increasing altitude, the NO level gradually increased, whereas ET-1, ADMA, VEGF, and HIF-1 levels showed a decreasing trend. With the increase of altitude, there is no correlation between the trend of FMD and hematologic-related factors such as VEGF, NO, and HIF-1. CONCLUSION A healthy young male population ascending to a high-altitude area experiences a low incidence of AMS. Entering an acute plateau exposure environment from different altitude gradients may weaken the effect of acute highland exposure on vascular endothelial dysfunction in healthy individuals. Changes in serum ET-1, VEGF, ADMA, NO, and HIF-1 levels in healthy young men may be related to the body's self-regulation and protect healthy individuals from AMS. A short stay in a subplateau region may initiate an oxygen-free preconditioning process in healthy individuals, thereby protecting them from AMS. Noninvasive brachial artery endothelial function test instead of the detection of invasive hematologic-related factors for early diagnosis and prediction of the occurrence and severity of acute high-altitude disease is still lack of sufficient theoretical basis.
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Affiliation(s)
- Ning Fan
- Graduate School of Qinghai University
| | - Cun Liu
- Qinghai Cardiovascular Hospital
| | - Ming Ren
- The Affiliated Hospital of Qing Hai University, Xi Ning, Qing Hai, China
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27
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Edmonston DL, Parikh KS, Rajagopal S, Shaw LK, Abraham D, Grabner A, Sparks MA, Wolf M. Pulmonary Hypertension Subtypes and Mortality in CKD. Am J Kidney Dis 2019; 75:713-724. [PMID: 31732231 DOI: 10.1053/j.ajkd.2019.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE Pulmonary hypertension (PH) contributes to cardiovascular disease and mortality in patients with chronic kidney disease (CKD), but the pathophysiology is mostly unknown. This study sought to estimate the prevalence and consequences of PH subtypes in the setting of CKD. STUDY DESIGN Observational retrospective cohort study. SETTING & PARTICIPANTS We examined 12,618 patients with a right heart catheterization in the Duke Databank for Cardiovascular Disease from January 1, 2000, to December 31, 2014. EXPOSURES Baseline kidney function stratified by CKD glomerular filtration rate category and PH subtype. OUTCOMES All-cause mortality. ANALYTICAL APPROACH Multivariable Cox proportional hazards analysis. RESULTS In this cohort, 73.4% of patients with CKD had PH, compared with 56.9% of patients without CKD. Isolated postcapillary PH (39.0%) and combined pre- and postcapillary PH (38.3%) were the most common PH subtypes in CKD. Conversely, precapillary PH was the most common subtype in the non-CKD cohort (35.9%). The relationships between mean pulmonary artery pressure, pulmonary capillary wedge pressure, and right atrial pressure with mortality were similar in both the CKD and non-CKD cohorts. Compared with those without PH, precapillary PH conferred the highest mortality risk among patients without CKD (HR, 2.27; 95% CI, 2.00-2.57). By contrast, in those with CKD, combined pre- and postcapillary PH was associated with the highest risk for mortality in CKD in adjusted analyses (compared with no PH, HRs of 1.89 [95% CI, 1.57-2.28], 1.87 [95% CI, 1.52-2.31], 2.13 [95% CI, 1.52-2.97], and 1.63 [95% CI, 1.12-2.36] for glomerular filtration rate categories G3a, G3b, G4, and G5/G5D). LIMITATIONS The cohort referred for right heart catheterization may not be generalizable to the general population. Serum creatinine data in the 6 months preceding catheterization may not reflect true baseline CKD. Observational design precludes assumptions of causality. CONCLUSIONS In patients with CKD referred for right heart catheterization, PH is common and associated with poor survival. Combined pre- and postcapillary PH was common and portended the worst survival for patients with CKD.
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Affiliation(s)
- Daniel L Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Kishan S Parikh
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Biochemistry, Duke University Medical Center, Durham, NC
| | - Linda K Shaw
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Dennis Abraham
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alexander Grabner
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Renal Section, Durham VA Medical Center, Durham, NC
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Sanders JL, Han Y, Urbina MF, Systrom DM, Waxman AB. Metabolomics of exercise pulmonary hypertension are intermediate between controls and patients with pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019882623. [PMID: 31695905 DOI: 10.1177/2045894019882623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/18/2019] [Indexed: 01/06/2023] Open
Abstract
Mechanisms underlying pulmonary arterial hypertension (PAH) remain elusive. Pulmonary arterial hypertension and exercise PH share similar physiologic consequences; it is debated whether they share biologic mechanisms and if exercise PH represents an early phase of pulmonary arterial hypertension. We conducted an observational study to test if there is a graded metabolic disturbance along the severity of PH, which may indicate shared or disparate pathophysiology. Individuals referred to an academic medical dyspnea center with unexplained exertional intolerance underwent invasive cardiopulmonary exercise testing. We identified controls with no hemodynamic exercise limitation, individuals with exercise PH (mean pulmonary arterial pressure (mPAP) < 25 mmHg at rest but ≥ 30 mmHg during exercise without pulmonary venous hypertension) and pulmonary arterial hypertension (mPAP > 25 mmHg at rest without pulmonary venous hypertension) (n = 26 in each group). Unbiased metabolomics with chromatography mass spectrometry was performed on pulmonary arterial blood at rest and peak exercise. Random forest analysis and hierarchical clustering were used to quantify metabolite prediction of group membership and rank metabolites which were significantly different between groups. Compared to controls, pulmonary arterial hypertension subjects exhibited perturbations in pathways involving glycolysis, TCA cycle, fatty acid and complex lipid oxidation, collagen deposition and fibrosis, nucleotide metabolism, and others. The metabolic signature of exercise PH was uniquely between that of control and pulmonary arterial hypertension subjects. Accuracy predicting control, exercise PH, and pulmonary arterial hypertension group was 96%, 90%, and 88%, respectively, using paired rest-exercise metabolic changes. Our data suggest the metabolic profile of exercise PH is between that of controls and patients with pulmonary arterial hypertension.
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Affiliation(s)
- Jason L Sanders
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Yuchi Han
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Mariana F Urbina
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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29
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Beghetti M, Gorenflo M, Ivy DD, Moledina S, Bonnet D. Treatment of pediatric pulmonary arterial hypertension: A focus on the NO-sGC-cGMP pathway. Pediatr Pulmonol 2019; 54:1516-1526. [PMID: 31313530 PMCID: PMC6771736 DOI: 10.1002/ppul.24442] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While pulmonary arterial hypertension (PAH) is rare in infants and children, it results in substantial morbidity and mortality. In recent years, prognosis has improved, coinciding with the introduction of new PAH-targeted therapies, although much of their use in children is off-label. Evidence to guide the treatment of children with PAH is less extensive than for adults. The goal of this review is to discuss the treatment recommendations for children with PAH, as well as the evidence supporting the use of prostanoids, endothelin receptor antagonists (ERAs), and phosphodiesterase type 5 inhibitors (PDE5i) in this setting. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected concentrating on the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway in PAH. The methodology of an ongoing study evaluating the sGC stimulator riociguat in children with PAH is also described. RESULTS Despite recent medical advances, improved therapeutic strategies for pediatric PAH are needed. The efficacy and tolerability of riociguat in adults with PAH have been well trialed. CONCLUSION The pooling of data across trials, supplemented by registry data, will help to confirm the safety and tolerability of prostanoids, ERAs, and PDE5i in children. Ongoing studies will clarify the place of sGC stimulators in the treatment strategy for pediatric PAH.
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Affiliation(s)
- Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque PédiatriqueChildren's University HospitalGenevaSwitzerland
| | - Matthias Gorenflo
- Department of Pediatrics II, Pediatric Cardiology and Congenital Heart Defects, Center for PediatricsUniversity Hospital HeidelbergGermany
| | - D. Dunbar Ivy
- Children's Hospital Colorado, Heart InstituteUniversity of Colorado School of MedicineDenverColorado
| | - Shahin Moledina
- Cardiology DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Damien Bonnet
- M3C‐Paediatric Cardiology, Necker Enfants Malades, AP‐HPUniversité Paris DescartesParisFrance
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30
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Clinical Value of Asymmetrical Dimethylarginine Detection in Patients with Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Cardiol Res Pract 2019; 2019:3741909. [PMID: 31485349 PMCID: PMC6710784 DOI: 10.1155/2019/3741909] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/29/2019] [Accepted: 07/27/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the clinical value of serum asymmetrical dimethylarginine (ADMA) in patients with connective tissue disease- (CTD-) associated pulmonary arterial hypertension (PAH). Methods 88 patients with CTD were recruited between December 2017 and August 2018 in Jiangxi Provincial People's Hospital. Patients were further divided into two groups: CTD-without PAH (n = 45 cases) and CTD-with PAH (n = 43 cases), according to the pulmonary systolic blood pressure measured by echocardiography. 40 healthy controls were also included (n = 40 cases). The clinical data, including laboratory examinations, echocardiographic measurements, pulmonary function, and serum ADMA levels determined by enzyme-linked immunosorbent assay, (ELISA) were collected. The correlation between ADMA levels and the occurrence of PAH, pulmonary function, and other laboratory indexes in CTD patients were analyzed. Statistical analyses were performed by SPSS (version 23); P < 0.05 was considered statistically significant. Results The serum levels of ADMA in the CTD-PAH group were significantly higher than those of the CTD-without PAH group and healthy control group (P < 0.05); the serum ADMA levels were (0.706 ± 0.153 μmol/L), (1.015 ± 0.122 μmol/L), and (0.661 ± 0.113 μmol/L), respectively. There was no significant difference between the CTD-without PAH group and healthy control group (P < 0.05). Correlation analysis showed that serum ADMA levels were positively correlated with sPAP and NT-proBNP and negatively correlated with DLCO% (r = 0.802, 0.475, −0.585, P < 0.001). Multivariate analysis indicated that elevated serum ADMA levels increased the risk for the appearance of PAH in CTD patients (OR = 57.460, P < 0.001). Using the receiver operating characteristic (ROC) curve analysis, at the cutoff level of 0.810 μmol/L, ADMA showed good diagnostic efficacy as follows: sensitivity was 97.7%, specificity was 75.6%, and the area under the curve (AUC) was 0.947 (P < 0.001). Conclusion Increased ADMA levels are independently associated with the presence and severity of PAH in CTD patients. The levels of ADMA in the serum may contribute to be a noninvasive indicator for early diagnosis of CTD-with PAH patients.
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31
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Zhang M, Zhang Y, Pang W, Zhai Z, Wang C. Circulating biomarkers in chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019844480. [PMID: 30942132 PMCID: PMC6552358 DOI: 10.1177/2045894019844480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition characterized with chronic organized thrombi that obstruct the pulmonary vessels, leading to pulmonary hypertension (PH) and ultimately right heart failure. Although CTEPH is the only form of PH that can be cured with surgical intervention, not all patients with CTEPH will be deemed operable. Some CTEPH patients still have a poor prognosis. Therefore, the determination of diagnostic and prognostic biomarkers of CTEPH is of great importance for the early intervention to improve prognosis of patients with CTEPH. Several markers related to multiple mechanisms of CTEPH have been recently identified as circulating diagnostic and prognostic biomarkers in these patients. However, the existing literature review of biomarkers of CTEPH is relatively sparse. In this article, we review recent advances in circulating biomarkers of CTEPH and describe future applications of these biomarkers in the management of CTEPH.
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Affiliation(s)
- Meng Zhang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yunxia Zhang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenyi Pang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chen Wang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Siques P, Brito J, Schwedhelm E, Pena E, León-Velarde F, De La Cruz JJ, Böger RH, Hannemann J. Asymmetric Dimethylarginine at Sea Level Is a Predictive Marker of Hypoxic Pulmonary Arterial Hypertension at High Altitude. Front Physiol 2019; 10:651. [PMID: 31191349 PMCID: PMC6545974 DOI: 10.3389/fphys.2019.00651] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/08/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Prolonged exposure to altitude-associated chronic hypoxia (CH) may cause high-altitude pulmonary hypertension (HAPH). Chronic intermittent hypobaric hypoxia (CIH) occurs in individuals who commute between sea level and high altitude. CIH is associated with repetitive acute hypoxic acclimatization and conveys the long-term risk of HAPH. As nitric oxide (NO) regulates pulmonary vascular tone and asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of NO synthesis, we investigated whether ADMA concentration at sea level predicts HAPH among Chilean frontiers personnel exposed to 6 months of CIH. Methods: In this prospective study, 123 healthy army draftees were subjected to CIH (5 days at 3,550 m, 2 days at sea level) for 6 months. In 100 study participants with complete data, ADMA, symmetric dimethylarginine (SDMA), L-arginine, arterial oxygen saturation (SaO2), systemic blood pressure, and hematocrit were assessed at months 0 (sea level), 1, 4, and 6. Acclimatization to altitude was determined using the Lake Louise Score (LLS) and the presence of acute mountain sickness (AMS). Echocardiography was performed after 6 months of CIH in 43 individuals with either good (n = 23) or poor (n = 20) acclimatization. Results: SaO2 acutely decreased at altitude and plateaued at 90% thereafter. ADMA increased and SDMA decreased during the study course. The incidence of AMS and the LLS was high after the first ascent (53 and 3.1 ± 2.4) and at 1 month of CIH (47 and 3.0 ± 2.6), but decreased to 20 and 1.4 ± 2.0 at month 6 (both p < 0.001). Eighteen participants (42%) showed a mean pulmonary arterial pressure (mPAP) >25 mm Hg, out of which 9 (21%) were classified as HAPH (mPAP ≥ 30 mm Hg). ADMA at sea level was significantly associated with mPAP at high altitude in month 6 (R = 0.413; p = 0.007). In ROC analysis, a cutoff for baseline ADMA of 0.665 μmol/L was determined to predict HAPH (mPAP > 30 mm Hg) with a sensitivity of 100% and a specificity of 63.6%. Conclusions: ADMA concentration increases during CIH. ADMA at sea level is an independent predictive biomarker of HAPH. SDMA concentration decreases during CIH and shows no association with HAPH. Our data support a role of impaired NO-mediated pulmonary vasodilation in the pathogenesis of HAPH.
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Affiliation(s)
- Patricia Siques
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile
| | - Julio Brito
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eduardo Pena
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile.,Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile
| | - Fabiola León-Velarde
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile.,Department of Biological and Physiological Sciences, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Juan José De La Cruz
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
| | - Rainer H Böger
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile.,Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Juliane Hannemann
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany and Iquique, Chile.,Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zhao WC, Li G, Huang CY, Jiang JL. Asymmetric dimethylarginine: An crucial regulator in tissue fibrosis. Eur J Pharmacol 2019; 854:54-61. [PMID: 30951718 DOI: 10.1016/j.ejphar.2019.03.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
Fibrosis is a reparative process with very few therapeutic options to prevent its progression to organ dysfunction. Chronic fibrotic diseases contribute to an estimated 45% of all death in the industrialized world. Asymmetric dimethylarginine (ADMA), an endothelial nitric oxide synthase inhibitor, plays a crucial role in the pathogenesis of various cardiovascular diseases associated with endothelial dysfunction. Recent reports have focused on ADMA in the pathogenesis of tissue fibrosis. This review discusses the current knowledge about ADMA biology, its association with risk factors of established fibrotic diseases and the potential pathophysiological mechanisms implicating ADMA in the process of tissue fibrosis.
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Affiliation(s)
- Wei-Chen Zhao
- Department of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410078, China
| | - Ge Li
- Department of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410078, China; Faculty of Medical Public Courses, Xinhua College of Sun Yat-sen University, Guangzhou, Guangdong, 510520, China
| | - Chu-Yi Huang
- Department of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410078, China
| | - Jun-Lin Jiang
- Department of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410078, China; Provincial Key Laboratory of Cardiovascular Research, Central South University, Changsha, 410078, China.
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Henrohn D, Björkstrand K, Lundberg JO, Granstam SO, Baron T, Ingimarsdóttir IJ, Hedenström H, Malinovschi A, Wernroth ML, Jansson M, Hedeland M, Wikström G. Effects of Oral Supplementation With Nitrate-Rich Beetroot Juice in Patients With Pulmonary Arterial Hypertension-Results From BEET-PAH, an Exploratory Randomized, Double-Blind, Placebo-Controlled, Crossover Study. J Card Fail 2018; 24:640-653. [PMID: 30244181 DOI: 10.1016/j.cardfail.2018.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The nitrate-nitrite-nitric oxide (NO) pathway may represent a potential therapeutic target in patients with pulmonary arterial hypertension (PAH). We explored the effects of dietary nitrate supplementation, with the use of nitrate-rich beetroot juice (BRJ), in patients with PAH. METHODS AND RESULTS We prospectively studied 15 patients with PAH in an exploratory randomized, double-blind, placebo-controlled, crossover trial. The patients received nitrate-rich beetroot juice (∼16 mmol nitrate per day) and placebo in 2 treatment periods of 7 days each. The assessments included; exhaled NO and NO flow-independent parameters (alveolar NO and bronchial NO flux), plasma and salivary nitrate and nitrite, biomarkers and metabolites of the NO-system, N-terminal pro-B-type natriuretic peptide, echocardiography, ergospirometry, diffusing capacity of the lung for carbon monoxide, and the 6-minute walk test. Compared with placebo ingestion of BRJ resulted in increases in; fractional exhaled NO at all flow-rates, alveolar NO concentrations and bronchial NO flux, and plasma and salivary levels of nitrate and nitrite. Plasma ornithine levels decreased and indices of relative arginine availability increased after BRJ compared to placebo. A decrease in breathing frequency was observed during ergospirometry after BRJ. A tendency for an improvement in right ventricular function was observed after ingestion of BRJ. In addition a tendency for an increase in the peak power output to peak oxygen consumption ratio (W peak/VO2 peak) was observed, which became significant in patients reaching an increase of plasma nitrite >30% (responders). CONCLUSIONS BRJ administered for 1 week increases pulmonary NO production and the relative arginine bioavailability in patients with PAH, compared with placebo. An increase in the W peak/VO2 peak ratio was observed after BRJ ingestion in plasma nitrite responders. These findings indicate that supplementation with inorganic nitrate increase NO synthase-independent NO production from the nitrate-nitrite-NO pathway.
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Affiliation(s)
- Dan Henrohn
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden.
| | - Kristoffer Björkstrand
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Jon O Lundberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Sven-Olof Granstam
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden; Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Inga J Ingimarsdóttir
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Hans Hedenström
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Mona-Lisa Wernroth
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Martin Jansson
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Mikael Hedeland
- Department of Chemistry, Environment and Feed Hygiene, National Veterinary Institute, (SVA), Uppsala, Sweden; Division of Analytical Pharmaceutical Chemistry, Department of Medicinal Chemistry, Uppsala University, Uppsala, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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Risk stratification strategy and assessment of disease progression in patients with pulmonary arterial hypertension: Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:20-29. [PMID: 30266353 DOI: 10.1016/j.ijcard.2018.08.084] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 11/22/2022]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available, and were last updated in the spring of 2018. This article focusses on the proposed risk stratification and assessment of disease progression in patients with pulmonary arterial hypertension (PAH), covering 3 parts: In part 1, methods and markers that are recommended to assess severity and progression of PAH are discussed and commented. These updated comments incorporate most recent data as well as challenges arising from the variability of phenotypes of PAH patients with increasing cardiopulmonary comorbidities. In part 2, the proposed ESC/ERS risk stratification strategy is discussed, together with a review of the recent validation studies from different European registries. Finally, in part 3, the working group of the Cologne Consensus Conference provides recommendations on how risk assessment may be implemented in routine clinical practice and may serve clinical decision making.
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36
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Farag M, El Amrousy D, El-Serogy H, Zoair A. Role of plasma asymmetric dimethyl-L-arginine levels in detection of pulmonary hypertension in children with CHD. Cardiol Young 2018; 28:1163-1168. [PMID: 29950194 DOI: 10.1017/s1047951118001026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The objectives of this study were to evaluate the plasma levels of asymmetric dimethyl-L-arginine in children with pulmonary hypertension due to CHD before and after treatment with sildenafil and to evaluate its diagnostic and prognostic value as a biomarker in such children. METHODS A total of 60 children with CHD and 30 healthy control children matched for age and sex were recruited. Children with CHD were divided into two equal groups: the normal pulmonary pressure group (n=30) and the pulmonary hypertension group (n=30). Children with pulmonary hypertension were treated with sildenafil and were followed up for 6 months. Clinical data, haemodynamic parameters, echocardiographic examination, and asymmetric dimethyl-L-arginine levels were evaluated before and after treatment. RESULTS Asymmetric dimethyl-L-arginine levels were significantly higher in patients with pulmonary hypertension than in those with CHD-only or the control group, and this increase was positively correlated with increased severity of pulmonary hypertension. Asymmetric dimethyl-L-arginine levels, mean pulmonary artery pressure, and pulmonary vascular resistance were significantly decreased after treatment with sildenafil. Moreover, asymmetric dimethyl-L-arginine level was significantly lower in patients who responded to sildenafil treatment compared with those who did not. At a cut-off point of more than 0.85 nmol/ml, asymmetric dimethyl-L-arginine has a sensitivity of 83% and a specificity of 80% to diagnose pulmonary hypertension-CHD. Asymmetric dimethyl-L-arginine has a sensitivity of 100% and a specificity of 94% to predict poor prognosis in pulmonary hypertension-CHD children at a cut-off point of 1.3 nmol/ml. CONCLUSION Asymmetric dimethyl-L-arginine level has a good diagnostic and prognostic value as a biomarker in children with pulmonary hypertension-CHD and can be used for following up patients with pulmonary hypertension and predicting response to treatment.
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Affiliation(s)
- Marwa Farag
- 1Pediatric Department, Faculty of Medicine,Tanta University,Tanta,Egypt
| | - Doaa El Amrousy
- 1Pediatric Department, Faculty of Medicine,Tanta University,Tanta,Egypt
| | - Hesham El-Serogy
- 2Clinical Pathology Department, Faculty of Medicine,Tanta University,Tanta,Egypt
| | - Amr Zoair
- 1Pediatric Department, Faculty of Medicine,Tanta University,Tanta,Egypt
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Curtiss P, Schwager Z, Lo Sicco K, Franks AG. The clinical effects of l-arginine and asymmetric dimethylarginine: implications for treatment in secondary Raynaud's phenomenon. J Eur Acad Dermatol Venereol 2018; 33:497-503. [PMID: 30004597 PMCID: PMC6916181 DOI: 10.1111/jdv.15180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 07/06/2018] [Indexed: 01/18/2023]
Abstract
Secondary Raynaud's phenomenon (RP) is often the sentinel clinical finding in systemic sclerosis and may precede systemic disease by several years. Altered nitric oxide metabolism plays a critical role in both fibrosis and severe secondary RP phenotypes in these patients. Increased flux through inducible nitric oxide synthase (iNOS) drives cutaneous fibrosis. Failure of flux through endothelial nitric oxide synthase (eNOS) contributes to increased vasoconstriction and decreased vasorelaxation. The underproduction of nitric oxide by eNOS is in part due to increased levels of asymmetric dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase. The inhibitory effects of increased ADMA levels may be counteracted increasing serum l‐arginine, which is often an effective treatment strategy in these patients. As such, l‐arginine‐based therapies should be considered in managing secondary RP, particularly given their favourable safety and tolerability profile. While there is no established dosing regimen, studies of oral l‐arginine in secondary RP suggest that divided dosing may begin at 1–2 g/day and may be titrated up to 10 g/day. Conversely, primary RP is not associated with increased ADMA production which likely accounts for the failure of l‐arginine trials to show benefit in primary RP.
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Affiliation(s)
- P Curtiss
- Skin Lupus & Autoimmune Connective Tissue Section, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| | - Z Schwager
- Skin Lupus & Autoimmune Connective Tissue Section, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| | - K Lo Sicco
- Skin Lupus & Autoimmune Connective Tissue Section, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| | - A G Franks
- Skin Lupus & Autoimmune Connective Tissue Section, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA.,Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
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Carpagnano GE, Radaeli A, Lacedonia D, Correale M, Carpagnano G, Palmiotti A, Barbaro MPF, Di Biase M, Brunetti N, Scioscia G, Malerba M. Exhaled Nitric Oxide and Exhaled Breath Temperature as Potential Biomarkers in Patients with Pulmonary Hypertension. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7292045. [PMID: 30225263 PMCID: PMC6129334 DOI: 10.1155/2018/7292045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a progressive fatal disease thus, noninvasive prognostic tools are needed to follow these patients. The aim of our study was to evaluate fractional exhaled nitric oxide (FeNO) and exhaled breath temperature (EBT) values in patients with PH from different causes and to correlate them with respiratory functional data. METHODS Twenty-four PH patients underwent spirometry, carbon monoxide diffusion (DLCO) test, transthoracic echocardiography, right-heart catheterization, and FeNO and EBT measurements. RESULTS We studied 3 groups according to the type of PH: 10 patients with pulmonary arterial hypertension (PAH) (group A), 11 patients with PH due to chronic obstructive pulmonary disease (COPD) (group B), and 3 patients with PH associated with left heart disease (group C). Mean FeNO values tend to be higher in group B (15.0 ± 9.3ppb) compared with other groups (respectively, 9.9 ± 5.7 and 8.5 ± 5.2 ppb in groups A and C; p = 0.271) but no statistical significance has been reached. Mean values of alveolar NO concentration (CANO) were higher in groups A and B compared to group C (respectively, 16.9 ± 12.6; 13.9 ± 6.8; and 6.7 ± 2.0 ppb) (p = 0.045). EBT mean values were significantly lower in group C when compared with other groups (group C: 29.0 +- 1.3°C, groups A and B: 30.9 ± 1.3 and 31.2 ± 1.2°C, respectively: p = 0.041). EBT levels were inversely correlated to mean pulmonary artery pressure (PAPm) levels (Spearman coefficient -0.481; p = 0.017). CONCLUSIONS eNO, CANO, and EBT have been evaluated in three groups of PH patients. Interestingly EBT reduction was correlated with PAPm increase, whereas FeNO was higher in COPD patients and CANO in PAH and COPD groups. Further studies are needed to clarify EBT, FeNO, and CANO roles as biomarkers in the monitoring of patients with PH.
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Affiliation(s)
- Giovanna Elisiana Carpagnano
- Sezione di Malattie dell'Apparato Respiratorio, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Alessandro Radaeli
- Dipartimento di Emergenza Urgenza, Spedali Civili di Brescia, Brescia, Italy
| | - Donato Lacedonia
- Sezione di Malattie dell'Apparato Respiratorio, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Michele Correale
- Cardiologia Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Giuseppe Carpagnano
- Cardiologia Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Antonio Palmiotti
- Cardiologia Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Maria Pia Foschino Barbaro
- Sezione di Malattie dell'Apparato Respiratorio, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Matteo Di Biase
- Cardiologia Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Natale Brunetti
- Cardiologia Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Giulia Scioscia
- Sezione di Malattie dell'Apparato Respiratorio, Dipartimento di Scienze Mediche e Chirurgiche, Universita' di Foggia, Foggia, Italy
| | - Mario Malerba
- Malattie dell'Apparato Respiratorio, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy
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Desmosine and Isodesmosine as a Novel Biomarker for Pulmonary Arterial Hypertension: A Pilot Study. Am J Ther 2018; 24:e399-e404. [PMID: 26237301 DOI: 10.1097/mjt.0000000000000260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Delayed diagnosis is common in patients with pulmonary arterial hypertension (PAH). Right-sided heart catheterization, the gold standard for diagnosis, is invasive and cannot be applied for routine screening. Some biomarkers have been looked into; however, due to the lack of a clear pathological mechanism linking the marker to PAH, the search for an ideal one is still ongoing. Elastin is a significant structural constituent of blood vessels. Its synthesis involves cross-linking of monomers by 2 amino acids, desmosine and isodesmosine (D&I). Being extremely stable, elastin undergoes little metabolic turnover in healthy individuals resulting in very low levels of D&I amino acids in the human plasma, urine, or sputum. We hypothesized that in PAH patients, the elastin turnover is high; which in turn should result in elevated levels of D&I in plasma and urine. Using mass spectrometry, plasma and urine levels of D&I were measured in 20 consecutive patients with PAH confirmed by cardiac catheterization. The levels were compared with 13 healthy controls. The mean level of total plasma D&I in patients with PAH was 0.47 ng/mL and in controls was 0.19 ng/mL (P = 0.001). The mean levels of total D&I in the urine of PAH patients was 20.55 mg/g creatinine and in controls was 12.78 mg/g creatinine (P = 0.005). The mean level of free D&I in the urine of PAH patients was 10.34 mg/g creatinine and in controls was 2.52 mg/g creatinine (P < 0.001). This is the first study highlighting that the serum and urine D&I has a potential to be a novel screening biomarker for patients with PAH. It paves the way for larger studies to analyze its role in assessing for disease severity and response to treatment.
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Abstract
Biomarkers are increasingly being investigated in the treatment of pulmonary vascular disease. In particular, the signaling pathways targeted by therapies for pulmonary arterial hypertension provide biomarkers that potentially can be used to guide therapy and to assess clinical response as an alternative to invasive procedures such as right-sided cardiac catheterization. Moreover, the growing use of combination therapy for both the initial and subsequent treatment of pulmonary arterial hypertension highlights the need for biomarkers in this treatment approach. Currently approved therapies for pulmonary arterial hypertension target 3 major signaling pathways: the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate pathway, the endothelin pathway, and the prostacyclin pathway. Although the main biomarker used in practice and evaluated in clinical trials is N-terminal pro-brain natriuretic peptide, other putative biomarkers include the endogenous nitric oxide (NO) synthase inhibitor asymmetric dimethylarginine, NO metabolites including S-nitrosothiols and nitrite, exhaled NO, endothelins, cyclic guanosine monophosphate, cyclic adenosine monophosphate, and atrial natriuretic peptide. This review describes accessible biomarkers, related to the actual molecules targeted by current therapies, for measuring and predicting response to the individual pulmonary arterial hypertension treatment classes as well as combination therapy.
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Sandqvist A, Schneede J, Kylhammar D, Henrohn D, Lundgren J, Hedeland M, Bondesson U, Rådegran G, Wikström G. Plasma L-arginine levels distinguish pulmonary arterial hypertension from left ventricular systolic dysfunction. Heart Vessels 2017; 33:255-263. [PMID: 28975394 PMCID: PMC5847178 DOI: 10.1007/s00380-017-1055-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/22/2017] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening condition, characterized by an imbalance of vasoactive substances and remodeling of pulmonary vasculature. Nitric oxide, formed from L-arginine, is essential for homeostasis and smooth muscle cell relaxation in PAH. Our aim was to compare plasma concentrations of L-arginine, asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA) in PAH compared to left ventricular systolic dysfunction (LVSD) and healthy subjects. This was an observational, multicenter study comparing 21 patients with PAH to 14 patients with LVSD and 27 healthy subjects. Physical examinations were obtained and blood samples were collected. Plasma levels of ADMA, SDMA, L-arginine, L-ornithine, and L-citrulline were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Plasma levels of ADMA and SDMA were higher, whereas L-arginine and L-arginine/ADMA ratio were lower in PAH patients compared to healthy subjects (p < 0.001). Patients with PAH also had lower levels of L-arginine than patients with LVSD (p < 0.05). L-Arginine correlated to 6 min walking distance (6MWD) (r s = 0.58, p = 0.006) and L-arginine/ADMA correlated to WHO functional class (r s = -0.46, p = 0.043) in PAH. In conclusion, L-arginine levels were significantly lower in treatment naïve PAH patients compared to patients with LVSD. Furthermore, L-arginine correlated with 6MWD in PAH. L-arginine may provide useful information in differentiating PAH from LVSD.
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Affiliation(s)
- Anna Sandqvist
- Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology, Umeå University, 901 87, Umeå, Sweden.
| | - Jörn Schneede
- Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology, Umeå University, 901 87, Umeå, Sweden
| | - David Kylhammar
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Dan Henrohn
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Jakob Lundgren
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Mikael Hedeland
- Department of Chemistry, National Veterinary Institute (SVA), Uppsala, Sweden.,Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry, Uppsala University, Uppsala, Sweden
| | - Ulf Bondesson
- Department of Chemistry, National Veterinary Institute (SVA), Uppsala, Sweden.,Department of Medicinal Chemistry, Analytical Pharmaceutical Chemistry, Uppsala University, Uppsala, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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42
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Hoeper MM, Simonneau G, Corris PA, Ghofrani HA, Klinger JR, Langleben D, Naeije R, Jansa P, Rosenkranz S, Scelsi L, Grünig E, Vizza CD, Chang M, Colorado P, Meier C, Busse D, Benza RL. RESPITE: switching to riociguat in pulmonary arterial hypertension patients with inadequate response to phosphodiesterase-5 inhibitors. Eur Respir J 2017; 50:50/3/1602425. [PMID: 28889107 PMCID: PMC5898946 DOI: 10.1183/13993003.02425-2016] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/12/2017] [Indexed: 01/20/2023]
Abstract
A proportion of pulmonary arterial hypertension (PAH) patients do not reach treatment goals with phosphodiesterase-5 inhibitors (PDE5i). RESPITE investigated the safety, feasibility and benefit of switching from PDE5i to riociguat in these patients. RESPITE was a 24-week, open-label, multicentre, uncontrolled study. Patients in World Health Organization (WHO) functional class (FC) III, with 6-min walking distance (6MWD) 165–440 m, cardiac index <3.0 L·min−1·m−2 and pulmonary vascular resistance >400 dyn·s·cm−5 underwent a 1–3 day PDE5i treatment-free period before receiving riociguat adjusted up to 2.5 mg maximum t.i.d. Exploratory end-points included change in 6MWD, WHO FC, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and safety. Of 61 patients enrolled, 51 (84%) completed RESPITE. 50 (82%) were receiving concomitant endothelin receptor antagonists. At week 24, mean±sd 6MWD had increased by 31±63 m, NT-proBNP decreased by 347±1235 pg·mL−1 and WHO FC improved in 28 patients (54%). 32 patients (52%) experienced study drug-related adverse events and 10 (16%) experienced serious adverse events (2 (3%) study drug-related, none during the PDE5i treatment-free period). Six patients (10%) experienced clinical worsening, including death in two (not study drug-related). In conclusion, selected patients with PAH may benefit from switching from PDE5i to riociguat, but this strategy needs to be further studied.
Switching to riociguat in PAH patients with inadequate response to PDE5i improved exercise capacity and NT-proBNPhttp://ow.ly/e6xL30dXCgy
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Affiliation(s)
- Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, member of the German Centre for Lung Research (DZL), Hannover, Germany
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and INSERM Unité 999, Le Kremlin-Bicêtre, France
| | - Paul A Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Centre, member of the German Centre for Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - James R Klinger
- Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - David Langleben
- Centre for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Robert Naeije
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Pavel Jansa
- Clinical Dept of Cardiology and Angiology, 1st Faculty of Medicine, 2nd Medical Dept, Charles University, Prague, Czech Republic
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology), and Centre for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Cardiovascular Research Centre (CCRC), University of Cologne, Cologne, Germany
| | - Laura Scelsi
- Division of Cardiology, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Policlinico S. Matteo, Pavia, Italy
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thorax Clinic at the University Hospital, Heidelberg, Germany
| | - Carmine Dario Vizza
- Pulmonary Hypertension Unit, Dept of Cardiovascular and Respiratory Disease, 'La Sapienza' University of Rome, Rome, Italy
| | - MiKyung Chang
- Global Medical Affairs, Bayer Pharma AG, Berlin, Germany
| | - Pablo Colorado
- Global Clinical Development, Bayer HealthCare Pharmaceuticals, Barcelona, Spain
| | | | | | - Raymond L Benza
- The Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
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43
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Lai Y, Li J, Li X, Zou C. Lipopolysaccharide modulates p300 and Sirt1 to promote PRMT1 stability via an SCF Fbxl17-recognized acetyldegron. J Cell Sci 2017; 130:3578-3587. [PMID: 28883095 DOI: 10.1242/jcs.206904] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 08/25/2017] [Indexed: 12/19/2022] Open
Abstract
E3 ubiquitin ligase recognizes its protein substrates via specific molecular signatures for ubiquitin proteasomal degradation. However, the role of acetylation/deacetylation in the process of E3 ubiquitin ligase recognizing its protein substrates is not fully studied. Here, we report that a tandem IK motif in protein arginine methyltransferase 1 (PRMT1) forms an acetyldegron to recruit the F-box/LRR-repeat protein 17 (FBXL17), a component of the SKP1-CUL1-F-box protein (SCF)-type E3 ubiquitin ligase complex. PRMT1 is polyubiquitylated for proteasome degradation with a half-life of approximately 4 h in lung epithelial cells. SCFFbxl17 mediates PRMT1 polyubiquitylation at K117. SCFFbxl17 specifically binds PRMT1 via a unique motif IKxxxIK. Strikingly, the acetylation/deacetylation status of the lysine residues within the motif determines Fbxl17 binding. Deacetylation on both K200 and K205 by Sirtuin 1 (Sirt1) and acetylation of p300 (EP300) on K205 collaboratively prepare the motif for SCFFbxl17 binding thereby triggering PRMT1 protein degradation. Pathogen-derived lipopolysaccharide (LPS) downregulates Sirt1 and p300 to protect PRMT1 from degradation. This study demonstrates that LPS promotes PRMT1 stability by blockade of PRMT1 and SCFFbxl17 binding via an acetylation/deacetylation-modified acetyldegron; and LPS-elevated levels of PRMT1 lead to bronchial epithelial cell overgrowth in pulmonary inflammatory diseases.
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Affiliation(s)
- Yandong Lai
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jin Li
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Xiuying Li
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Chunbin Zou
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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44
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Fulton DJR, Li X, Bordan Z, Haigh S, Bentley A, Chen F, Barman SA. Reactive Oxygen and Nitrogen Species in the Development of Pulmonary Hypertension. Antioxidants (Basel) 2017; 6:antiox6030054. [PMID: 28684719 PMCID: PMC5618082 DOI: 10.3390/antiox6030054] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/29/2017] [Accepted: 07/01/2017] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease of the lung vasculature that involves the loss of endothelial function together with inappropriate smooth muscle cell growth, inflammation, and fibrosis. These changes underlie a progressive remodeling of blood vessels that alters flow and increases pulmonary blood pressure. Elevated pressures in the pulmonary artery imparts a chronic stress on the right ventricle which undergoes compensatory hypertrophy but eventually fails. How PAH develops remains incompletely understood and evidence for the altered production of reactive oxygen and nitrogen species (ROS, RNS respectively) in the pulmonary circulation has been well documented. There are many different types of ROS and RNS, multiple sources, and collective actions and interactions. This review summarizes past and current knowledge of the sources of ROS and RNS and how they may contribute to the loss of endothelial function and changes in smooth muscle proliferation in the pulmonary circulation.
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Affiliation(s)
- David J R Fulton
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
| | - Xueyi Li
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
| | - Zsuzsanna Bordan
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
| | - Stephen Haigh
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
| | - Austin Bentley
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
| | - Feng Chen
- Department of Forensic Medicine, Nanjing Medical University, Nanjing 211166, China.
| | - Scott A Barman
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
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45
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Lüneburg N, Siques P, Brito J, De La Cruz JJ, León-Velarde F, Hannemann J, Ibanez C, Böger RH. Long-Term Intermittent Exposure to High Altitude Elevates Asymmetric Dimethylarginine in First Exposed Young Adults. High Alt Med Biol 2017; 18:226-233. [PMID: 28453332 PMCID: PMC5649417 DOI: 10.1089/ham.2016.0123] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Lüneburg, Nicole, Patricia Siques, Julio Brito, Juan José De La Cruz, Fabiola León-Velarde, Juliane Hannemann, Cristian Ibanez, and Rainer Böger. Long-term intermittent exposure to high altitude elevates asymmetric dimethylarginine in first exposed young adults. High Alt Med Biol. 18:226–233, 2017.—Hypoxia-induced dysregulation of pulmonary and cerebral circulation may be related to an impaired nitric oxide (NO) pathway. We investigated the effect of chronic intermittent hypobaric hypoxia (CIH) on metabolites of the NO pathway. We measured asymmetric and symmetric dimethylarginine (ADMA and SDMA) and monomethyl-L-arginine (L-NMMA) and assessed their associations with acclimatization in male draftees (n = 72) undergoing CIH shifts at altitude (3550 m) during 3 months. Sixteen Andean natives living at altitude (3675 m) (chronic hypobaric hypoxia [CH]) were included for comparison. In CIH, ADMA and L-NMMA plasma concentrations increased from 1.14 ± 0.04 to 1.95 ± 0.09 μmol/L (mean ± SE) and from 0.22 ± 0.07 to 0.39 ± 0.03 μmol/L, respectively, (p < 0.001 for both) after 3 months, whereas SDMA did not change. The concentrations of ADMA and L-NMMA were higher in CH (3.48 ± 0.07, 0.53 ± 0.08 μmol/L; p < 0.001) as compared with CIH. In both CIH and CH, ADMA correlated with hematocrit (r2 = 0.07, p < 0.05; r2 = 0.26; p < 0.01). In CIH, an association of ADMA levels with poor acclimatization status was observed. We conclude that the endogenous NO synthase inhibitors, ADMA and L-NMMA, are elevated in hypoxia. This may contribute to impaired NO production at altitude and may also be predictive of altitude-associated health impairment.
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Affiliation(s)
- Nicole Lüneburg
- Department of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patricia Siques
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile
| | - Julio Brito
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile
| | - Juan José De La Cruz
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
| | - Fabiola León-Velarde
- Department of Biological and Physiological Sciences, Facultad de Ciencias y Filosofía/IIA, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Juliane Hannemann
- Department of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cristian Ibanez
- Institute of Health Studies, Universidad Arturo Prat, Iquique, Chile
| | - Rainer H. Böger
- Department of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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46
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Toxic Dimethylarginines: Asymmetric Dimethylarginine (ADMA) and Symmetric Dimethylarginine (SDMA). Toxins (Basel) 2017; 9:toxins9030092. [PMID: 28272322 PMCID: PMC5371847 DOI: 10.3390/toxins9030092] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/04/2017] [Indexed: 02/07/2023] Open
Abstract
Asymmetric and symmetric dimethylarginine (ADMA and SDMA, respectively) are toxic, non-proteinogenic amino acids formed by post-translational modification and are uremic toxins that inhibit nitric oxide (NO) production and play multifunctional roles in many human diseases. Both ADMA and SDMA have emerged as strong predictors of cardiovascular events and death in a range of illnesses. Major progress has been made in research on ADMA-lowering therapies in animal studies; however, further studies are required to fill the translational gap between animal models and clinical trials in order to treat human diseases related to elevated ADMA/SDMA levels. Here, we review the reported impacts of ADMA and SDMA on human health and disease, focusing on the synthesis and metabolism of ADMA and SDMA; the pathophysiological roles of these dimethylarginines; clinical conditions and animal models associated with elevated ADMA and SDMA levels; and potential therapies against ADMA and SDMA. There is currently no specific pharmacological therapy for lowering the levels and counteracting the deleterious effects of ADMA and SDMA. A better understanding of the mechanisms underlying the impact of ADMA and SDMA on a wide range of human diseases is essential to the development of specific therapies against diseases related to ADMA and SDMA.
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47
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Panagiotou M, Vogiatzis I, Louvaris Z, Jayasekera G, MacKenzie A, Mcglinchey N, Baker JS, Church AC, Peacock AJ, Johnson MK. Near infrared spectroscopy for the assessment of peripheral tissue oxygenation in pulmonary arterial hypertension. Eur Respir J 2016; 48:1224-1227. [PMID: 27587562 DOI: 10.1183/13993003.01022-2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/13/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Marios Panagiotou
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Ioannis Vogiatzis
- National and Kapodistrian University of Athens, Dept of Physical Education and Sports Sciences, Athens, Greece
| | - Zafeiris Louvaris
- National and Kapodistrian University of Athens, Dept of Physical Education and Sports Sciences, Athens, Greece
| | - Geeshath Jayasekera
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Alison MacKenzie
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Neil Mcglinchey
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Julien S Baker
- Institute of Clinical Exercise and Health Science, University of the West of Scotland, Hamilton, UK
| | - Alistair C Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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48
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Homoarginine predicts mortality in treatment-naive patients with pulmonary arterial hypertension. Int J Cardiol 2016; 217:12-5. [DOI: 10.1016/j.ijcard.2016.04.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 04/29/2016] [Indexed: 11/17/2022]
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49
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Ghofrani HA, Humbert M, Langleben D, Schermuly R, Stasch JP, Wilkins MR, Klinger JR. Riociguat: Mode of Action and Clinical Development in Pulmonary Hypertension. Chest 2016; 151:468-480. [PMID: 27263466 DOI: 10.1016/j.chest.2016.05.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 04/05/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are progressive and debilitating diseases characterized by gradual obstruction of the pulmonary vasculature, leading to elevated pulmonary artery pressure (PAP) and increased pulmonary vascular resistance (PVR). If untreated, they can result in death due to right-sided heart failure. Riociguat is a novel soluble guanylate cyclase (sGC) stimulator that is approved for the treatment of PAH and CTEPH. We describe in detail the role of the nitric oxide-sGC-cyclic guanosine monophosphate (cGMP) signaling pathway in the pathogenesis of PAH and CTEPH and the mode of action of riociguat. We also review the preclinical data associated with the development of riociguat, along with the efficacy and safety data of riociguat from initial clinical trials and pivotal phase III randomized clinical trials in PAH and CTEPH.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany and the German Center for Lung Research (DZL); Department of Medicine, Imperial College London, London, England.
| | - Marc Humbert
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre and Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and INSERM Unité 999, Le Kremlin-Bicêtre, France
| | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
| | - Ralph Schermuly
- University of Giessen and Marburg Lung Center, Giessen, Germany and the German Center for Lung Research (DZL)
| | - Johannes-Peter Stasch
- Bayer Pharma AG, Wuppertal and University Halle, Institute of Pharmacy, Halle (Saale), Germany
| | - Martin R Wilkins
- Department of Medicine, Imperial College London, London, England
| | - James R Klinger
- Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
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50
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Assessment of heat shock proteins and endothelial dysfunction in acute pulmonary embolism. Blood Coagul Fibrinolysis 2016; 27:378-83. [DOI: 10.1097/mbc.0000000000000456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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