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Hilty MP, Siebenmann C, Rasmussen P, Keiser S, Müller A, Lundby C, Maggiorini M. Beta-adrenergic blockade increases pulmonary vascular resistance and causes exaggerated hypoxic pulmonary vasoconstriction at high altitude: a physiological study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:316-328. [PMID: 38216517 DOI: 10.1093/ehjcvp/pvae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/13/2023] [Accepted: 01/11/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND An increasing number of hypertensive persons travel to high altitude (HA) while using antihypertensive medications such as beta-blockers. Nevertheless, while hypoxic exposure initiates an increase in pulmonary artery pressure (Ppa) and pulmonary vascular resistance (PVR), the contribution of the autonomic nervous system is unclear. In animals, beta-adrenergic blockade has induced pulmonary vasoconstriction in normoxia and exaggerated hypoxic pulmonary vasoconstriction (HPV) and both effects were abolished by muscarinic blockade. We thus hypothesized that in humans, propranolol (PROP) increases Ppa and PVR in normoxia and exaggerates HPV, and that these effects of PROP are abolished by glycopyrrolate (GLYC). METHODS In seven healthy male lowlanders, Ppa was invasively measured without medication, with PROP and PROP + GLYC, both at sea level (SL, 488 m) and after a 3-week sojourn at 3454 m altitude (HA). Bilateral thigh-cuff release manoeuvres were performed to derive pulmonary pressure-flow relationships and pulmonary vessel distensibility. RESULTS At SL, PROP increased Ppa and PVR from (mean ± SEM) 14 ± 1 to 17 ± 1 mmHg and from 69 ± 8 to 108 ± 11 dyn s cm-5 (21% and 57% increase, P = 0.01 and P < 0.0001). The PVR response to PROP was amplified at HA to 76% (P < 0.0001, P[interaction] = 0.05). At both altitudes, PROP + GLYC abolished the effect of PROP on Ppa and PVR. Pulmonary vessel distensibility decreased from 2.9 ± 0.5 to 1.7 ± 0.2 at HA (P < 0.0001) and to 1.2 ± 0.2 with PROP, and further decreased to 0.9 ± 0.2% mmHg-1 with PROP + GLYC (P = 0.01). CONCLUSIONS Our data show that beta-adrenergic blockade increases, and muscarinic blockade decreases PVR, whereas both increase pulmonary artery elastance. Future studies may confirm potential implications from the finding that beta-adrenergic blockade exaggerates HPV for the management of mountaineers using beta-blockers for prevention or treatment of cardiovascular conditions.
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Affiliation(s)
- Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, ZH 8091, Switzerland
| | - Christoph Siebenmann
- Center for Integrative Human Physiology (ZIHP), Institute of Physiology, University of Zurich, ZH 8091, Switzerland
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, TA 39100, Italy
| | - Peter Rasmussen
- Center for Integrative Human Physiology (ZIHP), Institute of Physiology, University of Zurich, ZH 8091, Switzerland
| | - Stefanie Keiser
- Center for Integrative Human Physiology (ZIHP), Institute of Physiology, University of Zurich, ZH 8091, Switzerland
| | - Andrea Müller
- Institute of Intensive Care Medicine, University Hospital of Zurich, ZH 8091, Switzerland
| | - Carsten Lundby
- Center for Integrative Human Physiology (ZIHP), Institute of Physiology, University of Zurich, ZH 8091, Switzerland
- Department of Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, OP 2624, Norway
| | - Marco Maggiorini
- Institute of Intensive Care Medicine, University Hospital of Zurich, ZH 8091, Switzerland
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O'Meara K, Stone G, Buch E, Brownstein A, Saggar R, Channick R, Sherman AE, Bender A. Atrial Arrhythmias in Patients With Pulmonary Hypertension. Chest 2024; 166:201-211. [PMID: 38453002 DOI: 10.1016/j.chest.2024.03.002] [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: 10/03/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/09/2024] Open
Abstract
TOPIC IMPORTANCE Atrial arrhythmias (AA) are common in patients with pulmonary hypertension (PH) and contribute to morbidity and mortality. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AA in PH is important. REVIEW FINDINGS AA occurs in PH with a 5-year incidence of 10% to 25%. AA confers a higher morbidity and mortality, and restoration of normal sinus rhythm improves survival and functionality. AA is thought to develop because of structural alterations of the right atrium caused by changes to the right ventricle (RV) due to elevated pulmonary artery pressures. AA can subsequently worsen RV function. Current guidelines do not provide comprehensive recommendations for the management of AA in PH. Robust evidence to favor a specific treatment approach is lacking. Although the role of medical rate or rhythm control, and the use of cardioversion and ablation, can be inferred from other populations, evidence is lacking in the PH population. Much remains to be determined regarding the optimal management strategy. We present here our institutional approach and discuss areas for future research. SUMMARY This review highlights the epidemiology and pathophysiology of AA in patients with PH, describes the relationship between AA and RV dysfunction, and discusses current management practices. We outline our institutional approach and offer directions for future investigation.
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MESH Headings
- Humans
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/epidemiology
- Ventricular Dysfunction, Right/physiopathology
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Affiliation(s)
- Kyle O'Meara
- Department of Pulmonary & Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Gregory Stone
- UCLA Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric Buch
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Adam Brownstein
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Alexander E Sherman
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Aron Bender
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Wade RC, Mkorombindo T, Ling SX, Helgeson ES, MacDonald DM, Pew K, Voelker H, Bittner V, Kunisaki KM, Lammi MR, Dransfield MT. Association between P-pulmonale and respiratory morbidity in COPD: a secondary analysis of the BLOCK-COPD trial. BMC Pulm Med 2023; 23:434. [PMID: 37946165 PMCID: PMC10634074 DOI: 10.1186/s12890-023-02748-2] [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: 05/18/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
RATIONALE Pulmonary hypertension (PH) in COPD confers increased risk of exacerbations (ECOPD). Electrocardiogram (ECG) indicators of PH are prognostic both in PH and COPD. In the Beta-Blockers for the Prevention of Acute Exacerbations of COPD (BLOCK-COPD) trial, metoprolol increased risk of severe ECOPD through unclear mechanisms. OBJECTIVE We evaluated whether an ECG indicator of PH, P-pulmonale, would be associated with ECOPD and whether participants with P-pulmonale randomized to metoprolol were at higher risk of ECOPD and worsened respiratory symptoms given the potential detrimental effects of beta-blockers in PH. METHODS ECGs of 501 participants were analyzed for P-pulmonale (P wave enlargement in lead II). Cox proportional hazards models evaluated for associations between P-pulmonale and time to ECOPD (all and severe) for all participants and by treatment assignment (metoprolol vs. placebo). Linear mixed-effects models evaluated the association between treatment assignment and P-pulmonale on change in symptom scores (measured by CAT and SOBQ). RESULTS We identified no association between P-pulmonale and risk of any ECOPD or severe ECOPD. However, in individuals with P-pulmonale, metoprolol was associated with increased risk for ECOPD (aHR 2.92, 95% CI: 1.45-5.85). There was no association between metoprolol and ECOPD in individuals without P-pulmonale (aHR 1.01, 95% CI: 0.77-1.31). Individuals with P-pulmonale assigned to metoprolol experienced worsening symptoms (mean increase of 3.95, 95% CI: 1.32-6.58) whereas those assigned to placebo experienced a mean improvement in CAT score of -2.45 (95% CI: -0.30- -4.61). CONCLUSIONS In individuals with P-pulmonale, metoprolol was associated with increased exacerbation risk and worsened symptoms. These findings may explain the findings observed in BLOCK-COPD.
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Affiliation(s)
- R Chad Wade
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA.
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Takudzwa Mkorombindo
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sharon X Ling
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Erika S Helgeson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - David M MacDonald
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Krystle Pew
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ken M Kunisaki
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew R Lammi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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de Man FS, Vonk Noordegraaf A. The right ventricle tamed. Eur Respir J 2023; 61:61/5/2300509. [PMID: 37208035 DOI: 10.1183/13993003.00509-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Frances S de Man
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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Lippmann MR, Maron BA. The Right Ventricle: From Embryologic Development to RV Failure. Curr Heart Fail Rep 2022; 19:325-333. [PMID: 36149589 PMCID: PMC9818027 DOI: 10.1007/s11897-022-00572-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The right ventricle (RV) and left ventricle (LV) have different developmental origins, which likely plays a role in their chamber-specific response to physiological and pathological stress. RV dysfunction is encountered frequently in patients with congenital heart disease (CHD) and right heart abnormalities emerge from different causes than increased afterload alone as is observed in RV dysfunction due to pulmonary hypertension (PH). In this review, we describe the developmental, structural, and functional differences between ventricles while highlighting emerging therapies for RV dysfunction. RECENT FINDINGS There are new insights into the role of fibrosis, inflammation, myocyte contraction, and mitochondrial dynamics in the pathogenesis of RV dysfunction. We discuss the current state of therapies that may potentially improve RV function in both experimental and clinical trials. A clearer understanding of the differences in molecular alterations in the RV compared to the LV may allow for the development of better therapies that treat RV dysfunction.
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Affiliation(s)
- Matthew R. Lippmann
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 77 Ave. Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 77 Ave. Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA,Department of Cardiology, VA Boston Healthcare System, West Roxbury, MA, USA
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7
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed, but potentially curable pulmonary vascular disease. The increased pulmonary vascular resistance in CTEPH is caused by unresolved proximal thrombus and secondary microvasculopathy in the pulmonary vasculature, leading to adaptive and maladaptive remodeling of the right ventricle (RV), eventual right heart failure, and death. Knowledge on the RV remodeling process in CTEPH is limited. The progression to RV failure in CTEPH is a markedly slower process. A detailed understanding of the pathophysiology and underlying mechanisms of RV remodeling may facilitate early diagnosis and the development of targeted therapy. While ultrasound, magnetic resonance imaging, right heart catheterization, and serum biomarkers have been used to assess cardiac function, the current treatment strategies reduce the afterload of the right heart, but are less effective in improving the maladaptive remodeling of the right heart. This review systematically summarizes the current knowledge on adaptive and maladaptive remodeling of the right heart in CTEPH from molecular mechanisms to clinical practice.
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8
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Zolty R. Novel Experimental Therapies for Treatment of Pulmonary Arterial Hypertension. J Exp Pharmacol 2021; 13:817-857. [PMID: 34429666 PMCID: PMC8380049 DOI: 10.2147/jep.s236743] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and devastating disease characterized by pulmonary artery vasoconstriction and vascular remodeling leading to vascular rarefaction with elevation of pulmonary arterial pressures and pulmonary vascular resistance. Often PAH will cause death from right heart failure. Current PAH-targeted therapies improve functional capacity, pulmonary hemodynamics and reduce hospitalization. Nevertheless, today PAH still remains incurable and is often refractory to medical therapy, underscoring the need for further research. Over the last three decades, PAH has evolved from a disease of unknown pathogenesis devoid of effective therapy to a condition whose cellular, genetic and molecular underpinnings are unfolding. This article provides an update on current knowledge and summarizes the progression in recent advances in pharmacological therapy in PAH.
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Affiliation(s)
- Ronald Zolty
- Pulmonary Hypertension Program, University of Nebraska Medical Center, Lied Transplant Center, Omaha, NE, USA
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9
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Thenappan T, Weir EK, Prins KW, Pritzker MR, Archer SL. Carvedilol for Treatment of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. J Am Heart Assoc 2021; 10:e021518. [PMID: 34259020 PMCID: PMC8483454 DOI: 10.1161/jaha.121.021518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thenappan Thenappan
- Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - E Kenneth Weir
- Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Kurt W Prins
- Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Marc R Pritzker
- Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Stephen L Archer
- Department of Medicine Queen's University Kingston Ontario Canada
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Leopold JA, Kawut SM, Aldred MA, Archer SL, Benza RL, Bristow MR, Brittain EL, Chesler N, DeMan FS, Erzurum SC, Gladwin MT, Hassoun PM, Hemnes AR, Lahm T, Lima JA, Loscalzo J, Maron BA, Rosa LM, Newman JH, Redline S, Rich S, Rischard F, Sugeng L, Tang WHW, Tedford RJ, Tsai EJ, Ventetuolo CE, Zhou Y, Aggarwal NR, Xiao L. Diagnosis and Treatment of Right Heart Failure in Pulmonary Vascular Diseases: A National Heart, Lung, and Blood Institute Workshop. Circ Heart Fail 2021; 14:e007975. [PMID: 34422205 PMCID: PMC8375628 DOI: 10.1161/circheartfailure.120.007975] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Right ventricular dysfunction is a hallmark of advanced pulmonary vascular, lung parenchymal, and left heart disease, yet the underlying mechanisms that govern (mal)adaptation remain incompletely characterized. Owing to the knowledge gaps in our understanding of the right ventricle (RV) in health and disease, the National Heart, Lung, and Blood Institute (NHLBI) commissioned a working group to identify current challenges in the field. These included a need to define and standardize normal RV structure and function in populations; access to RV tissue for research purposes and the development of complex experimental platforms that recapitulate the in vivo environment; and the advancement of imaging and invasive methodologies to study the RV within basic, translational, and clinical research programs. Specific recommendations were provided, including a call to incorporate precision medicine and innovations in prognosis, diagnosis, and novel RV therapeutics for patients with pulmonary vascular disease.
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Affiliation(s)
- Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Micheala A. Aldred
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Department of Medicine, Indiana University, Indianapolis, IN
| | - Stephen L. Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ray L. Benza
- Department of Medicine, Allegheny General Hospital, Pittsburgh, PA
| | | | - Evan L. Brittain
- Division of Cardiovascular Medicine and Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, TN
| | - Naomi Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI
| | - Frances S. DeMan
- Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Mark T. Gladwin
- Department of Medicine, Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, UPMC and the University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M. Hassoun
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Anna R. Hemnes
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Department of Medicine, Indiana University, Indianapolis, IN
| | - Joao A.C. Lima
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School and Department of Cardiology, Boston VA Healthcare System, West Roxbury, MA
| | - Laura Mercer Rosa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John H. Newman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Susan Redline
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart Rich
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Franz Rischard
- Department of Medicine, University of Arizona- Tucson, Tucson, AZ
| | - Lissa Sugeng
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Emily J. Tsai
- Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Corey E. Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - YouYang Zhou
- Departments of Pediatrics (Division of Critical Care), Pharmacology, and Medicine, Northwestern University Feinberg School of Medicine. Chicago, Illinois
| | - Neil R. Aggarwal
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Lei Xiao
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
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11
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Reddy SA, Nethercott SL, Khialani BV, Grace AA, Martin CA. Management of arrhythmias in pulmonary hypertension. J Interv Card Electrophysiol 2021; 62:219-229. [DOI: 10.1007/s10840-021-00988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
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12
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Peters EL, Bogaard HJ, Vonk Noordegraaf A, de Man FS. Neurohormonal modulation in pulmonary arterial hypertension. Eur Respir J 2021; 58:13993003.04633-2020. [PMID: 33766951 PMCID: PMC8551560 DOI: 10.1183/13993003.04633-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/13/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension is a fatal condition of elevated pulmonary pressures, complicated by right heart failure. Pulmonary hypertension appears in various forms; one of those is pulmonary arterial hypertension (PAH) and is particularly characterised by progressive remodelling and obstruction of the smaller pulmonary vessels. Neurohormonal imbalance in PAH patients is associated with worse prognosis and survival. In this back-to-basics article on neurohormonal modulation in PAH, we provide an overview of the pharmacological and nonpharmacological strategies that have been tested pre-clinically and clinically. The benefit of neurohormonal modulation strategies in PAH patients has been limited by lack of insight into how the neurohormonal system is changed throughout the disease and difficulties in translation from animal models to human trials. We propose that longitudinal and individual assessments of neurohormonal status are required to improve the timing and specificity of neurohormonal modulation strategies. Ongoing developments in imaging techniques such as positron emission tomography may become helpful to determine neurohormonal status in PAH patients in different disease stages and optimise individual treatment responses.
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Affiliation(s)
- Eva L Peters
- Dept of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands.,Dept of Physiology, Amsterdam UMC, Amsterdam, The Netherlands
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13
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Prisco SZ, Thenappan T, Prins KW. Treatment Targets for Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2020; 5:1244-1260. [PMID: 33426379 PMCID: PMC7775863 DOI: 10.1016/j.jacbts.2020.07.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 01/10/2023]
Abstract
Right ventricle (RV) dysfunction is the strongest predictor of mortality in pulmonary arterial hypertension (PAH), but, at present, there are no therapies directly targeting the failing RV. Although there are shared molecular mechanisms in both RV and left ventricle (LV) dysfunction, there are important differences between the 2 ventricles that may allow for the development of RV-enhancing or RV-directed therapies. In this review, we discuss the current understandings of the dysregulated pathways that promote RV dysfunction, highlight RV-enriched or RV-specific pathways that may be of particular therapeutic value, and summarize recent and ongoing clinical trials that are investigating RV function in PAH. It is hoped that development of RV-targeted therapies will improve quality of life and enhance survival for this deadly disease.
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Key Words
- FAO, fatty acid oxidation
- IPAH, idiopathic pulmonary arterial hypertension
- LV, left ventricle/ventricular
- PAH, pulmonary arterial hypertension
- PH, pulmonary hypertension
- RAAS, renin-angiotensin-aldosterone system
- RV, right ventricle/ventricular
- RVH, right ventricular hypertrophy
- SSc-PAH, systemic sclerosis-associated pulmonary arterial hypertension
- clinical trials
- miRNA/miR, micro-ribonucleic acid
- pulmonary arterial hypertension
- right ventricle
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Affiliation(s)
- Sasha Z. Prisco
- Cardiovascular Division, Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thenappan Thenappan
- Cardiovascular Division, Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kurt W. Prins
- Cardiovascular Division, Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Neurohormonal Modulation as a Therapeutic Target in Pulmonary Hypertension. Cells 2020; 9:cells9112521. [PMID: 33266371 PMCID: PMC7700466 DOI: 10.3390/cells9112521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
The autonomic nervous system (ANS) and renin-angiotensin-aldosterone system (RAAS) are involved in many cardiovascular disorders, including pulmonary hypertension (PH). The current review focuses on the role of the ANS and RAAS activation in PH and updated evidence of potential therapies targeting both systems in this condition, particularly in Groups 1 and 2. State of the art knowledge in preclinical and clinical use of pharmacologic drugs (beta-blockers, beta-three adrenoceptor agonists, or renin-angiotensin-aldosterone signaling drugs) and invasive procedures, such as pulmonary artery denervation, is provided.
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15
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Klinke A, Schubert T, Müller M, Legchenko E, Zelt JGE, Shimauchi T, Napp LC, Rothman AMK, Bonnet S, Stewart DJ, Hansmann G, Rudolph V. Emerging therapies for right ventricular dysfunction and failure. Cardiovasc Diagn Ther 2020; 10:1735-1767. [PMID: 33224787 PMCID: PMC7666928 DOI: 10.21037/cdt-20-592] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
Therapeutic options for right ventricular (RV) dysfunction and failure are strongly limited. Right heart failure (RHF) has been mostly addressed in the context of pulmonary arterial hypertension (PAH), where it is not possible to discern pulmonary vascular- and RV-directed effects of therapeutic approaches. In part, opposing pathomechanisms in RV and pulmonary vasculature, i.e., regarding apoptosis, angiogenesis and proliferation, complicate addressing RHF in PAH. Therapy effective for left heart failure is not applicable to RHF, e.g., inhibition of adrenoceptor signaling and of the renin-angiotensin system had no or only limited success. A number of experimental studies employing animal models for PAH or RV dysfunction or failure have identified beneficial effects of novel pharmacological agents, with most promising results obtained with modulators of metabolism and reactive oxygen species or inflammation, respectively. In addition, established PAH agents, in particular phosphodiesterase-5 inhibitors and soluble guanylate cyclase stimulators, may directly address RV integrity. Promising results are furthermore derived with microRNA (miRNA) and long non-coding RNA (lncRNA) blocking or mimetic strategies, which can target microvascular rarefaction, inflammation, metabolism or fibrotic and hypertrophic remodeling in the dysfunctional RV. Likewise, pre-clinical data demonstrate that cell-based therapies using stem or progenitor cells have beneficial effects on the RV, mainly by improving the microvascular system, however clinical success will largely depend on delivery routes. A particular option for PAH is targeted denervation of the pulmonary vasculature, given the sympathetic overdrive in PAH patients. Finally, acute and durable mechanical circulatory support are available for the right heart, which however has been tested mostly in RHF with concomitant left heart disease. Here, we aim to review current pharmacological, RNA- and cell-based therapeutic options and their potential to directly target the RV and to review available data for pulmonary artery denervation and mechanical circulatory support.
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Affiliation(s)
- Anna Klinke
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Torben Schubert
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Marion Müller
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ekaterina Legchenko
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Jason G. E. Zelt
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - Duncan J. Stewart
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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16
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Hwang HV, Sandeep N, Paige SL, Ranjbarvaziri S, Hu DQ, Zhao M, Lan IS, Coronado M, Kooiker KB, Wu SM, Fajardo G, Bernstein D, Reddy S. 4HNE Impairs Myocardial Bioenergetics in Congenital Heart Disease-Induced Right Ventricular Failure. Circulation 2020; 142:1667-1683. [PMID: 32806952 DOI: 10.1161/circulationaha.120.045470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In patients with complex congenital heart disease, such as those with tetralogy of Fallot, the right ventricle (RV) is subject to pressure overload stress, leading to RV hypertrophy and eventually RV failure. The role of lipid peroxidation, a potent form of oxidative stress, in mediating RV hypertrophy and failure in congenital heart disease is unknown. METHODS Lipid peroxidation and mitochondrial function and structure were assessed in right ventricle (RV) myocardium collected from patients with RV hypertrophy with normal RV systolic function (RV fractional area change, 47.3±3.8%) and in patients with RV failure showing decreased RV systolic function (RV fractional area change, 26.6±3.1%). The mechanism of the effect of lipid peroxidation, mediated by 4-hydroxynonenal ([4HNE] a byproduct of lipid peroxidation) on mitochondrial function and structure was assessed in HL1 murine cardiomyocytes and human induced pluripotent stem cell-derived cardiomyocytes. RESULTS RV failure was characterized by an increase in 4HNE adduction of metabolic and mitochondrial proteins (16 of 27 identified proteins), in particular electron transport chain proteins. Sarcomeric (myosin) and cytoskeletal proteins (desmin, tubulin) also underwent 4HNE adduction. RV failure showed lower oxidative phosphorylation (moderate RV hypertrophy, 287.6±19.75 versus RV failure, 137.8±11.57 pmol/[sec×mL]; P=0.0004), and mitochondrial structural damage. Using a cell model, we show that 4HNE decreases cell number and oxidative phosphorylation (control, 388.1±23.54 versus 4HNE, 143.7±11.64 pmol/[sec×mL]; P<0.0001). Carvedilol, a known antioxidant did not decrease 4HNE adduction of metabolic and mitochondrial proteins and did not improve oxidative phosphorylation. CONCLUSIONS Metabolic, mitochondrial, sarcomeric, and cytoskeletal proteins are susceptible to 4HNE-adduction in patients with RV failure. 4HNE decreases mitochondrial oxygen consumption by inhibiting electron transport chain complexes. Carvedilol did not improve the 4HNE-mediated decrease in oxygen consumption. Strategies to decrease lipid peroxidation could improve mitochondrial energy generation and cardiomyocyte survival and improve RV failure in patients with congenital heart disease.
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Affiliation(s)
- HyunTae V Hwang
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Nefthi Sandeep
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Sharon L Paige
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Sara Ranjbarvaziri
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Dong-Qing Hu
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Mingming Zhao
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Ingrid S Lan
- Department of Bioengineering (I.S.L.), Stanford University, Palo Alto, CA
| | | | | | - Sean M Wu
- Department of Medicine (Cardiology) (S.M.W.), Stanford University, Palo Alto, CA
| | - Giovanni Fajardo
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
| | - Sushma Reddy
- Department of Pediatrics (Cardiology) (HT.V.H., N.S., S.L.P., S. Ranjbarvairi, D-Q.H., M.Z., G.F., D.B., S. Reddy), Stanford University, Palo Alto, CA
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17
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Rijnierse MT, Groeneveldt JA, van Campen JSJA, de Boer K, van der Bruggen CEE, Harms HJ, Raijmakers PG, Lammertsma AA, Knaapen P, Bogaard HJ, Westerhof BE, Vonk Noordegraaf A, Allaart CP, de Man FS. Bisoprolol therapy does not reduce right ventricular sympathetic activity in pulmonary arterial hypertension patients. Pulm Circ 2020; 10:2045894019873548. [PMID: 32363028 PMCID: PMC7187746 DOI: 10.1177/2045894019873548] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/29/2019] [Indexed: 11/27/2022] Open
Abstract
Right ventricular (RV) function and autonomic dysfunction are important
determinants of morbidity and mortality in patients with pulmonary arterial
hypertension (PAH). Although successful in animal studies, effects of
beta-blocker therapy on RV function in clinical trials were disappointing. To
understand this discrepancy, we studied whether beta-blocker therapy changes RV
sympathetic activity. Idiopathic PAH (IPAH) patients received beta-blocker
therapy (uptitrated to a maximal tolerated dose) and underwent cardiac magnetic
resonance imaging, right heart catheterization, and a
[11C]-hydroxyephedrine positron emission tomography
([11C]HED PET) scan at baseline to determine, respectively, RV
ejection fraction (RVEF), RV pressures, and sympathetic activity.
[11C]HED, a norepinephrine analogue, allows determination of
sympathetic innervation of the RV. [11C]HED retention index reflects
norepinephrine transporter activity. As a consequence of excessive catecholamine
levels in the synaptic cleft, this transporter may be downregulated. Therefore,
low [11C]HED retention index indicates high sympathetic activity. 13
IPAH patients underwent [11C]HED PET scans at baseline and after
bisoprolol treatment. Although heart rate was reduced, systemic modulation of
autonomic activity by bisoprolol did not affect local RV sympathetic nerve
activity, RV function, or RV wall tension. In PAH patients, RV
[11C]HED retention index was lower compared to LV tracer uptake
(p<0.01) and was related to systolic wall tension (R2 = 0.4731,
p<0.01) and RV function (R2 = 0.44, p = 0.01). In RV failure, the
tolerated dosage of bisoprolol did not result in an improvement of RV function
nor in a reduction in RV sympathetic activity.
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Affiliation(s)
- Mischa T Rijnierse
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joanne A Groeneveldt
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jasmijn S J A van Campen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Karin de Boer
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cathelijne E E van der Bruggen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hendrik J Harms
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Adriaan A Lammertsma
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harm Jan Bogaard
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Berend E Westerhof
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Medical Biology, Section of Systems Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frances S de Man
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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18
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Maron BA, Leopold JA, Hemnes AR. Metabolic syndrome, neurohumoral modulation, and pulmonary arterial hypertension. Br J Pharmacol 2020; 177:1457-1471. [PMID: 31881099 DOI: 10.1111/bph.14968] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
Pulmonary vascular disease, including pulmonary arterial hypertension (PAH), is increasingly recognized to be affected by systemic alterations including up-regulation of the renin-angiotensin-aldosterone system and perturbations to metabolic pathways, particularly glucose and fat metabolism. There is increasing preclinical and clinical data that each of these pathways can promote pulmonary vascular disease and right heart failure and are not simply disease markers. More recently, trials of therapeutics aimed at neurohormonal activation or metabolic dysfunction are beginning to shed light on how interventions in these pathways may affect patients with PAH. This review will focus on underlying mechanistic data that supports neurohormonal activation and metabolic dysfunction in the pathogenesis of PAH and right heart failure as well as discussing early translational data in patients with PAH.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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19
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Prins KW, Thenappan T, Weir EK, Kalra R, Pritzker M, Archer SL. Repurposing Medications for Treatment of Pulmonary Arterial Hypertension: What's Old Is New Again. J Am Heart Assoc 2020; 8:e011343. [PMID: 30590974 PMCID: PMC6405714 DOI: 10.1161/jaha.118.011343] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kurt W Prins
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Thenappan Thenappan
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - E Kenneth Weir
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Rajat Kalra
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Marc Pritzker
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
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20
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Vahdatpour CA, Luebbert JJ, Palevsky HI. Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910685. [PMID: 32215200 PMCID: PMC7065292 DOI: 10.1177/2045894020910685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.
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Affiliation(s)
- Cyrus A. Vahdatpour
- Department of Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jeffrey J. Luebbert
- Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Harold I. Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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22
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Stephens OR, Weiss K, Frimel M, Rose JA, Sun Y, Asosingh K, Farha S, Highland KB, Prasad SVN, Erzurum SC. Interdependence of hypoxia and β-adrenergic receptor signaling in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2019; 317:L369-L380. [PMID: 31242023 PMCID: PMC6766716 DOI: 10.1152/ajplung.00015.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/23/2022] Open
Abstract
The β-adrenergic receptor (βAR) exists in an equilibrium of inactive and active conformational states, which shifts in response to different ligands and results in downstream signaling. In addition to cAMP, βAR signals to hypoxia-inducible factor 1 (HIF-1). We hypothesized that a βAR-active conformation (R**) that leads to HIF-1 is separable from the cAMP-activating conformation (R*) and that pulmonary arterial hypertension (PAH) patients with HIF-biased conformations would not respond to a cAMP agonist. We compared two cAMP agonists, isoproterenol and salbutamol, in vitro. Isoproterenol increased cAMP and HIF-1 activity, while salbutamol increased cAMP and reduced HIF-1. Hypoxia blunted agonist-stimulated cAMP, consistent with receptor equilibrium shifting toward HIF-activating conformations. Similarly, isoproterenol increased HIF-1 and erythropoiesis in mice, while salbutamol decreased erythropoiesis. βAR overexpression in cells increased glycolysis, which was blunted by HIF-1 inhibitors, suggesting increased βAR leads to increased hypoxia-metabolic effects. Because PAH is also characterized by HIF-related glycolytic shift, we dichotomized PAH patients in the Pulmonary Arterial Hypertension Treatment with Carvedilol for Heart Failure trial (NCT01586156) based on right ventricular (RV) glucose uptake to evaluate βAR ligands. Patients with high glucose uptake had more severe disease than those with low uptake. cAMP increased in response to isoproterenol in mononuclear cells from low-uptake patients but not in high-uptake patients' cells. When patients were treated with carvedilol for 1 wk, the low-uptake group decreased RV systolic pressures and pulmonary vascular resistance, but high-uptake patients had no physiologic responses. The findings expand the paradigm of βAR activation and uncover a novel PAH subtype that might benefit from β-blockers.
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Affiliation(s)
- Olivia R Stephens
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Kelly Weiss
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew Frimel
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jonathan A Rose
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Yu Sun
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kewal Asosingh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samar Farha
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Sathyamangla V Naga Prasad
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serpil C Erzurum
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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23
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Right ventricular systolic to diastolic duration ratio: A novel predictor of outcome in adult idiopathic pulmonary arterial hypertension. Int J Cardiol 2019; 293:218-222. [PMID: 31126734 DOI: 10.1016/j.ijcard.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/17/2019] [Accepted: 05/06/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The systolic to diastolic (SD) duration ratio reflects global RV performance in pulmonary arterial hypertension (PAH) yet limited data exists on its application to adult non-congenital PAH. We measured SD ratios on echocardiogram in idiopathic PAH (IPAH) to establish its response to pulmonary vasodilator therapy and prognostic value at diagnosis and follow up. METHODS Incident patients with IPAH undergoing echocardiogram, haemodynamic and exercise assessments were identified within our centre between 2005 and 2018. SD ratios were adjusted for heart rate at diagnosis and follow up. RESULTS In 98 patients at diagnosis, the mean SD ratio was 1.03 ± 0.37 decreasing to 0.85 ± 0.25, p < 0.001 at follow-up echocardiogram performed at a median interval of 9.0 months. The SD ratio at diagnosis correlated weakly with RV basal diameter (r = 0.24, p = 0.04) and 6MWD (r = 0.23, p = 0.04). At follow up, the mean SD ratio was lower in those receiving combination vs monotherapy pulmonary vasodilator treatment (71 ± 25 vs 92 ± 22% baseline respectively, p < 0.001). After a median follow-up of 4.8 years, 3 patients were transplanted and 23 patients died. The SD ratio at diagnosis and follow up predicted an increased risk of death/transplantation (HR 2.41 (1.09-5.29), p = 0.03; HR 5.02 (1.27-19.77), p = 0.02 respectively), retaining its predictive value at diagnosis in bivariate models with 6MWD (HR 2.18 (1.06-4.08)), WHO Functional Class (HR 2.33 (1.04-5.21)) and TAPSE (HR 2.36 (1.07-5.19)), all p < 0.05. CONCLUSIONS The SD ratio carries prognostic value at diagnosis and follow up in IPAH. Its further evaluation alongside current PAH risk stratification parameters should be considered.
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24
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Power AS, Norman R, Jones TLM, Hickey AJ, Ward ML. Mitochondrial function remains impaired in the hypertrophied right ventricle of pulmonary hypertensive rats following short duration metoprolol treatment. PLoS One 2019; 14:e0214740. [PMID: 30964911 PMCID: PMC6456253 DOI: 10.1371/journal.pone.0214740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/19/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary hypertension (PH) increases the work of the right ventricle (RV) and causes right-sided heart failure. This study examined RV mitochondrial function and ADP transfer in PH animals advancing to right heart failure, and investigated a potential therapy with the specific β1-adrenergic-blocker metoprolol. Adult Wistar rats (317 ± 4 g) were injected either with monocrotaline (MCT, 60 mg kg-1) to induce PH, or with an equivalent volume of saline for controls (CON). At three weeks post-injection the MCT rats began oral metoprolol (10 mg kg-1 day-1-) or placebo treatment until heart failure was observed in the MCT group. Mitochondrial function was then measured using high-resolution respirometry from permeabilised RV fibres. Relative to controls, MCT animals had impaired mitochondrial function but maintained coupling between myofibrillar ATPases and mitochondria, despite an increase in ADP diffusion distances. Cardiomyocytes from the RV of MCT rats were enlarged, primarily due to an increase in myofibrillar protein. The ratio of mitochondria per myofilament area was decreased in both MCT groups (p ≤ 0.05) in comparison to control (CON: 1.03 ± 0.04; MCT: 0.74 ± 0.04; MCT + BB: 0.74 ± 0.03). This not only implicates impaired energy production in PH, but also increases the diffusion distance for metabolites within the MCT cardiomyocytes, adding an additional hindrance to energy supply. Together, these changes may limit energy supply in MCT rat hearts, particularly at high cardiac workloads. Metoprolol treatment did not delay the onset of heart failure symptoms, improve mitochondrial function, or regress RV hypertrophy.
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Affiliation(s)
- Amelia S. Power
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
- * E-mail: (M-L W); (ASP)
| | - Ruth Norman
- School of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Timothy L. M. Jones
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony J. Hickey
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Marie-Louise Ward
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
- * E-mail: (M-L W); (ASP)
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25
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Le T, Makar C, Morway P, Hoftman N, Umar S. Pulmonary artery denervation: a novel treatment modality for pulmonary hypertension. J Thorac Dis 2019; 11:1094-1096. [PMID: 31179049 DOI: 10.21037/jtd.2019.02.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Trixie Le
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Christian Makar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Philip Morway
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nir Hoftman
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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26
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Grinnan D, Trankle C, Andruska A, Bloom B, Spiekerkoetter E. Drug repositioning in pulmonary arterial hypertension: challenges and opportunities. Pulm Circ 2019; 9:2045894019832226. [PMID: 30729869 PMCID: PMC6852366 DOI: 10.1177/2045894019832226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Despite many advances in medical therapy for pulmonary arterial hypertension (PAH) over the past 20 years, long-term survival is still poor. Novel therapies which target the underlying pathology of PAH and which could be added to current vasodilatory therapies to halt disease progression and potentially reverse pulmonary vascular remodeling are highly sought after. Given the high attrition rates, substantial costs, and slow pace of new drug development, repositioning of “old” drugs is increasingly becoming an attractive path to identify novel treatment options, especially for a rare disease such as PAH. We here summarize the limitations of current PAH therapy, the general concept of repurposing and repositioning, success stories of approved repositioned drugs in PAH as well as novel repositioned drugs that show promise in preclinical models of pulmonary hypertension (PH) and are currently tested in clinical trials. We furthermore discuss various data-driven as well as experimental approaches currently used to identify repurposed drug candidates and review challenges for the “repositioning community” with regards to funding and patent and regulatory considerations, and to illustrate opportunities for collaborative solutions for drug repositioning relevant to PAH.
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Affiliation(s)
- Daniel Grinnan
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Cory Trankle
- 2 Department of Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam Andruska
- 3 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,4 Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | | | - Edda Spiekerkoetter
- 3 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,4 Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
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27
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Abstract
Pulmonary arterial hypertension (PAH) is a pulmonary vasculopathy that causes right ventricular dysfunction and exercise limitation and progresses to death. New findings from translational studies have suggested alternative pathways for treatment. These avenues include sex hormones, genetic abnormalities and DNA damage, elastase inhibition, metabolic dysfunction, cellular therapies, and anti-inflammatory approaches. Both novel and repurposed compounds with rationale from preclinical experimental models and human cells are now in clinical trials in patients with PAH. Findings from these studies will elucidate the pathobiology of PAH and may result in clinically important improvements in outcome.
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Affiliation(s)
- Edda Spiekerkoetter
- Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA; ,
| | - Steven M Kawut
- Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6021, USA;
| | - Vinicio A de Jesus Perez
- Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA; ,
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28
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Cheong HI, Farha S, Park MM, Thomas JD, Saygin D, Comhair SAA, Sharp J, Highland KB, Tang WHW, Erzurum SC. Endothelial Phenotype Evoked by Low Dose Carvedilol in Pulmonary Hypertension. Front Cardiovasc Med 2018; 5:180. [PMID: 30619887 PMCID: PMC6299019 DOI: 10.3389/fcvm.2018.00180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/30/2018] [Indexed: 01/06/2023] Open
Abstract
Background: The therapeutic benefits of β-blockers are well established in left heart failure. The Pulmonary Arterial Hypertension Treatment with Carvedilol for Heart Failure [PAHTCH] study showed safety and possible benefit of carvedilol in pulmonary arterial hypertension (PAH) associated right heart failure over 6 months. This study aims at evaluating the short-term cardiovascular effects and early mechanistic biomarkers of carvedilol therapy. Methods: Thirty patients with pulmonary hypertension (PH) received low dose carvedilol (3.125 mg twice daily) for 1 week prior to randomization to placebo, low-dose, or dose-escalating carvedilol therapy. Echocardiography was performed at baseline and 1 week. Exercise capacity was assessed by 6 min walk distance (6MWD). The L-arginine/nitric oxide pathway and other biological markers of endothelial function were measured. Results: All participants tolerated 1 week of carvedilol without adverse effects. After 1 week of carvedilol, 6MWD and heart rate at peak exercise did not vary (both p > 0.1). Heart rate at rest and 1 min post walk dropped significantly (both p < 0.05) with a trend for increase in heart rate recovery (p = 0.08). Right ventricular systolic pressure (RVSP) decreased by an average of 13 mmHg (p = 0.002). Patients who had a decrease in RVSP of more than 10 mm Hg were defined as responders (n = 17), and those with a lesser drop as non-responders (n = 13). Responders had a significant drop in pulmonary vascular resistance (PVR) after 1 week of carvedilol (p = 0.004). In addition, responders had a greater decrease in heart rate at rest and 1 min post walk compared to non-responders (both p < 0.05). Responders had higher plasma arginine and global bioavailability of arginine at baseline compared to non-responders (p = 0.03 and p = 0.05, respectively). After 1 week of carvedilol, responders had greater increase in urinary nitrate (p = 0.04). Responders treated with carvedilol had a sustained drop in RVSP and PVR after 6 months of carvedilol with no change in cardiac output. Conclusions: Low-dose carvedilol for 1 week can potentially identify a PH responder phenotype that may benefit from β-blockers that is associated with less endothelial dysfunction. Clinical Trial Registration:http://www.clinicaltrials.gov. identifier: NCT01586156.
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Affiliation(s)
- Hoi I Cheong
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Samar Farha
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Margaret M Park
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States
| | - James D Thomas
- Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL, United States
| | - Didem Saygin
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Suzy A A Comhair
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jacqueline Sharp
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States.,Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - W H Wilson Tang
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States.,Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Serpil C Erzurum
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States.,Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
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29
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Emanuel R, Chichra A, Patel N, Le Jemtel TH, Jaiswal A. Neurohormonal modulation as therapeutic avenue for right ventricular dysfunction in pulmonary artery hypertension: till the dawn, waiting. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:301. [PMID: 30211189 DOI: 10.21037/atm.2018.06.04] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Neuro-hormonal activation may lead to or be associated with pulmonary arterial hypertension (PAH) and right ventricular dysfunction. Notwithstanding whether it is the cause or the consequence of PAH-related right ventricle (RV) dysfunction neurohormonal activation contributes to significant morbidity and mortality in patients with PAH and the progression of RV dysfunction. Experimental data regarding the use of beta adrenergic blockade and renin-angiotensin aldosterone system modulation are encouraging. However, clinical studies have largely been negative or neutral; and, neuro-hormonal modulation is discouraged in patients with PAH related RV dysfunction for fear of systemic hypotension. Herein, we summarize the pathophysiological background that supports the potential role of neuro-hormonal modulation in the management of PAH related RV dysfunction; also present current clinical experience; and, discuss the need for controlled studies to move forward. Lastly, we review potential non- pharmacological modalities for neuro-hormonal modulations in PAH patients with RV dysfunction.
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Affiliation(s)
- Roy Emanuel
- Tulane Heart and Vascular Institute, Tulane School of Medicine, New Orleans, LA, USA
| | - Astha Chichra
- Department of Pulmonary and Critical Care Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nirav Patel
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT, USA
| | - Thierry H Le Jemtel
- Tulane Heart and Vascular Institute, Tulane School of Medicine, New Orleans, LA, USA
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT, USA
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30
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Fowler ED, Drinkhill MJ, Norman R, Pervolaraki E, Stones R, Steer E, Benoist D, Steele DS, Calaghan SC, White E. Beta1-adrenoceptor antagonist, metoprolol attenuates cardiac myocyte Ca 2+ handling dysfunction in rats with pulmonary artery hypertension. J Mol Cell Cardiol 2018; 120:74-83. [PMID: 29807024 PMCID: PMC6013283 DOI: 10.1016/j.yjmcc.2018.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/22/2018] [Indexed: 01/13/2023]
Abstract
Right heart failure is the major cause of death in Pulmonary Artery Hypertension (PAH) patients but is not a current, specific therapeutic target. Pre-clinical studies have shown that adrenoceptor blockade can improve cardiac function but the mechanisms of action within right ventricular (RV) myocytes are unknown. We tested whether the β1-adrenoceptor blocker metoprolol could improve RV myocyte function in an animal model of PAH, by attenuating adverse excitation-contraction coupling remodeling. PAH with RV failure was induced in rats by monocrotaline injection. When PAH was established, animals were given 10 mg/kg/day metoprolol (MCT + BB) or vehicle (MCT). The median time to the onset of heart failure signs was delayed from 23 days (MCT), to 31 days (MCT + BB). At 23 ± 1 days post-injection, MCT + BB showed improved in vivo cardiac function, measured by echocardiography. RV hypertrophy was reduced despite persistent elevated afterload. RV myocyte contractility during field stimulation was improved at higher pacing frequencies in MCT + BB. Preserved t-tubule structure, more uniform evoked Ca2+ release, increased SERCA2a expression and faster ventricular repolarization (measured in vivo by telemetry) may account for the improved contractile function. Sarcoplasmic reticulum Ca2+ overload was prevented in MCT + BB myocytes resulting in fewer spontaneous Ca2+ waves, with a lower pro-arrhythmic potential. Our novel finding of attenuation of defects in excitation contraction coupling by β1-adrenoceptor blockade with delays in the onset of HF, identifies the RV as a promising therapeutic target in PAH. Moreover, our data suggest existing therapies for left ventricular failure may also be beneficial in PAH induced RV failure.
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Affiliation(s)
- Ewan D Fowler
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK; School of Physiology, Pharmacology and Neuroscience, Faculty of Biomedical Sciences, University of Bristol, Bristol, UK
| | - Mark J Drinkhill
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Ruth Norman
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | | | - Rachel Stones
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Emma Steer
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - David Benoist
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK; L'institut de rythmologie et modélisation cardiaque, Inserm U-1045, Université de Bordeaux, Bordeaux, France
| | - Derek S Steele
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Sarah C Calaghan
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Ed White
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK.
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31
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Asosingh K, Erzurum S. Mechanisms of right heart disease in pulmonary hypertension (2017 Grover Conference Series). Pulm Circ 2017; 8:2045893217753121. [PMID: 29264954 PMCID: PMC5798686 DOI: 10.1177/2045893217753121] [Citation(s) in RCA: 11] [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: 11/17/2022] Open
Abstract
Current dogma is that pathological hypertrophy of the right ventricle is a direct consequence of pulmonary vascular remodeling. However, progression of right ventricle dysfunction is not always lung-dependent. Increased afterload caused by pulmonary vascular remodeling initiates the right ventricle hypertrophy, but determinants leading to adaptive or maladaptive hypertrophy and failure remain unknown. Ischemia in a hypertrophic right ventricle may directly contribute to right heart failure. Rapidly enlarging cardiomyocytes switch from aerobic to anaerobic energy generation resulting in cell growth under relatively hypoxic conditions. Cardiac muscle reacts to an increased afterload by over-activation of the sympathetic system and uncoupling and downregulation of β-adrenergic receptors. Recent studies suggest that β blocker therapy in PH is safe, well tolerated, and preserves right ventricle function and cardiac output by reducing right ventricular glycolysis. Fibrosis, an evolutionary conserved process in host defense and wound healing, is dysregulated in maladaptive cardiac tissue contributing directly to right ventricle failure. Despite several mechanisms having been suggested in right heart disease, the causes of maladaptive cardiac remodeling remain unknown and require further research.
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Affiliation(s)
- Kewal Asosingh
- 1 2569 Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Serpil Erzurum
- 1 2569 Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA.,2 2569 Lerner Research Institute and Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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32
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Yaoita N, Shimokawa H. Effect of heart rate reduction in pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2017; 314:H889-H891. [PMID: 29351475 DOI: 10.1152/ajpheart.00705.2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Nobuhiro Yaoita
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
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33
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Vaillancourt M, Chia P, Sarji S, Nguyen J, Hoftman N, Ruffenach G, Eghbali M, Mahajan A, Umar S. Autonomic nervous system involvement in pulmonary arterial hypertension. Respir Res 2017; 18:201. [PMID: 29202826 PMCID: PMC5715548 DOI: 10.1186/s12931-017-0679-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 11/13/2017] [Indexed: 01/28/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disease characterized by increased pulmonary vascular resistance (PVR) leading to right ventricular (RV) failure. Autonomic nervous system involvement in the pathogenesis of PAH has been demonstrated several years ago, however the extent of this involvement is not fully understood. PAH is associated with increased sympathetic nervous system (SNS) activation, decreased heart rate variability, and presence of cardiac arrhythmias. There is also evidence for increased renin-angiotensin-aldosterone system (RAAS) activation in PAH patients associated with clinical worsening. Reduction of neurohormonal activation could be an effective therapeutic strategy for PAH. Although therapies targeting adrenergic receptors or RAAS signaling pathways have been shown to reverse cardiac remodeling and improve outcomes in experimental pulmonary hypertension (PH)-models, the effectiveness and safety of such treatments in clinical settings have been uncertain. Recently, novel direct methods such as cervical ganglion block, pulmonary artery denervation (PADN), and renal denervation have been employed to attenuate SNS activation in PAH. In this review, we intend to summarize the multiple aspects of autonomic nervous system involvement in PAH and overview the different pharmacological and invasive strategies used to target autonomic nervous system for the treatment of PAH.
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Affiliation(s)
- Mylène Vaillancourt
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Pamela Chia
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Shervin Sarji
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Jason Nguyen
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Nir Hoftman
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Gregoire Ruffenach
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA.
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34
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Farha S, Saygin D, Park MM, Cheong HI, Asosingh K, Comhair SA, Stephens OR, Roach EC, Sharp J, Highland KB, DiFilippo FP, Neumann DR, Tang WHW, Erzurum SC. Pulmonary arterial hypertension treatment with carvedilol for heart failure: a randomized controlled trial. JCI Insight 2017; 2:95240. [PMID: 28814664 DOI: 10.1172/jci.insight.95240] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/18/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Right-sided heart failure is the leading cause of death in pulmonary arterial hypertension (PAH). Similar to left heart failure, sympathetic overactivation and β-adrenoreceptor (βAR) abnormalities are found in PAH. Based on successful therapy of left heart failure with β-blockade, the safety and benefits of the nonselective β-blocker/vasodilator carvedilol were evaluated in PAH. METHODS PAH Treatment with Carvedilol for Heart Failure (PAHTCH) is a single-center, double-blind, randomized, controlled trial. Following 1-week run-in, 30 participants were randomized to 1 of 3 arms for 24 weeks: placebo, low-fixed-dose, or dose-escalating carvedilol. Outcomes included clinical measures and mechanistic biomarkers. RESULTS Decreases in heart rate and blood pressure with carvedilol were well tolerated; heart rate correlated with carvedilol dose. Carvedilol-treated groups had no decrease in exercise capacity measured by 6-minute walk, but had lower heart rates at peak and after exercise, and faster heart rate recovery. Dose-escalating carvedilol was associated with reduction in right ventricular (RV) glycolytic rate and increase in βAR levels. There was no evidence of RV functional deterioration; rather, cardiac output was maintained. CONCLUSIONS Carvedilol is likely safe in PAH over 6 months of therapy and has clinical and mechanistic benefits associated with improved outcomes. The data provide support for longer and larger studies to establish guidelines for use of β-blockers in PAH. TRIAL REGISTRATION ClinicalTrials.gov NCT01586156FUNDING. This project was supported by NIH R01HL115008 and R01HL60917 and in part by the National Center for Advancing Translational Sciences, UL1TR000439.
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35
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van der Bruggen CE, Tedford RJ, Handoko ML, van der Velden J, de Man FS. RV pressure overload: from hypertrophy to failure. Cardiovasc Res 2017; 113:1423-1432. [DOI: 10.1093/cvr/cvx145] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/31/2017] [Indexed: 01/31/2023] Open
Affiliation(s)
- Cathelijne E.E. van der Bruggen
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Jolanda van der Velden
- Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Frances S. de Man
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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36
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Perros F, de Man FS, Bogaard HJ, Antigny F, Simonneau G, Bonnet S, Provencher S, Galiè N, Humbert M. Use of β-Blockers in Pulmonary Hypertension. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003703. [DOI: 10.1161/circheartfailure.116.003703] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/24/2017] [Indexed: 12/13/2022]
Abstract
Contrasting with the major attention that left heart failure has received, right heart failure remains understudied both at the preclinical and clinical levels. However, right ventricle failure is a major predictor of outcomes in patients with precapillary pulmonary hypertension because of pulmonary arterial hypertension, and in patients with postcapillary pulmonary hypertension because of left heart disease. In pulmonary hypertension, the status of the right ventricle is one of the most important predictors of both morbidity and mortality. Paradoxically, there are currently no approved therapies targeting the right ventricle in pulmonary hypertension. By analogy with the key role of β-blockers in the management of left heart failure, some authors have proposed to use these agents to support the right ventricle function in pulmonary hypertension. In this review, we summarize the current knowledge on the use of β-blockers in pulmonary hypertension.
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Affiliation(s)
- Frédéric Perros
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Frances S. de Man
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Harm J. Bogaard
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Fabrice Antigny
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Gérald Simonneau
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Sébastien Bonnet
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Steeve Provencher
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Nazzareno Galiè
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
| | - Marc Humbert
- From the University Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France (F.P., F.A., G.S., M.H.); Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France (F.P., F.A., G.S., M.H.); Department of Pulmonology, VU University Medical Centre, Amsterdam, The Netherlands (F.S.d.M., H.J.B.); Pulmonary Hypertension Research Group, Centre de Recherche de
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Metkus TS, Mullin CJ, Grandin EW, Rame JE, Tampakakis E, Hsu S, Kolb TM, Damico R, Hassoun PM, Kass DA, Mathai SC, Tedford RJ. Heart Rate Dependence of the Pulmonary Resistance x Compliance (RC) Time and Impact on Right Ventricular Load. PLoS One 2016; 11:e0166463. [PMID: 27861600 PMCID: PMC5115737 DOI: 10.1371/journal.pone.0166463] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/28/2016] [Indexed: 12/28/2022] Open
Abstract
Background The effect of heart rate (HR) and body surface area (BSA) on pulmonary RC time and right ventricular (RV) load is unknown. Methods To determine the association of HR and BSA with the pulmonary RC time and measures of RV load, we studied three large patient cohorts including subjects with 1) known or suspected pulmonary arterial hypertension (PAH) (n = 1008), 2) pulmonary hypertension due to left heart disease (n = 468), and 3) end-stage heart failure with reduced ejection fraction (n = 150). To corroborate these associations on an individual patient level, we performed an additional analysis using high-fidelity catheters in 22 patients with PAH undergoing right atrial pacing. Results A faster HR inversely correlated with RC time (p<0.01 for all), suggesting augmented RV pulsatile loading. Lower BSA directly correlated with RC time (p<0.05) although the magnitude of this effect was smaller than for HR. With incremental atrial pacing, cardiac output increased and total pulmonary resistance (TPR) fell. However, effective arterial elastance, its mean resistive component (TPR/heart period; 0.60±0.27 vs. 0.79±0.45;p = 0.048), and its pulsatile component (0.27±0.18 vs 0.39±0.28;p = 0.03) all increased at faster HR. Conclusion Heart rate and BSA are associated with pulmonary RC time. As heart rate increases, the pulsatile and total load on the RV also increase. This relationship supports a hemodynamic mechanism for adverse effects of tachycardia on the RV.
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Affiliation(s)
- Thomas S. Metkus
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Christopher J. Mullin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - E. Wilson Grandin
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - J. Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Emmanouil Tampakakis
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rachel Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David A. Kass
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ryan J. Tedford
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
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van Campen JSJA, de Boer K, van de Veerdonk MC, van der Bruggen CEE, Allaart CP, Raijmakers PG, Heymans MW, Marcus JT, Harms HJ, Handoko ML, de Man FS, Vonk Noordegraaf A, Bogaard HJ. Bisoprolol in idiopathic pulmonary arterial hypertension: an explorative study. Eur Respir J 2016; 48:787-96. [PMID: 27390285 DOI: 10.1183/13993003.00090-2016] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/21/2016] [Indexed: 01/08/2023]
Abstract
While beta-blockers are considered contraindicated in pulmonary arterial hypertension (PAH), the prognostic significance of sympathetic nervous system over-activity suggests a potential benefit of beta-blocker therapy. The aim of this randomised, placebo-controlled, crossover, single centre study was to determine the effects of bisoprolol on right ventricular ejection fraction (RVEF) in idiopathic PAH (iPAH) patients. Additional efficacy and safety parameters were explored.Patients with optimally treated, stable iPAH (New York Heart Association functional class II/III) were randomised to placebo or bisoprolol. Imaging and functional measurements were performed at baseline, crossover and end of study.18 iPAH patients were included, because inclusion faltered before enrolment of the targeted 25 patients. 17 patients completed 6 months of bisoprolol, 15 tolerated bisoprolol, one patient required intravenous diuretics. Bisoprolol was associated with a lower heart rate (17 beats per minute, p=0.0001) but RVEF remained unchanged. A drop in cardiac index (0.5 L·min(-1)·m(-2), p=0.015) was observed, along with a trend towards a decreased 6-min walking distance (6MWD).Although careful up-titration of bisoprolol was tolerated by most patients and resulted in a decreased heart rate, no benefit of bisoprolol in iPAH was demonstrated. Decreases in cardiac index and 6MWD suggest a deteriorated cardiac function. The results do not favour the use of bisoprolol in iPAH patients.
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Affiliation(s)
- Jasmijn S J A van Campen
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Both authors contributed equally
| | - Karin de Boer
- Dept of cardiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Both authors contributed equally
| | - Mariëlle C van de Veerdonk
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Dept of cardiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Cathelijne E E van der Bruggen
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Cor P Allaart
- Dept of cardiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Dept of nuclear medicine and PET-research, VU University medical center, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Dept of epidemiology, VU University medical center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Dept of physics and medical technology, VU University medical center, Amsterdam, The Netherlands
| | - Hendrik J Harms
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Dept of nuclear medicine and PET-research, VU University medical center, Amsterdam, The Netherlands
| | - M Louis Handoko
- Dept of cardiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Frances S de Man
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Dept of physiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Dept of pulmonary medicine, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands Dept of physiology, Institute for cardiovascular research, VU University medical center, Amsterdam, The Netherlands
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Pankey EA, Edward JA, Swan KW, Bourgeois CR, Bartow MJ, Yoo D, Peak TA, Song BM, Chan RA, Murthy SN, Prieto MC, Giles TD, Kadowitz PJ. Nebivolol has a beneficial effect in monocrotaline-induced pulmonary hypertension. Can J Physiol Pharmacol 2016; 94:758-68. [DOI: 10.1139/cjpp-2015-0431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pulmonary hypertension is a rare disorder that, without treatment, is progressive and fatal within 3–4 years. Current treatment involves a diverse group of drugs that target the pulmonary vascular bed. In addition, strategies that increase nitric oxide (NO) formation have a beneficial effect in rodents and patients. Nebivolol, a selective β1 adrenergic receptor-blocking agent reported to increase NO production and stimulate β3 receptors, has vasodilator properties suggesting that it may be beneficial in the treatment of pulmonary hypertension. The present study was undertaken to determine whether nebivolol has a beneficial effect in monocrotaline-induced (60 mg/kg) pulmonary hypertension in the rat. These results show that nebivolol treatment (10 mg/kg, once or twice daily) attenuates pulmonary hypertension, reduces right ventricular hypertrophy, and improves pulmonary artery remodeling in monocrotaline-induced pulmonary hypertension. This study demonstrates the presence of β3 adrenergic receptor immunoreactivity in pulmonary arteries and airways and that nebivolol has pulmonary vasodilator activity. Studies with β3 receptor agonists (mirabegron, BRL 37344) and antagonists suggest that β3 receptor-mediated decreases in systemic arterial pressure occur independent of NO release. Our results suggest that nebivolol, a selective vasodilating β1 receptor antagonist that stimulates β3 adrenergic receptors and induces vasodilation by increasing NO production, may be beneficial in treating pulmonary hypertensive disorders.
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Affiliation(s)
- Edward A. Pankey
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Justin A. Edward
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Kevin W. Swan
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Camille R.T. Bourgeois
- Department of Physiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Matthew J. Bartow
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Daniel Yoo
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Taylor A. Peak
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Bryant M. Song
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Ryan A. Chan
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Subramanyam N. Murthy
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Minolfa C. Prieto
- Department of Physiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Thomas D. Giles
- Department of Internal Medicine, Division of Cardiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Philip J. Kadowitz
- Department of Pharmacology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
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de Man FS, Handoko ML. β-blockers in pulmonary arterial hypertension: evolving concepts of right heart failure. Eur Respir J 2016; 46:619-21. [PMID: 26324694 DOI: 10.1183/09031936.00051215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Frances S de Man
- Dept of Pulmonology, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - M Louis Handoko
- Dept of Cardiology, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
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Update in treatment options in pulmonary hypertension. J Heart Lung Transplant 2016; 35:695-703. [DOI: 10.1016/j.healun.2016.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/19/2015] [Accepted: 01/10/2016] [Indexed: 12/16/2022] Open
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Ameri P, Bertero E, Meliota G, Cheli M, Canepa M, Brunelli C, Balbi M. Neurohormonal activation and pharmacological inhibition in pulmonary arterial hypertension and related right ventricular failure. Heart Fail Rev 2016; 21:539-47. [DOI: 10.1007/s10741-016-9566-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
In patients with pulmonary hypertension (PH), the primary cause of death is right ventricular (RV) failure. Improvement in RV function is therefore one of the most important treatment goals. In order to be able to reverse RV dysfunction and also prevent RV failure, a detailed understanding of the pathobiology of RV failure and the underlying mechanisms concerning the transition from a pressure-overloaded adapted right ventricle to a dilated and failing right ventricle is required. Here, we propose that insufficient RV contractility, myocardial fibrosis, capillary rarefaction, and a disturbed metabolism are important features of a failing right ventricle. Furthermore, an overview is provided about the potential direct RV effects of PH-targeted therapies and the effects of RV-directed medical treatments.
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Affiliation(s)
- Mariëlle C van de Veerdonk
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Harm J Bogaard
- Department of Pulmonary Diseases, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Norbert F Voelkel
- The Victoria Johnson Pulmonary Research Laboratory, Virginia Commonwealth University, 1220 East Broad Street, Richmond, VA, 23298, USA.
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Diller GP, Körten MA, Bauer UMM, Miera O, Tutarel O, Kaemmerer H, Berger F, Baumgartner H. Current therapy and outcome of Eisenmenger syndrome: data of the German National Register for congenital heart defects. Eur Heart J 2016; 37:1449-55. [PMID: 26843280 DOI: 10.1093/eurheartj/ehv743] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/15/2015] [Indexed: 01/25/2023] Open
Abstract
AIMS We aimed to assess the contemporary outcome of Eisenmenger syndrome (ES), delineate the use of disease targeting therapies (DTT) in these patients and to investigate the effect of treatment on outcome in the community. METHODS AND RESULTS Patients with ES were systematically identified from the German National Register for Congenital Heart Defects. Data on underlying diagnosis, medical therapy, and survival were collected. The impact of DTT on survival was assessed using time-dependant Cox analysis. Overall, 153 ES patients were included (mean age 34.0 ± 13.3 years, 46% females). Of these, 88 (57.5%) were treated with at least one DTT (76.1% Bosentan, 20.5% Sildenafil) while 17.6% were on dual DTT. In addition, 24.8% of patients received digoxin, 10.5% angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and 17.6% β-blockers. Moreover, 17.6% of patients were treated with oral anticoagulants, while 23.5% of patients received Aspirin. The survival rate at 1, 5, and 10 years of follow-up was only 92, 75, and 57% in the entire cohort, and was even worse in treatment naive ES patients (survival rate 86, 60, and 34% at 1, 5, and 10 years). Use of DTT was independently associated with a better survival (hazard ratio 0.42, P= 0.015). CONCLUSION This study illustrates the alarmingly poor survival prospects of Eisenmenger patients by community-based data even in the current era with advanced DTT and in a country with a wealthy health system. Treatment naive ES patients had especially high mortality rates approaching 60-70% at 10 years of follow-up. Treatment with DTT was associated with better survival.
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Affiliation(s)
- Gerhard-Paul Diller
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Str. 33, Muenster 48149, Germany Competence Network for Congenital Heart Defects, Germany
| | | | - Ulrike M M Bauer
- Competence Network for Congenital Heart Defects, Germany National Register for Congenital Heart Defects, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Oktay Tutarel
- Competence Network for Congenital Heart Defects, Germany Department of Cardiology & Angiology, Hannover Medical School, Hannover, Germany
| | - Harald Kaemmerer
- Competence Network for Congenital Heart Defects, Germany Department of Pediatric Cardiology and Congenital Heart Disease, The German Heart Centre, Technical University Munich, Munich, Germany
| | - Felix Berger
- Competence Network for Congenital Heart Defects, Germany Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Str. 33, Muenster 48149, Germany Competence Network for Congenital Heart Defects, Germany
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Malenfant S, Perros F. β-blockers in pulmonary arterial hypertension: generation might matter. Eur Respir J 2016; 47:682-4. [DOI: 10.1183/13993003.01244-2015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
PURPOSE OF REVIEW Right ventricular failure (RVF) is associated with significant morbidity and mortality. There is an increasing interest in proper assessment of right ventricle (RV) function as well as understanding mechanisms behind RVF. RECENT FINDINGS Within this article, we discuss the metabolic changes that occur in the RV in response to RVF, in particular, a shift toward glycolysis and increased glutaminolysis. We will detail the advances made in noninvasive imaging in assessing the function of the RV and review the methods to assess right ventricle-pulmonary artery coupling. We lastly investigate the role of new treatment options in the failing RV, such as β-blocker therapy. SUMMARY RVF is a complicated entity. Although some inferences on RV function and treatment can be made from our understanding of the left ventricle, the RV has unique features, anatomically, metabolically and embryologically, that require dedicated RV-directed research.
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Sardana M, Moll M, Farber HW. Novel investigational therapies for treating pulmonary arterial hypertension. Expert Opin Investig Drugs 2015; 24:1571-96. [DOI: 10.1517/13543784.2015.1098616] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Hipertensión pulmonar y cirrosis hepática. Rev Clin Esp 2015; 215:324-30. [DOI: 10.1016/j.rce.2015.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/14/2015] [Accepted: 02/23/2015] [Indexed: 02/07/2023]
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Pulmonary hypertension and hepatic cirrhosis. Rev Clin Esp 2015. [DOI: 10.1016/j.rceng.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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