1
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Doyle M, Rayarao G, Biederman RWW. The sine transform is the sine qua non of the pulmonary and systemic pressure relationship. Front Cardiovasc Med 2023; 10:1120330. [PMID: 37304951 PMCID: PMC10250723 DOI: 10.3389/fcvm.2023.1120330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.
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Affiliation(s)
- Mark Doyle
- Department Cardiology, Cardiovascular MRI, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, United States
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2
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Issapour A, Frank B, Crook S, Hite MD, Dorn ML, Rosenzweig EB, Ivy DD, Krishnan US. Safety and tolerability of combination therapy with ambrisentan and tadalafil for the treatment of pulmonary arterial hypertension in children: Real-world experience. Pediatr Pulmonol 2022; 57:724-733. [PMID: 34921523 PMCID: PMC8854334 DOI: 10.1002/ppul.25796] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/16/2021] [Accepted: 12/07/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To describe the safety and tolerability of treatment with ambrisentan and tadalafil in pediatric pulmonary hypertension (PH). STUDY DESIGN This retrospective observational two-center study included subjects (≤18 years of age) with PH receiving combination therapy with ambrisentan and tadalafil. Before initiating this therapy, many patients were on other therapies for PH. At baseline, patients either received no therapy or monotherapy with a phosphodiesterase 5 inhibitor (PDE5i) or endothelin receptor antagonist (ERA) (Group A), switched from a different PDE5i and ERA (Group B), or were on prostanoid therapy with or without a PDE5i and/or ERA (Group C and D). Demographics, symptoms, and adverse effects were collected. Pre- and postvalues for exercise capacity, hemodynamics, and biomarkers were compared. RESULTS There were 43 subjects (26 F, 17 M) ages 4-17.5 years (median 9.3) with World Symposium of PH group 1, 3, and 5. Significant improvements were seen in change scores at follow-up in the entire sample and Group A for 6-min walk distance: +37.0 (6.5-71.0) [p = 0.022], mean pulmonary artery pressure: -6.0 (-14.0 to -3.5) [p = .002], pulmonary vascular resistance: -1.7 (-6.2 to -1.0) [p = .003], NT-proBNP -32.9 (-148.9 to -6.7) [p = .025]. WHO functional class improved in 39.5% and was unchanged in 53.5%; PH risk scores improved in 16%; were unchanged in 56%; and declined in 14%. Three patients discontinued therapy (two headaches, one peripheral edema). Seven patients were hospitalized for worsening disease (2/7 had a Potts shunt placed, 2/7 had an atrial septostomy). There were no deaths or lung transplantation. CONCLUSIONS Combination therapy with ambrisentan and tadalafil was well-tolerated, with an acceptable safety profile in a select group of children. This therapy was associated with improved exercise capacity and hemodynamics in children who were treatment naïve or on monotherapy with a PH medication before the initiation of ambrisentan and tadalafil. Based on these early data, further study of combination therapy in pediatric PH is warranted.
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Affiliation(s)
- Azadeh Issapour
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin Frank
- Division of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sarah Crook
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Michelle D Hite
- Division of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michelle L Dorn
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - D Dunbar Ivy
- Division of Pediatric Cardiology, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Usha S Krishnan
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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3
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Scott JV, Garnett CE, Kanwar MK, Stockbridge NL, Benza RL. Enrichment Benefits of Risk Algorithms for Pulmonary Arterial Hypertension Clinical Trials. Am J Respir Crit Care Med 2021; 203:726-736. [PMID: 32937078 DOI: 10.1164/rccm.202002-0357oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Event-driven primary endpoints are increasingly used in pulmonary arterial hypertension clinical trials, substantially increasing required sample sizes and trial lengths. The U.S. Food and Drug Administration advocates the use of prognostic enrichment of clinical trials by preselecting a patient population with increased likelihood of experiencing the trial's primary endpoint.Objectives: This study compares validated clinical scales of risk (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension, the French score, and Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management [REVEAL] 2.0) to identify patients who are likely to experience a clinical worsening event for trial enrichment.Methods: Baseline data from three pulmonary arterial hypertension clinical trials (AMBITION [a Study of First-Line Ambrisentan and Tadalafil Combination Therapy in Subjects with Pulmonary Arterial Hypertension], SERAPHIN [Study of Macitentan on Morbidity and Mortality in Patients with Symptomatic Pulmonary Arterial Hypertension], and GRIPHON [Selexipag in Pulmonary Arterial Hypertension]) were pooled and standardized. Receiver operating curves were used to measure each algorithm's performance in predicting clinical worsening within the pooled placebo cohort. Power simulations were conducted to determine sample size and treatment time reductions for multiple enrichment strategies. A cost analysis was performed to illustrate potential financial savings by applying enrichment to GRIPHON.Measurements and Main Results: All risk algorithms were compared using area under the receiver operating curve and substantially outperformed prediction per New York Heart Association Functional Class. The REVEAL 2.0's risk grouping provided the greatest time and sample size savings in AMBITION and GRIPHON for all enrichment strategies but lacked appropriate inputs (i.e., N-terminal-proB-type natriuretic peptide) to perform as well in SERAPHIN. Cost analysis applied to GRIPHON demonstrated the greatest financial benefit by enrolling patients with a REVEAL score ≥8.Conclusions: This preliminary study demonstrates the feasibility of risk algorithms for pulmonary arterial hypertension trial enrichment and a need for further investigation.
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Affiliation(s)
- Jacqueline V Scott
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania.,Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland; and
| | - Christine E Garnett
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland; and
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Norman L Stockbridge
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland; and
| | - Raymond L Benza
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
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4
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Rawal H, Suman A, Bhoite RR, Kanwal A, Young RK, Aronow WS, Lavie C, Ghosh RK. Anticoagulation in Pulmonary Arterial Hypertension: Do We Know the Answer? Curr Probl Cardiol 2020; 46:100738. [PMID: 33250263 DOI: 10.1016/j.cpcardiol.2020.100738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 01/11/2023]
Abstract
The shear stress and hypoxia in the pulmonary artery in patients with pulmonary arterial hypertension(PAH) causes endothelial dysfunction, smooth muscle proliferation and activation of thrombotic pathways leading to in situ thrombosis. Targeting the thrombotic pathways is a proposed mechanism to slow disease progression and improve survival. Over the years, the survival in patients with PAH has improved due to multiple factors with the increased use of anticoagulation as one of them. Both European Respiratory Society/European Society of Cardiology and American College of Cardiology/American Heart Association guidelines make grade II recommendations for using anticoagulation in PAH. The guidelines are based on weak observational studies with high risk of bias which have only studied warfarin as the choice of anticoagulation. In this article, we review the pathophysiology, rationale and the current literature investigating the role of anticoagulation in PAH.
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Affiliation(s)
- Himanshu Rawal
- Department of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest Baptist Health, Winston-Salem, NC
| | - Annya Suman
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Rahul R Bhoite
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Arjun Kanwal
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Raymond K Young
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Carl Lavie
- John Ochsner Heart and Vascular Institute, New Orleans, LA
| | - Raktim K Ghosh
- MedStar Heart and Vascular Institute, Union Memorial Hospital, Baltimore, MD.
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5
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Nikkho S, Fernandes P, White RJ, Deng C(CQ, Farber HW, Corris PA. Clinical trial design in phase 2 and 3 trials for pulmonary hypertension. Pulm Circ 2020; 10:2045894020941491. [PMID: 33282181 PMCID: PMC7682228 DOI: 10.1177/2045894020941491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 11/15/2022] Open
Abstract
This article on clinical trial design incorporates the broad experience of members of the Pulmonary Vascular Research Institute's (PVRI) Innovative Drug Development Initiative (IDDI) as an open debate platform for academia, the pharmaceutical industry and regulatory experts surrounding the future design of clinical trials in pulmonary hypertension. It is increasingly clear that the design of phase 2 and 3 trials in pulmonary hypertension will have to diversify from the traditional randomised double-blind design, given the anticipated need to trial novel therapeutic approaches in the immediate future. This article reviews a wide range of differing approaches and places these into context within the field of pulmonary hypertension.
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Affiliation(s)
| | | | - R. James White
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Paul A Corris
- Translational and Clinical Science Institute, Newcastle University, Newcastle upon Tyne, UK
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6
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Abstract
Heart failure is a chronic disease with a multitude of different clinical manifestations. Empowering people living with heart failure requires education, support structure, understanding the needs of patients, and reimaging the care delivery systems currently offered to patients. In this article, the authors discuss practical approaches to activate and empower people with heart failure and enable patient-provider dialogue and shared decision making.
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Affiliation(s)
- Peter Wohlfahrt
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA; Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer Hospital, Prague, Czech Republic; Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Irene Z Pan
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA; College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA.
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7
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Maron BA. Pulmonary arterial hypertension: Rationale for using multiple vs. single drug therapy. Glob Cardiol Sci Pract 2020; 2020:e202008. [PMID: 33150152 PMCID: PMC7590936 DOI: 10.21542/gcsp.2020.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is defined by a heterogenous pathobiology that corresponds to variable clinical presentation, treatment response, and prognosis across affected patients. The approach to pharmacotherapeutics in PAH has evolved since the introduction of the first prostacyclin replacement drug, which was trialed in patients with end-stage disease as a strategy by which to delay or prevent mortality. Subsequently, the aim of care in PAH has shifted toward minimizing symptoms, improving functional capacity, delaying disease progression, and prolonging life. Thus, treatments are now implemented earlier and according to the evidence base, which spans more than twenty years and includes patients at various stages of disease. Overall, the evidence supports multidrug therapy rather than monotherapy in the majority of PAH patients. Among incident patients, up-front combination therapy with ambrisentan and tadalafil or other comparable agents within these drug classes is recommended based on strong clinical trial data. In the near future, up-front triple therapy may be emerge as bona fide treatment approach in selected patients. Future goals that are already under consideration in PAH include stronger integration of pathobiological characteristics when considering the use of specific drugs, or the development of novel therapies, toward precision medicine-based clinical pharmacology.
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Affiliation(s)
- Bradley A Maron
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.,The Boston VA Healthcare System, West Roxbury, MA, USA
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8
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Maron BA, Ryan JJ. A Concerning Trend for Patients With Pulmonary Hypertension in the Era of Evidence-Based Medicine. Circulation 2020; 139:1861-1864. [PMID: 30986105 DOI: 10.1161/circulationaha.118.037613] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.A.M.).,Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.)
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9
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Huston JH, Frantz RP, Brittain EL. Early intervention: should we conduct therapeutic trials for mild pulmonary hypertension before onset of symptoms? Pulm Circ 2019; 9:2045894019845615. [PMID: 30931829 PMCID: PMC6469279 DOI: 10.1177/2045894019844994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease that carries a poor
prognosis. For 45 years, the definition of pulmonary hypertension (PH) has been
a mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg, based on expert opinion.
Recent data indicate that the mortality risk starts in the mPAP range of
21–24 mmHg, which has recently been reflected in the World Symposium on PH
consensus document defining PH as a mPAP > 20 mmHg. The mortality associated
with these lower levels of pulmonary pressures suggests that these values
reflect a more advanced disease stage than previously recognized. It is unknown
whether interventions targeting patients with mPAP values in the range of
21–24 mmHg in the absence of left ventricular or hypoxic lung disease are of
clinical benefit. Here we present historical perspective on the hemodynamic
definition of PH, discuss recent epidemiologic data, and outline obstacles to
enrolling and evaluating response to therapy in mild PAH patients, as well as
potentially useful study designs.
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Affiliation(s)
- Jessica H Huston
- 1 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Frantz
- 2 Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Evan L Brittain
- 1 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,3 Vanderbilt Translational and Clinical Research Center, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Affiliation(s)
- Stephen C. Mathai
- From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (S.C.M.); and Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.)
| | - John J. Ryan
- From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (S.C.M.); and Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City (J.J.R.)
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11
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Maron BA, Gladwin MT, Simon MA. Update in Pulmonary Vascular Disease 2015. Am J Respir Crit Care Med 2017; 193:1337-44. [PMID: 27304242 DOI: 10.1164/rccm.201601-0143up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Bradley A Maron
- 1 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,2 Department of Cardiology, Boston Veterans Affairs Healthcare System, Boston, Massachusetts; and
| | - Mark T Gladwin
- 3 Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Marc A Simon
- 4 Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center and Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Clinical trial research in focus: improving drug development and trial design in pulmonary arterial hypertension. THE LANCET RESPIRATORY MEDICINE 2017; 5:544-546. [DOI: 10.1016/s2213-2600(17)30223-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/25/2017] [Indexed: 12/18/2022]
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13
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Newman JH, Rich S, Abman SH, Alexander JH, Barnard J, Beck GJ, Benza RL, Bull TM, Chan SY, Chun HJ, Doogan D, Dupuis J, Erzurum SC, Frantz RP, Geraci M, Gillies H, Gladwin M, Gray MP, Hemnes AR, Herbst RS, Hernandez AF, Hill NS, Horn EM, Hunter K, Jing ZC, Johns R, Kaul S, Kawut SM, Lahm T, Leopold JA, Lewis GD, Mathai SC, McLaughlin VV, Michelakis ED, Nathan SD, Nichols W, Page G, Rabinovitch M, Rich J, Rischard F, Rounds S, Shah SJ, Tapson VF, Lowy N, Stockbridge N, Weinmann G, Xiao L. Enhancing Insights into Pulmonary Vascular Disease through a Precision Medicine Approach. A Joint NHLBI-Cardiovascular Medical Research and Education Fund Workshop Report. Am J Respir Crit Care Med 2017; 195:1661-1670. [PMID: 28430547 PMCID: PMC5476915 DOI: 10.1164/rccm.201701-0150ws] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/18/2017] [Indexed: 12/18/2022] Open
Abstract
The Division of Lung Diseases of the NHLBI and the Cardiovascular Medical Education and Research Fund held a workshop to discuss how to leverage the anticipated scientific output from the recently launched "Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics" (PVDOMICS) program to develop newer approaches to pulmonary vascular disease. PVDOMICS is a collaborative, protocol-driven network to analyze all patient populations with pulmonary hypertension to define novel pulmonary vascular disease (PVD) phenotypes. Stakeholders, including basic, translational, and clinical investigators; clinicians; patient advocacy organizations; regulatory agencies; and pharmaceutical industry experts, joined to discuss the application of precision medicine to PVD clinical trials. Recommendations were generated for discussion of research priorities in line with NHLBI Strategic Vision Goals that include: (1) A national effort, involving all the stakeholders, should seek to coordinate biosamples and biodata from all funded programs to a web-based repository so that information can be shared and correlated with other research projects. Example programs sponsored by NHLBI include PVDOMICS, Pulmonary Hypertension Breakthrough Initiative, the National Biological Sample and Data Repository for PAH, and the National Precision Medicine Initiative. (2) A task force to develop a master clinical trials protocol for PVD to apply precision medicine principles to future clinical trials. Specific features include: (a) adoption of smaller clinical trials that incorporate biomarker-guided enrichment strategies, using adaptive and innovative statistical designs; and (b) development of newer endpoints that reflect well-defined and clinically meaningful changes. (3) Development of updated and systematic variables in imaging, hemodynamic, cellular, genomic, and metabolic tests that will help precisely identify individual and shared features of PVD and serve as the basis of novel phenotypes for therapeutic interventions.
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Affiliation(s)
- John H. Newman
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stuart Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Steven H. Abman
- Pediatric Heart and Lung Center, University of Colorado, Aurora, Colorado
| | | | | | | | - Raymond L. Benza
- Department of Cardiovascular Disease, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Todd M. Bull
- Division of Pulmonary and Critical Care Medicine and
| | - Stephen Y. Chan
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Jocelyn Dupuis
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Serpil C. Erzurum
- Department of Pathobiology, and
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Geraci
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
| | - Hunter Gillies
- Independent Consultant and Pharmaceutical Physician, Half Moon Bay, California
| | - Mark Gladwin
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Roy S. Herbst
- Division of Medical Oncology, Department of Medicine, Yale University, New Haven, Connecticut
| | | | - Nicholas S. Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts University, Boston, Massachusetts
| | - Evelyn M. Horn
- Division of Cardiology, Cornell University, New York, New York
| | - Kendall Hunter
- College of Engineering and Applied Science, University of Colorado, Denver, Colorado
| | - Zhi-Cheng Jing
- FuWai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Roger Johns
- Department of Anesthesiology and Critical Care and
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Greg D. Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Steven D. Nathan
- Advanced Lung Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - William Nichols
- Department of Human Genetics, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Marlene Rabinovitch
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jonathan Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Franz Rischard
- Division of Cardiology, University of Arizona, Tucson, Arizona
| | - Sharon Rounds
- Department of Medicine and Laboratory Medicine, Brown University, Providence, Rhode Island
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Victor F. Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Naomi Lowy
- Division of Cardiovascular and Renal Products, Food and Drug Administration, Office of Drug Evaluation I, Office of New Drugs, Food and Drug Administration Silver Spring, Maryland; and
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Food and Drug Administration, Office of Drug Evaluation I, Office of New Drugs, Food and Drug Administration Silver Spring, Maryland; and
| | - Gail Weinmann
- Division of Lung Diseases, NHLBI, National Institutes of Health, Bethesda, Maryland
| | - Lei Xiao
- Division of Lung Diseases, NHLBI, National Institutes of Health, Bethesda, Maryland
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14
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Lajoie AC, Bonnet S, Provencher S. Combination therapy in pulmonary arterial hypertension: recent accomplishments and future challenges. Pulm Circ 2017; 7:312-325. [PMID: 28597774 PMCID: PMC5467950 DOI: 10.1177/2045893217710639] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by a progressive increase in pulmonary vascular resistance, ultimately leading to right heart failure and death. Throughout the past 20 years, numerous specific pharmacologic agents, including phosphodiesterase-5 inhibitors, endothelin receptor antagonists, prostaglandins, and more recently, soluble guanylate cyclase stimulators and selective IP prostacyclin receptor agonist, have emerged for the treatment of PAH. Early clinical trials were typically of short-term duration, comparing the effects of PAH-targeted therapies versus placebo and using exercise tolerance as the primary endpoint in most trials. A meta-analysis of these trials documented a reduction in short-term mortality of ∼40% with monotherapy. More recently, we have witnessed a progressive shift in PAH study designs using longer event-driven trials comparing the effects of upfront and sequential combination therapy on clinical worsening that is perceived as a more clinically relevant outcome measure. Recent meta-analyses also documented that combination therapy significantly reduced the risk of clinical worsening by ∼35% compared with monotherapy alone. In this review article, we will discuss the evolution of treatments and clinical trial design in the field of PAH over the past decades with a special focus on combination therapy and its current role in the management of PAH. We will also detail unresolved questions regarding the future of PAH patients’ care and the challenges of future clinical trials.
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Affiliation(s)
- Annie-Christine Lajoie
- 1 Pulmonary Hypertension Research Group, Canada.,2 Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Sebastien Bonnet
- 1 Pulmonary Hypertension Research Group, Canada.,2 Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada.,3 Department of Medicine, Université Laval, Québec, Canada
| | - Steeve Provencher
- 1 Pulmonary Hypertension Research Group, Canada.,2 Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada.,3 Department of Medicine, Université Laval, Québec, Canada
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15
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Huston JH, Ryan JJ. The emerging role of epigenetics in pulmonary arterial hypertension: an important avenue for clinical trials (2015 Grover Conference Series). Pulm Circ 2016; 6:274-84. [PMID: 27683604 DOI: 10.1086/687765] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Epigenetics is an emerging field of research and clinical trials in cancer therapy that also has applications for pulmonary arterial hypertension (PAH), as there is evidence that epigenetic control of gene expression plays a significant role in PAH. The three types of epigenetic modification include DNA methylation, histone modification, and RNA interference. All three have been shown to be involved in the development of PAH. Currently, the enzymes that perform these modifications are the primary targets of neoplastic therapy. These targets are starting to be explored for therapies in PAH, mostly in animal models. In this review we summarize the basics of each type of epigenetic modification and the known sites and molecules involved in PAH, as well as current targets and prospects for clinical trials.
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Affiliation(s)
- Jessica H Huston
- Department of Medicine, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
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Cirulis MM, Ryan JJ. Where do we go from here? Reappraising the data on anticoagulation in pulmonary arterial hypertension. J Thorac Dis 2016; 8:E298-304. [PMID: 27162687 PMCID: PMC4842822 DOI: 10.21037/jtd.2016.03.67] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 03/02/2016] [Indexed: 01/24/2023]
Abstract
The use of anticoagulation as part of the treatment regimen in pulmonary arterial hypertension (PAH) remains a topic of debate. A recently published analysis of anticoagulation use in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) study offers conflicting conclusions regarding the benefit of this therapeutic strategy. There remains no robust randomized trial in PAH weighing the risks versus benefits of including anticoagulation in treatment regimens, leaving clinicians to surmise value in individual patients. Reexamination of available data may help to provide guidance on this controversial topic in the absence of future dedicated investigations.
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Affiliation(s)
- Meghan M Cirulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
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