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Simpson CE. The evolving epidemiology of systemic sclerosis-associated pulmonary hypertension. J Heart Lung Transplant 2024; 43:1640-1641. [PMID: 39260922 DOI: 10.1016/j.healun.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 06/22/2024] [Indexed: 09/13/2024] Open
Affiliation(s)
- Catherine E Simpson
- Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, Maryland.
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2
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Chin KM, Gaine SP, Gerges C, Jing ZC, Mathai SC, Tamura Y, McLaughlin VV, Sitbon O. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J 2024:2401325. [PMID: 39209476 DOI: 10.1183/13993003.01325-2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
Pulmonary arterial hypertension leads to significant impairment in haemodynamics, right heart function, exercise capacity, quality of life and survival. Current therapies have mechanisms of action involving signalling via one of four pathways: endothelin-1, nitric oxide, prostacyclin and bone morphogenetic protein/activin signalling. Efficacy has generally been greater with therapeutic combinations and with parenteral therapy compared with monotherapy or nonparenteral therapies, and maximal medical therapy is now four-drug therapy. Lung transplantation remains an option for selected patients with an inadequate response to therapies.
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Affiliation(s)
- Kelly M Chin
- Division of Pulmonary and Critical Care Medicine, UT Southwestern, Dallas, TX, USA
| | - Sean P Gaine
- Department of Respiratory Medicine, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Olivier Sitbon
- Department of Respiratory Medicine, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
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3
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Mathai SC. Pulmonary Hypertension Associated with Connective Tissue Disease. Rheum Dis Clin North Am 2024; 50:359-379. [PMID: 38942575 DOI: 10.1016/j.rdc.2024.03.005] [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] [Indexed: 06/30/2024]
Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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4
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Gaine S, Escribano‐Subias P, Muller A, Fernandes CC, Fontana M, Remenova T, Söderberg S, Lange TJ. Selexipag in patients with pulmonary arterial hypertension associated with connective tissue disease (PAH-CTD): Real-world experience from EXPOSURE. Pulm Circ 2024; 14:e12403. [PMID: 39076250 PMCID: PMC11284239 DOI: 10.1002/pul2.12403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/03/2024] [Accepted: 06/11/2024] [Indexed: 07/31/2024] Open
Abstract
Selexipag is indicated for the treatment of pulmonary arterial hypertension (PAH), including PAH associated with connective tissue disease (CTD), and further insights into the management of selexipag-treated PAH-CTD patients in clinical settings are needed. These analyses of the ongoing, multicenter, prospective EXPOSURE (EUPAS19085) study describe characteristics, treatment patterns, tolerability, and outcomes of PAH-CTD patients initiating selexipag in Europe/Canada. All analyses were descriptive, with idiopathic PAH patients who typically display better prognosis included for context. Six hundred ninety-eight selexipag-treated patients had follow-up information; 178 (26%) had PAH-CTD. The median age was 68 years, patients were predominantly female (88%), and with WHO functional class III symptoms (63%); the median time since diagnosis was 1.7 years. There were 5% patients at low, 25% intermediate-low, 40% intermediate-high, and 30% high risk of 1-year mortality, according to the ESC/ERS 4-strata risk score. Most (80%) initiated selexipag as a triple oral therapy, and most of these (62%) remained on triple therapy 6 months post-baseline. Over a median (Q1-Q3) selexipag exposure period of 8.6 (2.5-17.2) months, 79 (44%) patients discontinued selexipag; 36 (20%) due to tolerability/adverse events. Sixty (34%) patients were hospitalized at least once; 120 hospitalizations occurred, with 49 (48%) deemed PAH-related. Survival at 1 year was 85%, and at 2 years was 71%; 29 (16%) patients died. These results describe the use of combination therapy with selexipag for patients with PAH-CTD. These findings suggest an opportunity to optimize the benefits of selexipag among patients with PAH-CTD by moving from escalating after years in response to clinical deterioration to escalating sooner to prevent clinical deterioration.
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Affiliation(s)
- Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University HospitalDublinIreland
| | - Pilar Escribano‐Subias
- Pulmonary Hypertension Unit, Cardiology DepartmentCIBERCV, Hospital 12 de OctubreMadridSpain
| | - Audrey Muller
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global EpidemiologyAllschwilSwitzerland
| | - Catarina C. Fernandes
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Medical AffairsAllschwilSwitzerland
| | - Martina Fontana
- Janssen‐Cilag S.p.A, a Johnson & Johnson Company, Statistics and Decision SciencesMilanItaly
| | - Tatiana Remenova
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Medical SafetyAllschwilSwitzerland
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Cardiology and Heart CentreUmeå UniversityUmeåSweden
| | - Tobias J. Lange
- Department of PulmonologyKreisklinik Bad ReichenhallBad ReichenhallGermany
- Department Internal Medicine II, Faculty of MedicineRegensburg UniversityRegensburgGermany
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5
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Coursen JC, Tuhy T, Naranjo M, Woods A, Hummers LK, Shah AA, Suresh K, Visovatti SH, Mathai SC, Hassoun PM, Damico RL, Simpson CE. Aberrant long-chain fatty acid metabolism associated with evolving systemic sclerosis-associated pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2024; 327:L54-L64. [PMID: 38651694 PMCID: PMC11380974 DOI: 10.1152/ajplung.00057.2024] [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: 02/16/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
We sought to investigate differential metabolism in patients with systemic sclerosis (SSc) who develop pulmonary arterial hypertension (PAH) versus those who do not, as a method of identifying potential disease biomarkers. In a nested case-control design, serum metabolites were assayed in SSc subjects who developed right heart catheterization-confirmed PAH (n = 22) while under surveillance in a longitudinal cohort from Johns Hopkins, then compared with metabolites assayed in matched SSc patients who did not develop PAH (n = 22). Serum samples were collected at "proximate" (within 12 months) and "distant" (within 1-5 yr) time points relative to PAH diagnosis. Metabolites were identified using liquid chromatography-mass spectroscopy (LC-MS). An LC-MS dataset from SSc subjects with either mildly elevated pulmonary pressures or overt PAH from the University of Michigan was compared. Differentially abundant metabolites were tested as predictors of PAH in two additional validation SSc cohorts. Long-chain fatty acid metabolism (LCFA) consistently differed in SSc-PAH versus SSc without PH. LCFA metabolites discriminated SSc-PAH patients with mildly elevated pressures in the Michigan cohort and predicted SSc-PAH up to 2 yr before clinical diagnosis in the Hopkins cohort. Acylcholines containing LCFA residues and linoleic acid metabolites were most important for discriminating SSc-PAH. Combinations of acylcholines and linoleic acid metabolites provided good discrimination of SSc-PAH across cohorts. Aberrant lipid metabolism is observed throughout the evolution of PAH in SSc. Lipidomic signatures of abnormal LCFA metabolism distinguish SSc-PAH patients from those without PH, including before clinical diagnosis and in mild disease.NEW & NOTEWORTHY Abnormal lipid metabolism is evident across time in the development of SSc-PAH, and dysregulated long-chain fatty acid metabolism predicts overt PAH.
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Affiliation(s)
- Julie C Coursen
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Tijana Tuhy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Mario Naranjo
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pennsylvania, United States
| | - Adrianne Woods
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Laura K Hummers
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Karthik Suresh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Scott H Visovatti
- Division of Cardiology, Department of Medicine, The Ohio State University, Columbus, Ohio, United States
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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Budhram B, Weatherald J, Humbert M. Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:419-434. [PMID: 38499196 DOI: 10.1055/s-0044-1782217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.
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Affiliation(s)
- Brandon Budhram
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, European Reference Network for Rare Respiratory Diseases (ERN-LUNG), Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Le Kremlin-Bicêtre, France
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7
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Channick R, Chin KM, McLaughlin VV, Lammi MR, Zamanian RT, Turricchia S, Ong R, Mitchell L, Kim NH. Macitentan in Pulmonary Arterial Hypertension Associated with Connective Tissue Disease (CTD-PAH): Real-World Evidence from the Combined OPUS/OrPHeUS Dataset. Cardiol Ther 2024; 13:315-339. [PMID: 38451426 PMCID: PMC11093922 DOI: 10.1007/s40119-024-00361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/14/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Data on real-world clinical practice and outcomes of patients with pulmonary arterial hypertension associated with connective tissue disease (CTD-PAH) are scarce. The OPUS/OrPHeUS studies enrolled patients newly initiating macitentan, including those with CTD-PAH. This analysis describes patient characteristics, treatment patterns, outcomes, and safety profiles of patients with CTD-PAH newly initiating macitentan in the US using the OPUS/OrPHeUS combined dataset. METHODS OPUS was a prospective, US, multicenter, long-term, observational drug registry (April 2014-June 2020). OrPHeUS was a retrospective, US, multicenter medical chart review (October 2013-March 2017). The characteristics, treatment patterns, safety, and outcomes during macitentan treatment of patients with CTD-PAH and its subgroups systemic sclerosis (SSc-PAH), systemic lupus erythematosus (SLE-PAH), and mixed CTD (MCTD-PAH) were descriptively compared to patients with idiopathic/heritable PAH (I/HPAH). RESULTS The combined OPUS/OrPHeUS population included 2498 patients with I/HPAH and 1192 patients with CTD-PAH (708 SSc-PAH; 159 SLE-PAH; 124 MCTD-PAH, and 201 other CTD-PAH etiologies). At macitentan initiation for patients with I/HPAH and CTD-PAH, respectively: 61.2 and 69.3% were in World Health Organization functional class (WHO FC) III/IV; median 6-min walk distance was 289 and 279 m; and 58.1 and 65.2% received macitentan as combination therapy. During follow-up, for patients with I/HPAH and CTD-PAH, respectively: median duration of macitentan exposure observed was 14.0 and 15.8 months; 79.0 and 83.0% experienced an adverse event; Kaplan-Meier estimates (95% confidence limits [CL]) of patients free from all-cause hospitalization at 1 year were 60.3% (58.1, 62.4) and 59.3% (56.1, 62.3); and Kaplan-Meier estimates (95% CL) of survival at 1 year were 90.5% (89.1, 91.7) and 90.6% (88.6, 92.3). CONCLUSIONS Macitentan was used in clinical practice in patients with CTD-PAH and its subgroups, including as combination therapy. The safety and tolerability profile of macitentan in patients with CTD-PAH was comparable to that of patients with I/HPAH. TRIAL REGISTRATION OPsumit® Users Registry (OPUS): NCT02126943; Opsumit® Historical Users cohort (OrPHeUS): NCT03197688; www. CLINICALTRIALS gov Graphical abstract available for this article.
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Affiliation(s)
- Richard Channick
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, 37-131 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | | | | | | | | | - Stefano Turricchia
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Medical Affairs, Allschwil, Switzerland
| | - Rose Ong
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Epidemiology, Allschwil, Switzerland
| | - Lada Mitchell
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Statistics & Decision Sciences-Medical Affairs and Established Products, Allschwil, Switzerland
| | - Nick H Kim
- University of California, San Diego, La Jolla, CA, USA
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8
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Gigante A, Papa S, Rosato E, Badagliacca R, Marra AM. When pulmonary arterial hypertension complicates connective tissue diseases: we still have not found what we are looking for. Intern Emerg Med 2024; 19:883-884. [PMID: 38637488 DOI: 10.1007/s11739-024-03598-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.
| | - Silvia Papa
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alberto Maria Marra
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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9
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Stącel T, Sybila P, Mędrala A, Ochman M, Nęcki M, Pasek P, Kegler K, Przybyłowski P, Hrapkowicz T, Borowik D, Urlik M. Lung Transplantation in Patients With Systemic Scleroderma-Description of the First Consecutive Cases in Poland: Case Series Report and a Short Literature Review. Transplant Proc 2024; 56:868-876. [PMID: 38702265 DOI: 10.1016/j.transproceed.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
Pulmonary complications of systemic scleroderma (SSc), such as interstitial lung disease and pulmonary hypertension (PH), are responsible for up to 60% of deaths among patients. For many years, most centers considered SSc a contraindication to lung transplantation (LTx); however, recent publications show that appropriately selected SSc candidates for LTx give results comparable to patients with idiopathic PH or idiopathic pulmonary fibrosis. This paper presents the cases of a 60-year-old male patient (patient 1) and a 42-year-old female patient (patient 2) diagnosed with SSc in 2019 and 2013, respectively. In both patients, interstitial-fibrotic changes in the lungs leading to respiratory failure were confirmed by high-resolution computed tomography as well as pulmonary hypertension (WHO group 3), which was also diagnosed during right heart catheterization. In both cases, despite pharmacotherapy, pulmonary fibrosis progressed, leading to severe respiratory failure. The patients were referred for LTx qualification. LTx was possible to consider in patients due to the lack of significant changes in other internal organs. Double LTx was successfully performed in both patients (patient 1-July 19, 2022; patient 2-September 14, 2022). They were discharged from the hospital in good condition on the 22nd and 20th postoperative day, respectively. LTx is a last-chance therapy that saves lives among patients with extreme respiratory failure in the course of SSc. It prolongs and improves the quality of life. The selection of appropriate patients is key to the success of the procedure.
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Affiliation(s)
- Tomasz Stącel
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Paweł Sybila
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland.
| | - Agata Mędrala
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Mirosław Nęcki
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Pasek
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Kamil Kegler
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Hrapkowicz
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Dawid Borowik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac Anaesthesia and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Urlik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
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10
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Nikitin D, Lin GA, Whittington MD, Nhan E, Kayali Y, Rind DM, Pearson SD, Agboola F. The effectiveness and value of sotatercept for pulmonary arterial hypertension: A summary from the Institute for Clinical and Economic Review's Midwest Comparative Effectiveness Public Advisory Council. J Manag Care Spec Pharm 2024; 30:491-495. [PMID: 38701024 PMCID: PMC11068652 DOI: 10.18553/jmcp.2024.30.5.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Affiliation(s)
| | - Grace A. Lin
- Institute for Clinical and Economic Review, Boston, MA
| | - Melanie D. Whittington
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | - Emily Nhan
- Institute for Clinical and Economic Review, Boston, MA
| | | | - David M. Rind
- Institute for Clinical and Economic Review, Boston, MA
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11
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Erdogan M, Esatoglu SN, Kilickiran Avci B, Hatemi G. Treatment of pulmonary arterial hypertension in patients with connective tissue diseases: a systematic review and meta-analysis. Intern Emerg Med 2024; 19:731-743. [PMID: 38378970 PMCID: PMC11039558 DOI: 10.1007/s11739-024-03539-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/11/2024] [Indexed: 02/22/2024]
Abstract
The evidence for the treatment of connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) mostly depends on subgroup or post hoc analysis of randomized controlled trials (RCTs). Thus, we performed a meta-analysis of RCTs that reported outcomes for CTD-PAH. PubMed and EMBASE were searched for CTD-PAH treatment. The selected outcomes were functional class (FC) change, survival rates, 6-min walk distance (6-MWD), clinical worsening (CW), N-terminal prohormone BNP (NT-proBNP), pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (mPAP), right atrial pressure (RAP), and cardiac index (CI). The meta-analysis was conducted according to the PRISMA guidelines and registered in PROSPERO (CRD42020153560). Twelve RCTs conducted with 1837 patients were included. The diagnoses were systemic sclerosis in 59%, SLE in 20%, and other CTDs in 21%. The pharmacological interventions were epoprostenol, treprostinil, sildenafil, tadalafil, bosentan, macitentan, ambrisentan, riociguat, and selexipag. There was a significant difference between interventions and placebo in FC, 6MWD, CW, PVR, RAP, and CI that favored intervention. Our analysis showed a 39% reduction in the CW risk with PAH treatment. The short-term survival rates and mean serum NT-proBNP changes were similar between the study and control groups. Treatment for CTD-PAH had favorable effects on clinical and hemodynamic outcomes but not on survival and NT-proBNP levels. Different from the previous meta-analyses that focused on 6-MWD, time to clinical worsening, and CW as outcomes, this meta-analysis additionally reports the pooled analysis of change in FC, hemodynamic measurements (RAP, PVR, CI), and NT-proBNP, some of which have prognostic value for PAH.
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Affiliation(s)
- Mustafa Erdogan
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical School, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical School, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Burcak Kilickiran Avci
- Department of Cardiology, Cerrahpaşa Medical School, Istanbul University-Cerrahpaşa, Cerrahpaşa Campus, Kocamustafapaşa Cad. No: 34/E, Fatih, 34998, Istanbul, Turkey.
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical School, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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12
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Favoino E, Prete M, Liakouli V, Leone P, Sisto A, Navarini L, Vomero M, Ciccia F, Ruscitti P, Racanelli V, Giacomelli R, Perosa F. Idiopathic and connective tissue disease-associated pulmonary arterial hypertension (PAH): Similarities, differences and the role of autoimmunity. Autoimmun Rev 2024; 23:103514. [PMID: 38181859 DOI: 10.1016/j.autrev.2024.103514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024]
Abstract
Pre-capillary pulmonary arterial hypertension (PAH) is hemodynamically characterized by a mean pulmonary arterial pressure (mPAP) ≥ 20 mmHg, pulmonary capillary wedge pressure (PAWP) ≤15 mmHg and pulmonary vascular resistance (PVR) > 2. PAH is classified in six clinical subgroups, including idiopathic PAH (IPAH) and PAH associated to connective tissue diseases (CTD-PAH), that will be the main object of this review. The aim is to compare these two PAH subgroups in terms of epidemiology, histological and pathogenic findings in an attempt to define disease-specific features, including autoimmunity, that may explain the heterogeneity of response to therapy between IPAH and CTD-PAH.
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Affiliation(s)
- Elvira Favoino
- Laboratory of Cellular and Molecular Immunology, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy.
| | - Marcella Prete
- Internal Medicine Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Vasiliki Liakouli
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Patrizia Leone
- Internal Medicine Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Adriana Sisto
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy
| | - Luca Navarini
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Marta Vomero
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Francesco Ciccia
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Vito Racanelli
- Centre for Medical Sciences, University of Trento and Internal Medicine Division, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy
| | - Roberto Giacomelli
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy; Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Federico Perosa
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Interdisciplinary Medicine, University of Bari Medical School, Bari, Italy.
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Shi H, Gao P, Liu H, Su J, He X. Diagnostic value of combined FVC%/DLCO% and echocardiography in connective tissue disorder‑associated pulmonary hypertension. MEDICINE INTERNATIONAL 2024; 4:8. [PMID: 38283134 PMCID: PMC10811443 DOI: 10.3892/mi.2024.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024]
Abstract
The main objective of the present study was to investigate whether forced vital capacity (FVC)%/diffusing capacity of the lungs for carbon monoxide (DLCO)% can be used to predict the presence of pulmonary hypertension (PH) in connective tissue disorders (CTDs). For this purpose, a total of 53 individuals who were diagnosed with CTDs and had undergone right heart catheterization between July, 2019 and July, 2022 were included in the present study. Based on the mean pulmonary artery pressure (mPAP) measured during right heart catheterization, the participants were divided into the PH and non-PH groups. The differences in demographic characteristics, including sex, age, body mass index, smoking index, FVC%/DLCO% and pulmonary artery systolic pressure (PASP) were determined by echocardiography; moreover, the 6-min walk distance, plasma brain natriuretic peptide (BNP) levels, white blood cell count, red blood cell distribution width, erythrocyte sedimentation rate and C-reactive protein levels were compared between the two groups to identify independent predictors of PH. The independent predictors were subsequently evaluated for their correlation with mPAP to assess their predictive value for PH. FVC%/DLCO%, echocardiographic PASP, and plasma BNP levels were identified as independent predictors of PH. FVC%/DLCO% and echocardiographic PASP exhibited a significant correlation with mPAP, while the correlation between plasma BNP and mPAP levels was not statistically significant. The area under the curve (AUC) value for FVC%/DLCO% alone in predicting PH was 0.791, with an optimal diagnostic threshold of 1.35, a sensitivity of 0.794 and a specificity of 0.789. The AUC for echocardiographic PASP alone in predicting PH was 0.783, with an optimal diagnostic threshold of 39.5 mmHg, a sensitivity of 0.794 and a specificity of 0.684. When combined, the AUC of the two factors in predicting PH was 0.872, with a sensitivity of 0.941 and a specificity of 0.684. Collectively, the data of the present study indicate that FVC%/DLCO% may be used as a predictive factor for CTD-PH, and its combined application with echocardiographic PASP measurement may provide additional evidence for the clinical diagnosis of CTD-PH.
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Affiliation(s)
- Huimin Shi
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Pengfei Gao
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Huijin Liu
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Jie Su
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Xuegai He
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
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Xiong J, Peng Y, Li J, Cai S, Wu R. Total iron binding capacity: an independent predictor of prognosis for pulmonary arterial hypertension in systemic lupus erythematosus. Scand J Rheumatol 2024; 53:44-48. [PMID: 37605880 DOI: 10.1080/03009742.2023.2240586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/21/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE To investigate the role of parameters of iron metabolism in systemic lupus erythematosus (SLE) patients with pulmonary arterial hypertension (PAH). METHOD This was a prospective observational study recruiting patients diagnosed with systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH). Patients with other factors that might lead to PAH were excluded from the study. All patients were assessed for PAH every 1-3 months and were followed up for 6 months. The primary outcome was considered improved if the grade of risk stratification declined at the endpoint; otherwise, it was considered unimproved. RESULTS In total, 29 patients with SLE-PAH were included in this study. The mean of serum ferritin was higher than normal, and total iron binding capacity (TIBC) decreased in 48% of patients. Correlation analyses showed that serum iron (SI) was negatively correlated with World Health Organization functional class (WHO-FC) (r = -0.409, p = 0.028), and positively correlated with Six-Minute Walk Test distance (6MWD) (r = 0.427, p = 0.021) and tricuspid annular plane systolic excursion (TAPSE) (r = 0.388, p = 0.037). Primary outcomes improved in 12 patients at the endpoint, and univariate logistic regression analyses indicated that TIBC was associated with improved primary outcomes in patients with SLE-PAH (odds ratio 12.00, 95% confidence interval 1.90-75.72). CONCLUSION SI was negatively correlated with WHO-FC, and positively correlated with 6MWD and TAPSE. Furthermore, TIBC was associated with improved outcomes of patients with SLE-PAH, which could be an independent predictor of prognosis. Further research is needed to verify the findings.
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Affiliation(s)
- J Xiong
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Y Peng
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - J Li
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - S Cai
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - R Wu
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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15
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Simpson CE, Hemnes AR, Griffiths M, Grunig G, Wilson Tang W, Garcia JGN, Barnard J, Comhair SA, Damico RL, Mathai SC, Hassoun PM. Metabolomic Differences in Connective Tissue Disease-Associated Versus Idiopathic Pulmonary Arterial Hypertension in the PVDOMICS Cohort. Arthritis Rheumatol 2023; 75:2240-2251. [PMID: 37335853 PMCID: PMC10728345 DOI: 10.1002/art.42632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) experience worse survival and derive less benefit from pulmonary vasodilator therapies than patients with idiopathic PAH (IPAH). We sought to identify differential metabolism in patients with CTD-PAH versus patients with IPAH that might underlie these observed clinical differences. METHODS Adult participants with CTD-PAH (n = 141) and IPAH (n = 165) from the Pulmonary Vascular Disease Phenomics (PVDOMICS) study were included. Detailed clinical phenotyping was performed at cohort enrollment, including broad-based global metabolomic profiling of plasma samples. Participants were followed prospectively for ascertainment of outcomes. Supervised and unsupervised machine learning algorithms and regression models were used to compare CTD-PAH versus IPAH metabolomic profiles and to measure metabolite-phenotype associations and interactions. Gradients across the pulmonary circulation were assessed using paired mixed venous and wedged samples in a subset of 115 participants. RESULTS Metabolomic profiles distinguished CTD-PAH from IPAH, with patients with CTD-PAH demonstrating aberrant lipid metabolism with lower circulating levels of sex steroid hormones and higher free fatty acids (FAs) and FA intermediates. Acylcholines were taken up by the right ventricular-pulmonary vascular (RV-PV) circulation, particularly in CTD-PAH, while free FAs and acylcarnitines were released. In both PAH subtypes, dysregulated lipid metabolites, among others, were associated with hemodynamic and RV measurements and with transplant-free survival. CONCLUSIONS CTD-PAH is characterized by aberrant lipid metabolism that may signal shifted metabolic substrate utilization. Abnormalities in RV-PV FA metabolism may imply a reduced capacity for mitochondrial beta oxidation within the diseased pulmonary circulation.
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Affiliation(s)
| | - Anna R. Hemnes
- Vanderbilt University Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Megan Griffiths
- University of Texas Southwestern Medical Center, Division of Pediatric Cardiology
| | - Gabriele Grunig
- Divisions of Environmental and Pulmonary Medicine, Department of Medicine, NYU Grossman School of Medicine
| | - W.H. Wilson Tang
- Cleveland Clinic Department of Cardiovascular Medicine, Section of Heart Failure and Transplant Medicine
| | - Joe G. N. Garcia
- University of Arizona College of Medicine – Tucson, Department of Medicine
| | | | | | - Rachel L. Damico
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
| | - Stephen C. Mathai
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
| | - Paul M. Hassoun
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
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16
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Miller E, Sampson CU, Desai AA, Karnes JH. Differential drug response in pulmonary arterial hypertension: The potential for precision medicine. Pulm Circ 2023; 13:e12304. [PMID: 37927610 PMCID: PMC10621006 DOI: 10.1002/pul2.12304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare, complex, and deadly cardiopulmonary disease. It is characterized by changes in endothelial cell function and smooth muscle cell proliferation in the pulmonary arteries, causing persistent vasoconstriction, resulting in right heart hypertrophy and failure. There are multiple drug classes specific to PAH treatment, but variation between patients may impact treatment response. A small subset of patients is responsive to pulmonary vasodilators and can be treated with calcium channel blockers, which would be deleterious if prescribed to a typical PAH patient. Little is known about the underlying cause of this important difference in vasoresponsive PAH patients. Sex, race/ethnicity, and pharmacogenomics may also factor into efficacy and safety of PAH-specific drugs. Research has indicated that endothelin receptor antagonists may be more effective in women and there have been some minor differences found in certain races and ethnicities, but these findings are muddled by the impact of socioeconomic factors and a lack of representation of non-White patients in clinical trials. Genetic variants in genes such as CYP3A5, CYP2C9, PTGIS, PTGIR, GNG2, CHST3, and CHST13 may influence the efficacy and safety of certain PAH-specific drugs. PAH research faces many challenges, but there is potential for new methodologies to glean new insights into PAH development and treatment.
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Affiliation(s)
- Elise Miller
- Department of Pharmacy Practice and ScienceUniversity of Arizona R. Ken Coit College of PharmacyTucsonArizonaUSA
| | - Chinwuwanuju Ugo‐Obi Sampson
- Department of Pharmacy Practice and ScienceUniversity of Arizona R. Ken Coit College of PharmacyTucsonArizonaUSA
| | - Ankit A. Desai
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jason H. Karnes
- Department of Pharmacy Practice and ScienceUniversity of Arizona R. Ken Coit College of PharmacyTucsonArizonaUSA
- Department of Biomedical InformaticsVanderbilt University School of MedicineNashvilleTennesseeUSA
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Marlin N, Godolphin PJ, Hooper RL, Riley RD, Rogozińska E. Nonlinear effects and effect modification at the participant-level in IPD meta-analysis part 2: methodological guidance is available. J Clin Epidemiol 2023; 159:319-329. [PMID: 37146657 DOI: 10.1016/j.jclinepi.2023.04.014] [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: 01/16/2023] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES To review methodological guidance for nonlinear covariate-outcome associations (NL), and linear effect modification and nonlinear effect modification (LEM and NLEM) at the participant level in individual participant data meta-analyses (IPDMAs) and their power requirements. STUDY DESIGN AND SETTING We searched Medline, Embase, Web of Science, Scopus, PsycINFO and the Cochrane Library to identify methodology publications on IPDMA of LEM, NL or NLEM (PROSPERO CRD42019126768). RESULTS Through screening 6,466 records we identified 54 potential articles of which 23 full texts were relevant. Nine further relevant publications were published before or after the literature search and were added. Of these 32 references, 21 articles considered LEM, 6 articles NL or NLEM and 6 articles described sample size calculations. A book described all four. Sample size may be calculated through simulation or closed form. Assessments of LEM or NLEM at the participant level need to be based on within-trial information alone. Nonlinearity (NL or NLEM) can be modeled using polynomials or splines to avoid categorization. CONCLUSION Detailed methodological guidance on IPDMA of effect modification at participant-level is available. However, methodology papers for sample size and nonlinearity are rarer and may not cover all scenarios. On these aspects, further guidance is needed.
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Affiliation(s)
- Nadine Marlin
- Methodology Research Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, UK.
| | - Peter J Godolphin
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Richard L Hooper
- Methodology Research Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, UK
| | - Richard D Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Ewelina Rogozińska
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
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Orihara Y, Asakura M, Min KD, Matsumoto Y, Sunayama I, Nishimura K, Eguchi A, Okuhara Y, Ishihara M. Mean pulmonary artery pressure estimated by echocardiogram rapidly exceeds 20 mmHg from the normal range in patients with connective tissue disease. Heart Vessels 2023:10.1007/s00380-023-02267-4. [PMID: 37074476 DOI: 10.1007/s00380-023-02267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
Earlier intervention for pulmonary hypertension (PH) has been reported to improve the prognosis of patients with connective tissue disease (CTD). However, it is not fully elucidated how rapidly PH develops in patients showing normal mean pulmonary arterial pressure (mPAP) at the index investigation. We evaluated 191 CTD patients with normal mPAP retrospectively. The mPAP was estimated by the formerly defined method employing echocardiography (mPAPecho). We investigated predictive factors that predict increasing mPAPecho at follow-up transthoracic echocardiography (TTE) using uni- and multi variable analysis. The mean age was 61.5 years old, and 160 patients were female. The percentage of patients in whom mPAPecho exceeded 20 mmHg at follow-up TTE was 38%. Multivariable analysis revealed that acceleration time/ejection time (AcT/ET) measured at the right ventricular outflow tract at initial TTE was independently associated with the consequent increase of mPAPecho at the follow-up TTE. When using 0.43 of best cutoff value in AcT/ET calculated by receiver operating characteristic analysis, the change in mPAPecho in patients with low AcT/ET was significantly higher than in those with high AcT/ET (3.05 mmHg in patients with AcT/ET < 0.43 and 1.00 mmHg in patients with AcT/ET ≥ 0.43, p < 0.001). Thirty-eight percent of CTD patients who show the normal estimated mPAP by TTE develop gradual elevation of mPAP to the level to consider early intervention within 2 years. AcT/ET at initial TTE can predict increasing mPAP at follow-up TTE.
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Affiliation(s)
- Yoshiyuki Orihara
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Kyung-Duk Min
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yuki Matsumoto
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Isamu Sunayama
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Koichi Nishimura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akiyo Eguchi
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshitaka Okuhara
- Department of Cardiology, Hakuhokai Central Hospital, Amagasaki, Hyogo, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Tsang Y, Singh R, Verma S, Panjabi S. Hospitalization Among Pulmonary Arterial Hypertension Patients With and Without Connective Tissue Disease Comorbidities Prescribed Oral Selexipag. Rheumatol Ther 2023; 10:741-756. [PMID: 36959524 PMCID: PMC10140235 DOI: 10.1007/s40744-023-00547-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/06/2023] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Patients with connective tissue disorders (CTD) and pulmonary arterial hypertension (PAH) have a poorer prognosis than those with other PAH etiologies. This study assessed the impact of CTD on healthcare outcomes among PAH patients with and without CTD comorbidities that were treated with oral selexipag. METHODS The study utilized Optum's de-identified Clinformatics® Data Mart Database (2007-2021) from January 1, 2014 to June 30, 2019, and identified patients with PAH without CTD and PAH with CTD treated with oral selexipag. Patients had ≥ 12-month baseline period with no requirement for a minimum follow-up period. Patients were followed until any of the following events: discontinuation of oral selexipag, or health plan disenrollment, or death, or presence of a diagnosis claim for CTEPH, or study end date, whichever occurred first. PAH-related hospitalizations, PAH disease progression, and healthcare utilizations and costs were assessed in the follow-up period. The Cox proportional hazards model was used to evaluate the time to hospitalization and generalized linear models were used to examine healthcare costs and utilization between the two cohorts. RESULTS In the analysis, 237 PAH without CTD, and 80 PAH patients with CTD comorbidities prescribed oral selexipag were included. The PAH without CTD comorbidities cohort was older (65 vs. 63 years old), had proportionately less females (72 vs. 83%), and higher comorbidity burden than PAH with CTD comorbidities (mean CCI index 3 vs. 2). After adjusting for potential confounders, the risk for PAH-related hospitalization (hazard ratio (HR) 1.13, p value 0.641), all-cause hospitalization (HR 1.09, p value: 0.765), and PAH disease progression (HR 1.14, p value 0.522) between the two cohorts were similar. After adjusting for baseline demographic and clinical characteristics, PAH with CTD comorbidities incurred higher total mean all-cause PAH-related medical care costs compared to PAH without CTD comorbidities. CONCLUSIONS In this real-world study, the risk of hospitalization and PAH disease progression were similar between the two cohorts who received oral selexipag. The results from this study corroborate findings of the GRIPHON post hoc analysis of PAH-associated CTD patients and support oral selexipag use in PAH-CTD patients.
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Affiliation(s)
- Yuen Tsang
- Janssen Scientific Affairs, Titusville, NJ, USA
| | - Risho Singh
- STATinMED, LLC, 13101 Preston Rd Suite 110, #3395, Dallas, TX, 75240, USA
| | - Sumit Verma
- STATinMED, LLC, 13101 Preston Rd Suite 110, #3395, Dallas, TX, 75240, USA.
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Zhu T, Wu P, Tan Z, Jin Q, Chen Y, Li L, Chen Z, Tang Y, Li J, Fang Z. Differences in right ventricular function and response to targeted therapy between patients with IPAH and PAH-CHD. Front Pharmacol 2023; 14:1124746. [PMID: 36860300 PMCID: PMC9968930 DOI: 10.3389/fphar.2023.1124746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
Background and aims: Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disorder characterized by elevated pulmonary vascular resistance (PVR) and pulmonary arterial pressure (PAP). Right heart failure is a life-threatening complication of PAH and predicts a poor prognosis. PAH associated with congenital heart disease (PAH-CHD) and idiopathic PAH (IPAH) are two prevalent PAH subtypes in China. In this section, we set out to explore baseline right ventricular (RV) function and its response to targeted agents between IPAH and PAH-CHD. Methods and results: Consecutive patients diagnosed with IPAH or PAH-CHD by right heart catheterization (RHC) in the Second Xiangya Hospital from November 2011 to June 2020 were included. All patients received PAH-targeted therapy and the RV function was assessed by echocardiography at baseline and during follow-up. A total of 303 patients (age, 36.23 ± 13.10 years; women, 213 (70.3%); mean PAP [mPAP], 63.54 ± 16.12 mmHg; PVR, 14.74 ± 7.61 WU) with IPAH (n = 121) or PAH-CHD (n = 182) were included in this study. Compared with PAH-CHD, patients with IPAH had worse baseline RV function. As of the latest follow-up, forty-nine patients with IPAH and six patients with PAH-CHD died. Kaplan-Meier analyses showed better survival in PAH-CHD versus IPAH. After PAH-targeted therapy, patients with IPAH had less improvement in 6 MWD, World Health Organization functional class, and RV functional parameters compared with patients with PAH-CHD. Conclusion: Compared with patients with PAH-CHD, patients with IPAH had worse baseline RV function, unfavourable prognosis, and inadequate response to targeted treatment.
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Affiliation(s)
- Tengteng Zhu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Panyun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhen Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Quan Jin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lian Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zewei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yirui Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Hirsch K, Nolley S, Ralph DD, Zheng Y, Altemeier WA, Rhodes CJ, Morrell NW, Wilkins MR, Leary PJ, Rayner SG. Circulating markers of inflammation and angiogenesis and clinical outcomes across subtypes of pulmonary arterial hypertension. J Heart Lung Transplant 2023; 42:173-182. [PMID: 36470771 PMCID: PMC9840657 DOI: 10.1016/j.healun.2022.10.026] [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: 05/01/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Subtypes of pulmonary arterial hypertension (PAH) differ in both fundamental disease features and clinical outcomes. Angiogenesis and inflammation represent disease features that may differ across subtypes and are of special interest in connective tissue disease-associated PAH (CTD-PAH). We compared inflammatory and angiogenic biomarker profiles across different etiologies of PAH and related them to clinical outcomes. METHODS Participants with idiopathic PAH, CTD-PAH, toxin-associated PAH (tox-PAH), or congenital heart disease-associated PAH (CHD-PAH) were enrolled into a prospective observational cohort. Baseline serum concentrations of 33 biomarkers were related to 3-year mortality, echocardiogram, REVEAL score, and 6-minute walk distance (6MWD). Findings were validated using plasma proteomic data from the UK PAH Cohort Study. RESULTS One hundred twelve patients were enrolled: 45 idiopathic, 27 CTD-PAH, 20 tox-PAH, and 20 CHD-PAH. Angiogenic and inflammatory biomarkers were distinctly elevated within the CTD-PAH cohort. Six biomarkers were associated with mortality within the entire PAH cohort: interleukin-6 (IL-6, HR:1.6, 95% CI:1.18-2.18), soluble fms-like tyrosine kinase 1 (sFlt-1, HR:1.35, 95% CI:1.02-1.80), placental growth factor (PlGF, HR:1.55, 95% CI:1.07-2.25), interferon gamma-induced protein 10 (IP-10, HR:1.44, 95% CI:1.04-1.99), tumor necrosis factor-beta (TNF-β, HR:1.81, 95% CI:1.11-2.95), and NT-proBNP (HR:2.19, 95% CI:1.52-3.14). Only IL-6 and NT-proBNP remained significant after controlling for multiple comparisons. IL-6, IP-10, and sFlt-1 significantly associated with mortality in CTD-PAH, but not non-CTD-PAH subgroups. In the UK cohort, IP-10, PlGF, TNF-β, and NT-proBNP significantly associated with 5-year survival. CONCLUSION Levels of angiogenic and inflammatory biomarkers are elevated in CTD-PAH, compared with other etiologies of PAH, and may correlate with clinical outcomes including mortality.
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Affiliation(s)
- Kellen Hirsch
- Department of Medicine, University of Washington, Seattle, Washington
| | - Stephanie Nolley
- Department of Medicine, University of Washington, Seattle, Washington
| | - David D Ralph
- Department of Medicine, University of Washington, Seattle, Washington
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, Washington
| | - William A Altemeier
- Department of Medicine, University of Washington, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington
| | - Christopher J Rhodes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Peter J Leary
- Department of Medicine, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Samuel G Rayner
- Department of Medicine, University of Washington, Seattle, Washington; Department of Bioengineering, University of Washington, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington.
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22
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The Role of Pulmonary Function Test for Pulmonary Arterial Hypertension in Patients with Connective Tissue Disease. DISEASE MARKERS 2022; 2022:6066291. [PMID: 36212174 PMCID: PMC9536996 DOI: 10.1155/2022/6066291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 12/02/2022]
Abstract
Objective: The study aimed to investigate the value of pulmonary function test (PFT) in evaluating and predicting pulmonary arterial hypertension (PAH) in patients with connective tissue disease (CTD). Methods: This was a prospective observational study recruiting patients diagnosed with CTD-PAH. Patients with interstitial lung disease and pulmonary hypertension induced by other causes were not eligible for enrollment. All patients were assessed for PAH every 1–3 months. A patient was considered to have clinical improvement if the grade of risk stratification declined or at least two parameters improved during follow-up, otherwise no improvement. Results: A total of 31 patients with CTD-PAH were recruited in this study. Nearly 70% of patients had declined forced vital capacity (FVC), 60% had declined total lung capacity and maximum expiratory flow at 50% of vital capacity, and 95% had normal or mild decline in forced expiratory volume in 1 second (FEV1)/FVC. A decline in diffusing capacity of the lung for carbon monoxide (DLCO) was present in 96% of patients, and 60% were moderate to severe. Furthermore, 50% of patients had an FVC/DLCO ratio of less than 1.4. Univariate analysis showed that FEV1/FVC, DLCO, and FVC/DLCO were associated with disease prognosis. After adjusting for age as a confounding factor, multivariate logistic regression analysis revealed that DLCO was an independent predictive factor for the prognosis of CTD-PAH. Conclusion: The pulmonary function of patients with CTD-PAH is abnormal in parameters such as lung volume, small airway, and gas exchange. PFT can reveal complex pathophysiological changes in the lungs of CTD-PAH patients and predict prognosis.
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23
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Frech TM, Austin ED. Is It Still "Idiopathic"? Features of Autoimmunity in Idiopathic Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2022; 206:8-10. [PMID: 35442875 PMCID: PMC9954332 DOI: 10.1164/rccm.202202-0413ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tracy M. Frech
- Department of MedicineVanderbilt University Medical CenterNashville, Tennessee
| | - Eric D. Austin
- Department of PediatricsVanderbilt University Medical CenterNashville, Tennessee
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24
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Prognostic Significance of Small Pulmonary Vessel Alteration Measured by Chest Computed Tomography in Connective Tissue Diseases With Pulmonary Arterial Hypertension. J Thorac Imaging 2022; 37:336-343. [DOI: 10.1097/rti.0000000000000643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Ruaro B, Salton F, Baratella E, Confalonieri P, Geri P, Pozzan R, Torregiani C, Bulla R, Confalonieri M, Matucci-Cerinic M, Hughes M. An Overview of Different Techniques for Improving the Treatment of Pulmonary Hypertension Secondary in Systemic Sclerosis Patients. Diagnostics (Basel) 2022; 12:616. [PMID: 35328169 PMCID: PMC8947575 DOI: 10.3390/diagnostics12030616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
In systemic sclerosis (SSc) mortality is mainly linked to lung involvement which is characterized by interstitial lung disease (ILD) and pulmonary hypertension (PH). In SSc, PH may be due to different etiologies, including ILD, chronic thromboembolic disease, pulmonary veno-occlusive disease, and pulmonary arterial hypertension (PAH). The main tool to screen PAH is transthoracic echocardiography (TTE), which has a sensitivity of 90%, even if definitive diagnosis should be confirmed by right heart catheterization (RHC). The radiological evaluation (i.e., HRTC) plays an important role in defining the possible causes and in monitoring the evolution of lung damage. For PAH, identifying individuals who have borderline elevation of pulmonary arterial pressure needs to be appropriately managed and followed. In the past few years, the strategy for the management of PAH has significantly evolved and new trials are underway to test other therapies. This review provides an overview of the tools to evaluate PAH in SSc patients and on treatment options for these patients.
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Affiliation(s)
- Barbara Ruaro
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Francesco Salton
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Elisa Baratella
- Department of Radiology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy;
| | - Paola Confalonieri
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Pietro Geri
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Riccardo Pozzan
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Chiara Torregiani
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Roberta Bulla
- Department of Life Sciences, University of Trieste, 34149 Trieste, Italy;
| | - Marco Confalonieri
- Department of Pulmonology, Cattinara Hospital, University of Trieste, 34149 Trieste, Italy; (F.S.); (P.C.); (P.G.); (R.P.); (C.T.); (M.C.)
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, 50139 Florence, Italy;
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Michael Hughes
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-Under-Lyne OL6 9RW, UK;
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester M1 1AA, UK
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26
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:3989-3996. [DOI: 10.1093/rheumatology/keac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/27/2021] [Indexed: 11/14/2022] Open
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27
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Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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28
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Haque A, Kiely DG, Kovacs G, Thompson AAR, Condliffe R. Pulmonary hypertension phenotypes in patients with systemic sclerosis. Eur Respir Rev 2021; 30:30/161/210053. [PMID: 34407977 DOI: 10.1183/16000617.0053-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/04/2021] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension (PH) commonly affects patients with systemic sclerosis (SSc) and is associated with significant morbidity and increased mortality. PH is a heterogenous condition and several different forms can be associated with SSc, including pulmonary arterial hypertension (PAH) resulting from a pulmonary arterial vasculopathy, PH due to left heart disease and PH due to interstitial lung disease. The incidence of pulmonary veno-occlusive disease is also increased. Accurate and early diagnosis to allow optimal treatment is, therefore, essential. Recent changes to diagnostic haemodynamic criteria at the 6th World Symposium on Pulmonary Hypertension have resulted in therapeutic uncertainty regarding patients with borderline pulmonary haemodynamics. Furthermore, the optimal pulmonary vascular resistance threshold for diagnosing PAH and the role of exercise in identifying early disease require further elucidation. In this article we review the epidemiology, diagnosis, outcomes and treatment of the spectrum of pulmonary vascular phenotypes associated with SSc.
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Affiliation(s)
- Ashraful Haque
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Dept of Rheumatology, Royal Hallamshire Hospital, Sheffield, UK.,Both authors contributed equally
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK .,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Both authors contributed equally
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29
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Naranjo M, Hassoun PM. Systemic Sclerosis-Associated Pulmonary Hypertension: Spectrum and Impact. Diagnostics (Basel) 2021; 11:911. [PMID: 34065226 PMCID: PMC8161029 DOI: 10.3390/diagnostics11050911] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a catastrophic complication of one of the most common and devastating autoimmune diseases. Once diagnosed, it becomes the leading cause of mortality among this patient population. Screening modalities and risk assessments have been designed and validated by various organizations and societies in order to identify patients early in their disease course and promptly refer them to expert centers for a hemodynamic assessment and formal diagnosis. Moreover, several large multicenter clinical trials have now included patients with SSc-PAH to assess their response to therapy. Despite an improved understanding of the condition and significant advances in supportive and targeted therapy, outcomes have remained far from optimal. Therefore, rigorous phenotyping and search for novel therapies are desperately needed for this devastating condition.
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Affiliation(s)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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30
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Wu CH, Lin CY, Hsu CH, Lin SH, Weng CT. Connective Tissue Disease-Associated Pulmonary Arterial Hypertension in Southern Taiwan: A Single-Center 10-Year Longitudinal Observation Cohort. Healthcare (Basel) 2021; 9:healthcare9050615. [PMID: 34065585 PMCID: PMC8160731 DOI: 10.3390/healthcare9050615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a life-threatening disease with different etiologies and outcomes. We aimed to explore differences in clinical features and outcomes of idiopathic PAH (iPAH) and connective tissue disease-related PAH (CTD-PAH) in Taiwanese patients and determine risk factors for mortality. Methods: We retrospectively reviewed the medical records of patients with right-sided heart catheterization-diagnosed PAH between January 2005 and December 2015. The iPAH (n = 31) and CTD-PAH (n = 14) patients were enrolled and followed until December 31, 2019. Between-group comparisons were conducted. Potential predictors of the mortality of PAH were determined using the Cox proportional hazard regression model. Results: CTD-PAH patients had higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and lower predicted diffusing capacity of carbon monoxide (DLCO) than iPAH patients. The mortality rates were similar between CTD-PAH and iPAH (21.4% vs. 22.6%, p = 0.99). A mean pulmonary arterial pressure (mPAP) > 46 mmHg was a predictor of PAH-induced mortality (adjusted hazard ratio 21.8, 95% confidence interval 2.32–204.8). Conclusions: A higher mPAP level, but not underlying CTDs, imposed a significantly increased risk of mortality to patients with PAH.
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Affiliation(s)
- Chun-Hsin Wu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
- Division of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
- Correspondence: ; Tel.: +886-6-235-3535 (ext. 5383)
| | - Chun-Yu Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Chia-Tse Weng
- Division of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
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31
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Khanna D, Zhao C, Saggar R, Mathai SC, Chung L, Coghlan JG, Shah M, Hartney J, McLaughlin V. Long-Term Outcomes in Patients With Connective Tissue Disease-Associated Pulmonary Arterial Hypertension in the Modern Treatment Era: Meta-Analyses of Randomized, Controlled Trials and Observational Registries. Arthritis Rheumatol 2021; 73:837-847. [PMID: 33538058 PMCID: PMC8251834 DOI: 10.1002/art.41669] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
Objective Data on the magnitude of benefit of modern therapies for pulmonary arterial hypertension (PAH) in connective tissue disease (CTD)–associated PAH are limited. In this study, we performed meta‐analyses of randomized, controlled trials (RCTs) and registries to quantify the benefit of these modern therapies in patients with CTD‐PAH. Methods The PubMed and Embase databases were searched for articles reporting data from RCTs or registries published between January 1, 2000 and November 25, 2019. Eligibility criteria included multicenter studies with ≥30 CTD‐PAH patients. For an RCT to be included, the trial had to evaluate an approved PAH therapy, and long‐term risks of clinical morbidity and mortality or 6‐minute walk distance had to be reported. For a registry to be included, survival rates had to be reported. Random‐effects models were used to pool the data. Results Eleven RCTs (total of 4,329 patients; 1,267 with CTD‐PAH) and 19 registries (total of 9,739 patients; 4,008 with CTD‐PAH) were included. Investigational therapy resulted in a 36% reduction in the risk of clinical morbidity/mortality events both in the overall PAH population (hazard ratio [HR] 0.64, 95% confidence interval [95% CI] 0.54, 0.75; P < 0.001) and in CTD‐PAH patients (HR 0.64, 95% CI 0.51, 0.81; P < 0.001) as compared to control subjects. The survival rate was lower in CTD‐PAH patients compared to all PAH patients (survival rate 62%, 95% CI 57, 67% versus 72%, 95% CI 69, 75% at 3 years). The survival rate in CTD‐PAH patients treated primarily after 2010 was higher than that in CTD‐PAH patients treated before 2010 (survival rate 73%, 95% CI 62, 81% versus 65%, 95% CI 59, 71% at 3 years). Conclusion Modern therapy provides a similar reduction in morbidity/mortality risk in patients with CTD‐PAH when compared to the PAH population overall. Risk of death is higher in CTD‐PAH patients than in those with PAH overall, but survival has improved in the last 10 years, which may be related to increased screening and/or new treatment approaches. Early detection of PAH in patients with CTD and up‐front intensive treatment are warranted.
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Affiliation(s)
| | - Carol Zhao
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | | | - Stephen C Mathai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Mehul Shah
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | - John Hartney
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
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32
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Denton CP, Spierings J. Combining Data Sets as Well as Therapies Shows Improved Outcome in Connective Tissue Disease-Associated Pulmonary Hypertension. Arthritis Rheumatol 2021; 73:725-727. [PMID: 33533554 DOI: 10.1002/art.41670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/26/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Julia Spierings
- University College London and Royal Free Hospital, London, UK
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33
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Zhao M, Wu J, Wu H, Sawalha AH, Lu Q. Clinical Treatment Options in Scleroderma: Recommendations and Comprehensive Review. Clin Rev Allergy Immunol 2021; 62:273-291. [PMID: 33449302 DOI: 10.1007/s12016-020-08831-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
There are two major clinical subsets of scleroderma: (i) systemic sclerosis (SSc) is a complex systemic autoimmune disorder characterized by inflammation, vasculopathy, and excessive fibrosis of the skin and multiple internal organs and (ii) localized scleroderma (LoS), also known as morphea, is confined to the skin and/or subcutaneous tissues resulting in collagen deposition and subsequent fibrosis. SSc is rare but is associated with significant morbidity and mortality compared with other rheumatic diseases. Fatal outcomes in SSc often originate from organ complications of the disease, such as lung fibrosis, pulmonary artery hypertension (PAH), and scleroderma renal crisis (SRC). Current treatment modalities in SSc have focused on targeting vascular damage, fibrosis, and regulation of inflammation as well as autoimmune responses. Some drugs previously used in an attempt to suppress fibrosis, like D-penicillamine (D-Pen) or colchicine, have been disappointing in clinical practice despite anecdotal evidence of their advantages. Some canonical medications, including glucocorticoids, immunosuppressants, and vasodilators, have had some success in treating various manifestations in SSc patients. Increasing evidence suggests that some biologic agents targeting collagen, cytokines, and cell surface molecules might have promising therapeutic effects in SSc. In recent years, hematopoietic stem cell transplantation (HSCT), mostly autologous, has made great progress as a promising treatment option in severe and refractory SSc. Due to the complexity and heterogeneity of SSc, there are currently no optimal treatments for all aspects of the disease. As for LoS, local skin-targeted therapy is generally used, including topical application of glucocorticoids or other immunomodulatory ointments and ultraviolet (UV) irradiation. In addition, systemic immunosuppressants are also utilized in several forms of LoS. Here, we comprehensively discuss current treatment options for scleroderma, encompassing old, new, and future potential treatment options. In addition, we summarize data from new clinical trials that have the potential to modify the disease process and improve long-term outcomes in SSc.
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Affiliation(s)
- Ming Zhao
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Unit of Key Technologies of Immune-Related Skin Diseases Diagnosis and Treatment, Chinese Academy of Medical Sciences, Changsha, China
| | - Jiali Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Unit of Key Technologies of Immune-Related Skin Diseases Diagnosis and Treatment, Chinese Academy of Medical Sciences, Changsha, China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Unit of Key Technologies of Immune-Related Skin Diseases Diagnosis and Treatment, Chinese Academy of Medical Sciences, Changsha, China
| | - Amr H Sawalha
- Departments of Pediatrics, Medicine, and Immunology, and Lupus Center of Excellence, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Qianjin Lu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China. .,Research Unit of Key Technologies of Immune-Related Skin Diseases Diagnosis and Treatment, Chinese Academy of Medical Sciences, Changsha, China. .,Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China.
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34
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Chauvelot L, Gamondes D, Berthiller J, Nieves A, Renard S, Catella-Chatron J, Ahmad K, Bertoletti L, Camara B, Gomez E, Launay D, Montani D, Mornex JF, Prévot G, Sanchez O, Schott AM, Subtil F, Traclet J, Turquier S, Zeghmar S, Habib G, Reynaud-Gaubert M, Humbert M, Cottin V. Hemodynamic Response to Treatment and Outcomes in Pulmonary Hypertension Associated With Interstitial Lung Disease Versus Pulmonary Arterial Hypertension in Systemic Sclerosis: Data From a Study Identifying Prognostic Factors in Pulmonary Hypertension Associated With Interstitial Lung Disease. Arthritis Rheumatol 2020; 73:295-304. [PMID: 32892515 DOI: 10.1002/art.41512] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 08/27/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Patients with systemic sclerosis and both pulmonary hypertension and interstitial lung disease (SSc-PH-ILD) generally carry a worse prognosis than patients with SSc and pulmonary arterial hypertension (SSc-PAH) without ILD. There is no evidence of the efficacy of PAH therapies in SSc-PH-ILD. We undertook this study to compare survival of and response to treatment in patients with SSc-PH-ILD and those with SSc-PAH. METHODS We analyzed 128 patients (66 with SSc-PH-ILD and 62 with SSc-PAH) from 15 centers, in whom PH was diagnosed by right-sided heart catheterization; they were prospectively included in the PH registry. All patients received PAH-specific therapy. Computed tomography of the chest was used to confirm or exclude ILD. RESULTS At baseline, patients with SSc-PH-ILD had less severe hemodynamic impairment than those with SSc-PAH (pulmonary vascular resistance 5.7 Wood units versus 8.7 Wood units; P = 0.0005) and lower diffusing capacity for carbon monoxide (median 25% [interquartile range (IQR) 18%, 35%] versus 40% [IQR 31%, 51%]; P = 0.0005). Additionally, patients with SSc-PH-ILD had increased mortality (8.1% at 1 year, 21.2% at 2 years, and 41.5% at 3 years) compared to those with SSc-PAH (4.1%, 8.7%, and 21.4%, respectively; P = 0.04). Upon treatment with PAH-targeted therapy, no improvement in the 6-minute walk distance was observed in either group. Improvement in the World Health Organization functional class was observed less frequently in patients with SSc-ILD-PH compared to those with SSc-PAH (13.6% versus 33.3%; P = 0.02). Hemodynamics improved similarly in both groups. CONCLUSION ILD confers a worse prognosis to SSc-PH. Response to PAH-specific therapy is clinically poor in SSc-PH-ILD but was not found to be hemodynamically different from the response observed in SSc-PAH.
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Affiliation(s)
- Louis Chauvelot
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | | | - Julien Berthiller
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, and Health Services and Performance Research (HESPER) EA7425, Lyon, France
| | - Ana Nieves
- Centre de Compétences des Maladies Pulmonaires Rares, and Hôpital Nord, AP-HM, Marseille, France
| | | | | | - Kais Ahmad
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | | | - Boubou Camara
- Clinique Universitaire de Pneumologie and CHU de Grenoble Alpes, Grenoble, France
| | | | - David Launay
- Université de Lille, CHU de Lille, and Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Lille, France
| | - David Montani
- Hôpital Bicêtre, AP-HP, Centre de Référence de l'Hypertension Pulmonaire, INSERM U999, Université Paris-Saclay, Paris, France
| | - Jean-François Mornex
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | - Grégoire Prévot
- Centre de Compétences des Maladies Pulmonaires Rares, CHU de Toulouse, and Hôpital Larrey, Toulouse, France
| | - Olivier Sanchez
- Hôpital Européen Georges Pompidou, AP-HP, Centre de Compétences des Maladies Pulmonaires Rares, Université Paris Descartes, INSERM U1140, Paris, France
| | - Anne-Marie Schott
- Centre de Compétences des Maladies Pulmonaires Rares, and Hôpital Nord, AP-HM, Marseille, France
| | - Fabien Subtil
- Université de Lyon, Université Claude Bernard Lyon 1, CNRS UMR 5558, Villeurbanne, France, and Hospices Civils de Lyon, Lyon, France
| | - Julie Traclet
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | - Ségolène Turquier
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | - Sabrina Zeghmar
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
| | | | - Martine Reynaud-Gaubert
- Centre de Compétences des Maladies Pulmonaires Rares, and Hôpital Nord, AP-HM, Marseille, France
| | - Marc Humbert
- Hôpital Bicêtre, AP-HP, Centre de Référence de l'Hypertension Pulmonaire, INSERM U999, Université Paris-Saclay, Paris, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Centre de Référence National des Maladies Pulmonaires Rares, Centre de Compétence de l'Hypertension Pulmonaire, Hôpital Louis Pradel, UMR 754, Université Claude Bernard Lyon 1, OrphaLung, RespiFil, and ERN-LUNG, Lyon, France
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Faure M, Valentin S, Zysman M, Sitbon O, Peretti L, Guillaumot A, Gomez E, Huttin O, Selton-Suty C, Chabot F, Chaouat A. Exercise Hemodynamics in the Prognosis of Patients with Pulmonary Arterial Hypertension. Respiration 2020; 99:678-685. [PMID: 32862181 DOI: 10.1159/000509144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Assessment of prognosis is of major importance when deciding on a therapeutic strategy in patients with pulmonary arterial hypertension (PAH). OBJECTIVES The aim of this study was to investigate the prognostic value of pulmonary hemodynamics during exercise and changes during treatment in patients with PAH. METHODS Consecutive incident patients (n = 49) with PAH undergoing right heart catheterization at rest and during a constant workload cycle exercise in supine position were included. Predictors of survival were identified at baseline using Cox proportional hazard regression models in a univariate analysis unadjusted and adjusted for age and gender. RESULTS During a median follow-up period of 42 months, 13 (27%) of the 49 patients studied died. Two predictors of death were found: rest-to-exercise changes in heart rate and systolic pulmonary artery pressure. Adjusted hazard ratios were 0.92 (95% CI 0.86-0.99) and 0.93 (95% CI 0.88-0.99), respectively. These 2 variables were correlated with each other (r = 0.55, p < 0.001). CONCLUSIONS Rest-to-exercise changes in heart rate and systolic pulmonary artery pressure measured at diagnosis are predictors of survival in patients with PAH. These measurements taken from an exercise test reflect right ventricular function.
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Affiliation(s)
- Morgane Faure
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Simon Valentin
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France, .,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France,
| | | | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Laura Peretti
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Anne Guillaumot
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Emmanuel Gomez
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Olivier Huttin
- Département de Cardiologie, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Nancy, France
| | - Christine Selton-Suty
- Département de Cardiologie, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Nancy, France
| | - François Chabot
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Ari Chaouat
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France
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36
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Park JB, Paeng JC, Lee SP. Reply to Tang et al.: Positron Emission Tomography: A Novel Approach to Detect Pulmonary Artery Hypertension at the Early Stage? Am J Respir Crit Care Med 2020; 202:475-476. [PMID: 32353249 PMCID: PMC7397794 DOI: 10.1164/rccm.202003-0557le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jun-Bean Park
- Seoul National University HospitalSeoul, Republic of Koreaand
- Seoul National University College of MedicineSeoul, Republic of Korea
| | - Jin Chul Paeng
- Seoul National University HospitalSeoul, Republic of Koreaand
- Seoul National University College of MedicineSeoul, Republic of Korea
| | - Seung-Pyo Lee
- Seoul National University HospitalSeoul, Republic of Koreaand
- Seoul National University College of MedicineSeoul, Republic of Korea
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Shivakumar S, Thynne TR, Mohammadi L, Burdeniuk C, Mangoni AA. Effectiveness and safety of endothelin receptor antagonists, alone and in combination therapy, in the pulmonary arterial hypertension-connective tissue disease subtype: A systematic review and meta-analysis. Int J Rheum Dis 2020; 23:1276-1287. [PMID: 32691518 DOI: 10.1111/1756-185x.13916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/19/2020] [Accepted: 06/18/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is limited information regarding the effectiveness of endothelin receptor antagonists (ERA) in patients with connective tissue disease-pulmonary arterial hypertension (CTD-PAH), a condition that is characterized by poorer clinical outcomes compared to other PAH subtypes. OBJECTIVE To conduct a systematic review and meta-analysis of the effectiveness and safety of ERA in CTD-PAH. METHODS A literature search, using MEDLINE, COCHRANE, CINAHL and EMBASE databases was conducted, from inception to May 2019 to identify randomized control studies of ERA, as monotherapy or in combination with phosphodiesterase type 5 inhibitors (PDE5i), in CTD-PAH. A protocol was registered in PROSPERO (CRD42019136956). Efficacy outcomes, including the 6-minute walk distance (6MWD) and composite clinical failure endpoints (CFE), and safety outcomes were evaluated. RESULTS A total of 13 studies, including 784 CTD-PAH participants, were identified. ERA, as monotherapy, did not reduce the risk of CFE compared to placebo (odds ratio [OR] 0.77, 95% CI 0.50-1.19, P = .25). By contrast, combination therapy (ERA + PDE5i) significantly reduced the risk of developing CFE vs monotherapy (OR 0.54, 95% CI 0.32-0.90, P = .02). 6MWD did not improve when comparing monotherapy vs placebo (+17.41 m; 95% CI -19.83-54.66) P = .36) or combination therapy vs monotherapy (+13.17 m; 95% CI -16.44-42.78, P = .38). ERA-related adverse events rates in CTD-PAH and general PAH cohorts were comparable. CONCLUSIONS ERA, when used in combination with PDE5is, are associated with reduced risk of CFE, but no significant changes in 6MWD, in CTD-PAH. This warrants further studies investigating early combination therapy as a standard of care in this group.
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Affiliation(s)
- Senthuran Shivakumar
- Department of Clinical Pharmacology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Tilenka R Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre, Adelaide, South Australia, Australia.,Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | | | - Christine Burdeniuk
- Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders Medical Centre, Adelaide, South Australia, Australia.,Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Li M, Jing ZC, Li Y, Huo Y, Yu Z, Zhang G, Zhu P, Liu J, Ji Q, Wu B, Zhong J, Wang P, Zhu W, Zeng X. Efficacy and safety of ambrisentan in Chinese patients with connective tissue disease-pulmonary arterial hypertension: a post-hoc analysis. BMC Cardiovasc Disord 2020; 20:339. [PMID: 32680480 PMCID: PMC7367256 DOI: 10.1186/s12872-020-01591-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/16/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The efficacy and safety of ambrisentan has been previously evaluated in Chinese patients with pulmonary arterial hypertension (PAH). This post-hoc analysis assessed the efficacy and safety of ambrisentan in a subgroup of connective tissue disease (CTD) patients with PAH. METHODS In this open-label, single-arm study, patients received ambrisentan 5 mg once daily for 12 weeks, followed by 12-week dose titration period (dose up to 10 mg). Efficacy endpoints included change from baseline in exercise capacity (measured by 6-min walk test [6MWT]), N-terminal pro B type natriuretic peptide (NT-proBNP) plasma levels, WHO Functional Class (FC) and Borg Dyspnoea Index (BDI) scores from baseline to weeks 12 and 24. Safety endpoints included time to clinical worsening and incidence of adverse events (AEs). RESULTS In total, 71 Chinese patients with CTD-PAH were included in this analysis. Ambrisentan treatment significantly improved exercise capacity (6MWT) from baseline (mean: 366.4 m) to week 12 (63.8 m, p < 0.001) and week 24 (73.2 m, p < 0.001). A significant reduction in NT-proBNP levels was observed from baseline (mean: 1837.5 ng/L) to week 12 (- 1156.8 ng/L, p < 0.001) and week 24 (- 1095.5 ng/L, p < 0.001). BDI scores decreased significantly at week 12 (- 0.6, p < 0.001) and week 24 (- 0.4, p = 0.002) from baseline (mean: 2.7). The WHO FC improved in 29 (40.8%) and 34 (47.9%) patients at weeks 12 and 24, respectively. Adverse events were reported in 52 (73.2%) patients. One patient (1.4%) experienced clinical worsening at week 24. CONCLUSION Ambrisentan showed significant improvement in exercise capacity and no clinical worsening in the majority of Chinese patients with CTD-PAH in the 24-week treatment period. The AEs observed in the CTD-PAH subgroup were consistent with the known safety profile of ambrisentan in the overall Chinese PAH population. TRIAL REGISTRATION ClinicalTrial.gov Identifier, https://clinicaltrials.gov/, NCT01808313 Registration date (first time): February 28, 2013.
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Affiliation(s)
- Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Zhi-Cheng Jing
- Key Lab of Pulmonary Vascular Medicine & FuWai Hospital, State Key lab of Cardiovascular disease, National center for Cardiovascular disease, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yang Li
- 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yong Huo
- 1st Affiliated Hospital of Peking University, Beijing, China
| | - Zaixin Yu
- Xiangya Hospital Central-South University, Changsha, Hunan, China
| | | | - Ping Zhu
- 1st Affiliated Hospital of the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jinming Liu
- Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Qiushang Ji
- Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Bingxiang Wu
- 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jinhua Zhong
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Pingping Wang
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Wenjing Zhu
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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Attanasio U, Cuomo A, Pirozzi F, Loffredo S, Abete P, Petretta M, Marone G, Bonaduce D, De Paulis A, Rossi FW, Tocchetti CG, Mercurio V. Pulmonary Hypertension Phenotypes in Systemic Sclerosis: The Right Diagnosis for the Right Treatment. Int J Mol Sci 2020; 21:E4430. [PMID: 32580360 PMCID: PMC7352262 DOI: 10.3390/ijms21124430] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
Systemic sclerosis is an auto-immune disease characterized by skin involvement that often affects multiple organ systems. Pulmonary hypertension is a common finding that can significantly impact prognosis. Molecular pathophysiological mechanisms underlying pulmonary hypertension in systemic sclerosis can be extremely heterogeneous, leading to distinct clinical phenotypes. In addition, different causes of pulmonary hypertension may overlap within the same patient. Since pulmonary hypertension treatment is very different for each phenotype, it is fundamental to perform an adequate diagnostic work-up to properly and promptly identify the prevalent mechanism underlying pulmonary hypertension in order to start the right therapies. When pulmonary hypertension is caused by a primary vasculopathy of the small pulmonary arteries, treatment with pulmonary vasodilators, often in an initial double-combination regimen, is indicated, aimed at reducing the mortality risk profile. In this review, we describe the different clinical phenotypes of pulmonary hypertension in the scleroderma population and discuss the utility of clinical tools to identify the presence of pulmonary vascular disease. Furthermore, we focus on systemic sclerosis-associated pulmonary arterial hypertension, highlighting the advances in the knowledge of right ventricular dysfunction in this setting and the latest updates in terms of treatment with pulmonary vasodilator drugs.
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Affiliation(s)
- Umberto Attanasio
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Alessandra Cuomo
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Flora Pirozzi
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Stefania Loffredo
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
- Center for Basic and Clinical Immunology Research (CISI), 80131 Naples, Italy
- World Allergy Organization (WAO), Center of Excellence, 80131 Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Mario Petretta
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Gianni Marone
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
- Center for Basic and Clinical Immunology Research (CISI), 80131 Naples, Italy
- World Allergy Organization (WAO), Center of Excellence, 80131 Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Amato De Paulis
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
- Center for Basic and Clinical Immunology Research (CISI), 80131 Naples, Italy
- World Allergy Organization (WAO), Center of Excellence, 80131 Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
- Center for Basic and Clinical Immunology Research (CISI), 80131 Naples, Italy
- World Allergy Organization (WAO), Center of Excellence, 80131 Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
| | - Valentina Mercurio
- Department of Translational Medical Sciences. Federico II University, 80131 Naples, Italy; (U.A.); (A.C.); (F.P.); (S.L.); (P.A.); (M.P.); (G.M.); (D.B.); (A.D.P.); (F.W.R.); (C.G.T.)
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Clapham KR, Highland KB, Rao Y, Fares WH. Reduced RVSWI Is Associated With Increased Mortality in Connective Tissue Disease Associated Pulmonary Arterial Hypertension. Front Cardiovasc Med 2020; 7:77. [PMID: 32426373 PMCID: PMC7203784 DOI: 10.3389/fcvm.2020.00077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 04/14/2020] [Indexed: 11/13/2022] Open
Abstract
Rationale: The prognosis of pulmonary arterial hypertension is poor, especially amongst patients with connective tissue disease related pulmonary arterial hypertension. Right ventricular contractility is known to be decreased in scleroderma related pulmonary arterial hypertension. However, it is not known whether intrinsic right ventricular dysfunction is seen in a general CTD population. Objectives: In this study of a large cohort of patients with pulmonary arterial hypertension with multi-year follow-up, we sought to examine the association of measurements of right ventricular function with survival in connective tissue disease associated pulmonary arterial hypertension. Methods: Clinical characteristics of a deidentified cohort of 845 patients with pulmonary arterial hypertension were compared between patients with and without connective tissue disease. The Kaplan-Meier method was used to examine the survival of patients over more than 4 years. The association between right ventricular stroke work index and mortality was examined in patients with connective tissue disease associated pulmonary arterial hypertension. Measurements and Main Results: Significant differences in the 6-min walk distance, Borg dyspnea index, right ventricular stroke work index, and pulmonary artery pulsatility index were identified between patients with and without connective tissue disease associated pulmonary arterial hypertension. Patients with connective tissue disease had a lower right ventricular stroke work index, which was associated with decreased survival in this group; this association approached significance when adjusting for age and renal function. Conclusions: Right ventricular dysfunction as measured by right ventricular stroke work index is associated with decreased survival in patients with connective tissue disease associated pulmonary arterial hypertension despite similar pulmonary vascular resistance. These findings are suggestive of intrinsic right ventricular function in connective tissue disease associated pulmonary arterial hypertension that has a negative impact on the long-term survival of these individuals.
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Affiliation(s)
- Katharine R Clapham
- Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT, United States
| | | | - Youlan Rao
- United Therapeutics Corporation, Research Triangle Park, Raleigh, NC, United States
| | - Wassim H Fares
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, CT, United States
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41
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Almaaitah S, Highland KB, Tonelli AR. Management of Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Integr Blood Press Control 2020; 13:15-29. [PMID: 32280271 PMCID: PMC7125406 DOI: 10.2147/ibpc.s232038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare and complex immune-mediated connective tissue disease characterized by multi-organ fibrosis and dysfunction. Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a leading cause of death in this population. Pulmonary arterial hypertension (PAH) can coexist with other forms of pulmonary hypertension in SSc, including pulmonary hypertension related to left heart disease, interstitial lung disease, chronic thromboembolism and pulmonary venous occlusive disease, which further complicates diagnosis and management. Available pulmonary arterial hypertension therapies target the nitric oxide, endothelin and prostacyclin pathways. These therapies have been studied in SSc-PAH in addition to idiopathic PAH, often with different treatment responses. In this article, we discuss the management as well as the treatment options for patients with SSc-PAH.
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Affiliation(s)
- Saja Almaaitah
- Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristin B Highland
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
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42
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Argula RG, Ward C, Feghali-Bostwick C. Therapeutic Challenges And Advances In The Management Of Systemic Sclerosis-Related Pulmonary Arterial Hypertension (SSc-PAH). Ther Clin Risk Manag 2019; 15:1427-1442. [PMID: 31853179 PMCID: PMC6916691 DOI: 10.2147/tcrm.s219024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disorder with multi-organ involvement. SSc-associated pulmonary arterial hypertension (SSc-PAH) is one of the leading causes of morbidity and mortality in the SSc population. With advances in our understanding of pulmonary arterial hypertension (PAH) diagnosis and treatment, outcomes for all PAH patients have significantly improved. While SSc-PAH patients have also benefited from these advances, significant challenges remain. Diagnosis of PAH is a challenging endeavor in SSc patients who often have many co-existing pulmonary and cardiac comorbidities. Given the significantly elevated prevalence and lifetime risk of PAH in the SSc population, screening for SSc-PAH is a critically useful strategy. Treatment with pulmonary arterial (PA) vasodilators has resulted in a dramatic improvement in the survival and quality of life of PAH patients. While therapy with PA vasodilators is beneficial in SSc-PAH patients, therapy effects appear to be attenuated when compared to responses in patients with idiopathic PAH (IPAH). This review attempts to chronicle and summarize the advances in our understanding of the optimal screening strategies to identify PAH in patients with SSc. The article also reviews the advances in the therapeutic and risk stratification strategies for SSc-PAH patients.
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Affiliation(s)
- Rahul G Argula
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Celine Ward
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
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43
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Hachulla E, Launay D, Boucly A, Mouthon L, de Groote P, Cottin V, Pugnet G, Prévôt G, Bourlier D, Dauphin C, Chaouat A, Weatherald J, Simonneau G, Montani D, Humbert M, Sitbon O, Giovannelli J. Survival Improved in Patients Aged ≤ 70 Years With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension During the Period 2006 to 2017 in France. Chest 2019; 157:945-954. [PMID: 31756332 DOI: 10.1016/j.chest.2019.10.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/06/2019] [Accepted: 10/19/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND To date, nothing is known about the evolution of survival in systemic sclerosis-associated pulmonary arterial hypertension (PAH) over the last decade. METHODS This study used a multivariate Cox regression model adjusted for clinically relevant baseline confounders to assess the association between the occurrence of death and date of PAH diagnosis comparing two periods of the same duration (2006-2011 vs 2012-2017). Interactions between the two diagnosis periods and baseline variables were tested. RESULTS A total of 306 incident patients were included, 167 (54.6%) with a PAH diagnosis occurring in 2006 to 2011 and 139 (45.4%) in 2012 to 2017. No significant difference in survival was observed between patients diagnosed with PAH in 2012 to 2017 compared with those diagnosed in 2006 to 2011 (hazard ratio [HR], 0.76 [0.46-1.26]; P = .29). A significant interaction was observed between PAH diagnosis periods and age (P = .05). When stratifying according to age (based on the median age of 70 years), a significant increase was observed in survival in patients aged ≤ 70 years between the 2006 to 2011 period and the 2012 to 2017 period (HR, 0.40 [0.17-0.99]; P = .046) but not in older patients (HR, 1.29 [0.67-2.51]; P = .44). A significantly higher proportion of initial (ie, within the first 4 months) endothelin receptor antagonist/phosphodiesterase type 5 inhibitor combination therapy was observed in younger patients diagnosed from 2012 to 2017 vs those diagnosed from 2006 to 2011 (42.9% vs 19.5%; P = .002) but not in older patients. CONCLUSIONS Over the period 2006 to 2017, survival in systemic sclerosis-associated PAH improved over time in patients aged ≤ 70 years but not in older patients. Further investigations are needed to confirm this relation, as general improvement in medical care and management may also be a possible explanation.
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Affiliation(s)
- Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, Referral Center for Rare Systemic Autoimmune Diseases North and Northwest of France, Lille, France; Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France.
| | - David Launay
- Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, Referral Center for Rare Systemic Autoimmune Diseases North and Northwest of France, Lille, France; Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France
| | - Athénaïs Boucly
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Luc Mouthon
- APHP, Hôpital Cochin, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes Systémiques Rares Ile de France, Université Paris Descartes, Paris, France
| | - Pascal de Groote
- CHU de Lille, Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Department of Respiratory Medicine, Louis Pradel Hospital, University Claude Bernard Lyon 1, University of Lyon, UMR 754, Lyon, France
| | | | - Grégoire Prévôt
- CHU de Toulouse, Hôpital Larrey, Service de Pneumologie, Toulouse, France
| | - Delphine Bourlier
- Université de Bordeaux, CHU de Bordeaux, Hôpital du Haut Lévêque, Service de Maladies Respiratoires, Pessac, France
| | - Claire Dauphin
- University of Auvergne, CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France
| | - Ari Chaouat
- CHU Nancy, Pôle des Spécialités Médicales, Département de Pneumologie, Université de Lorraine, INGRES, EA 7298, Vandoeuvre-lès-Nancy, France
| | - Jason Weatherald
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France; Department of Medicine, Section of Respiratory Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Gérald Simonneau
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - David Montani
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Marc Humbert
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Olivier Sitbon
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Jonathan Giovannelli
- Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France
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Huang H, Chen D, Pu J, Yuan A, Fu Q, Li J, Leng L, Bucala R, Ye S, Lu L. The small molecule macrophage migration inhibitory factor antagonist MIF098, inhibits pulmonary hypertension associated with murine SLE. Int Immunopharmacol 2019; 76:105874. [PMID: 31499270 DOI: 10.1016/j.intimp.2019.105874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/31/2019] [Accepted: 09/01/2019] [Indexed: 01/11/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication of systemic lupus erythematosus (SLE), with unclear etiopathogenesis. We evaluated the role of macrophage migration inhibitory factor (MIF), which has been implicated in idiopathic pulmonary hypertension (PH), in SLE-associated PAH. Circulating MIF was measured in SLE patients, SLE-PAH patients, and healthy donors. In situ pulmonary artery MIF protein expression was determined in spontaneous SLE mice (MRL/lpr) and hypoxia-induced C57BL/6J mice. Daily MIF098 was administered to C57BL/6J mice, and these mice were maintained in a hypoxic chamber for 4 weeks. The right ventricular systolic pressure (RVSP) and pathological characteristics of the pulmonary artery (PA), such as hyperproliferation, muscularization, and fibrosis were then measured in each group of mice. Data were also obtained in vitro using pulmonary smooth muscle cells (PASMC) challenged with platelet-derived growth factor (PDGF)-BB or 1% O2 hypoxia. As a result, circulating MIF was elevated in SLE-PAH patients compared with SLE patients or healthy donors. Higher RVSP SLE mice produced more MIF protein than lower RVSP SLE mice in the pulmonary artery. MIF098 decreased RVSP and inhibited distal pulmonary artery hyperproliferation, muscularization, and collagen deposition in hypoxia challenged mice. In addition, MIF098 inhibited PASMC proliferation and migration by regulating mitogen-activated protein kinase/extracellular signal-regulated kinase 1/2 (MAPK/ERK1/2) signal- and cell-cycle-related proteins. MIF098 also reduced collagen synthesis by inhibiting the TGFβ1/Smad2/Smad3 pathway in cell-based experiments. In conclusion, MIF may serve as a biomarker and a therapeutic target of SLE-associated PAH. Pharmacologic MIF antagonism may be an effective means to ameliorate SLE-PAH.
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Affiliation(s)
- Huijing Huang
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dandan Chen
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ancai Yuan
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qiong Fu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jia Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lin Leng
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Richard Bucala
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital South Campus, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Liangjing Lu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Jang AY, Kim S, Park SJ, Choi H, Oh PC, Oh S, Kim KH, Kim KH, Byun K, Chung WJ. A Nationwide multicenter registry and biobank program for deep phenotyping of idiopathic and hereditary pulmonary arterial hypertension in Korea: the PAH platform for deep phenotyping in Korean subjects (PHOENIKS) cohort. Clin Hypertens 2019; 25:21. [PMID: 31534782 PMCID: PMC6745060 DOI: 10.1186/s40885-019-0126-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a progressive, chronic disease without curative treatment. Large registry data of these patient populations have been published, although, phenotypic variants within each subtype of PAH have not been elucidated. As interest towards personalized medicine grows, the need for a PAH cohort with a comprehensive understanding of patient phenotypes through multiomics approaches, called deep phenotyping, is on the rise. The PAH Platform for Deep Phenotyping in Korean Subjects (PHOENIKS) cohort is designed to collect clinical data as well as biological specimens for deep phenotyping in patients with idiopathic PAH (IPAH) and heritable PAH (HPAH) in Korea. Methods A total of 17 regional hospitals are currently working on enrolling up to 100 consecutive IPAH/HPAH patients for obtaining clinical data and biological specimens across Korea. The diagnosis of PAH is based on right heart catheterization. All clinical data is stored in a government-based online database. Each participating hospitals collect a whole blood sample from each patient, through which DNA, RNA, serum, plasma, and peripheral blood mononuclear cells will be extracted from the buffy coat layer for further multiomics analysis. Results Not applicable. Conclusions The PHOENIKS cohort is enrolling IPAH and HPAH patients across Korea to determine the prognosis and drug response in different phenotypic variant. The data generated by this cohort are expected to open new doors for personalized medicine in PAH patients of South Korea. Trial registration ClinicalTrials.gov NCT03933579. Registered on May 1st, 2019.
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Affiliation(s)
- Albert Youngwoo Jang
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,2Division of Cardiovascular Disease, Department of Internal Medicine, Gachon University Gil Hospital, Medical Center, Incheon, South Korea
| | - Sungseek Kim
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea
| | - Su Jung Park
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,2Division of Cardiovascular Disease, Department of Internal Medicine, Gachon University Gil Hospital, Medical Center, Incheon, South Korea
| | - Hanul Choi
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,2Division of Cardiovascular Disease, Department of Internal Medicine, Gachon University Gil Hospital, Medical Center, Incheon, South Korea
| | - Pyung Chun Oh
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,2Division of Cardiovascular Disease, Department of Internal Medicine, Gachon University Gil Hospital, Medical Center, Incheon, South Korea
| | - Seyeon Oh
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,3Center for Genomics and Proteomics, Institute for Regenerative Medicine, Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, South Korea
| | - Kyung-Hee Kim
- 4Department of Cardiology, Sejong General Hospital, Bucheon, South Korea
| | - Kye Hun Kim
- 5Department of Cardiology, Chonnam University Hospital, Gwangju, South Korea
| | - Kyunghee Byun
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,3Center for Genomics and Proteomics, Institute for Regenerative Medicine, Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, South Korea
| | - Wook-Jin Chung
- 1Gachon Cardiovascular Research Institute, College of Medicine, Gachon University, Incheon, South Korea.,2Division of Cardiovascular Disease, Department of Internal Medicine, Gachon University Gil Hospital, Medical Center, Incheon, South Korea.,6Department of Cardiovascular Medicine, School of Medicine, Gachon University, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon, 21565 Republic of Korea
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Coghlan JG, Picken C, Clapp LH. Selexipag in the management of pulmonary arterial hypertension: an update. DRUG HEALTHCARE AND PATIENT SAFETY 2019; 11:55-64. [PMID: 31496830 PMCID: PMC6689562 DOI: 10.2147/dhps.s181313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/02/2019] [Indexed: 12/27/2022]
Abstract
Selexipag is a compound that was designed to overcome the issues associated with oral administration of prostanoid compounds, beraprost and treprostinil in the treatment of pulmonary hypertension (PAH). As a selective IP agonist, it was designed to avoid the off-target prostanoid effects especially in the gastrointestinal system. To place this compound in context, this paper briefly reviews the efficacy, tolerability, and safety of subcutaneous, inhaled, and oral prostanoid preparations and comparesthemto selexipag. Selexipag is the first agent targeting a prostanoid receptor where a reduction in the primary efficacy morbidity/mortality composite end-point has been demonstrated. While safety outcomes favor selexipag over placebo, tolerability issues remain. Efficacy in terms of improvement in effort tolerance, hemodynamic and mortality benefit is less than seen with IV therapy. This is the first prostanoid demonstrated in a clinical trial to have added benefit in those on background double combination therapy and the first non IV prostanoid to demonstrate outcome benefit in the connective tissue disease (CTD) population in a randomized controlled trial.
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Affiliation(s)
- J Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London NW3 2QG, UK
| | - Christina Picken
- Institute of Cardiovascular Sciences, University College London, London WC1E 6JF, UK
| | - Lucie H Clapp
- Institute of Cardiovascular Sciences, University College London, London WC1E 6JF, UK
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Mercurio V, Mukherjee M, Tedford RJ, Zamanian RT, Khair RM, Sato T, Minai OA, Torres F, Girgis RE, Chin K, Damico R, Kolb TM, Mathai SC, Hassoun PM. Improvement in Right Ventricular Strain with Ambrisentan and Tadalafil Upfront Therapy in Scleroderma-associated Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2019; 197:388-391. [PMID: 28661697 DOI: 10.1164/rccm.201704-0789le] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Monica Mukherjee
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Ryan J Tedford
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | | | - Rubina M Khair
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Takahiro Sato
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | | | - Fernando Torres
- 4 University of Texas Southwestern Medical Center Dallas, Texas and
| | - Reda E Girgis
- 5 Spectrum Health/Michigan State University Grand Rapids, Michigan
| | - Kelly Chin
- 4 University of Texas Southwestern Medical Center Dallas, Texas and
| | - Rachel Damico
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Todd M Kolb
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Stephen C Mathai
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Paul M Hassoun
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
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48
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Mira-Avendano I, Abril A, Burger CD, Dellaripa PF, Fischer A, Gotway MB, Lee AS, Lee JS, Matteson EL, Yi ES, Ryu JH. Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases. Mayo Clin Proc 2019; 94:309-325. [PMID: 30558827 DOI: 10.1016/j.mayocp.2018.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.
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Affiliation(s)
- Isabel Mira-Avendano
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Paul F Dellaripa
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Mayo Clinic, Scottsdale, AZ
| | - Augustine S Lee
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Eric L Matteson
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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49
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Cost Effectiveness of Bosentan for Pulmonary Arterial Hypertension: A Systematic Review. Can Respir J 2018; 2018:1015239. [PMID: 30581511 PMCID: PMC6276424 DOI: 10.1155/2018/1015239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/18/2018] [Indexed: 12/16/2022] Open
Abstract
Objectives Although many studies have reported on the cost-effectiveness of bosentan for treating pulmonary arterial hypertension (PAH), a systematic review of economic evaluations of bosentan is currently lacking. Objective evaluation of current pharmacoeconomic evidence can assist decision makers in determining the appropriate place in therapy of a new medication. Methods Systematic literature searches were conducted in English-language databases (MEDLINE, EMBASE, EconLit databases, and the Cochrane Library) and Chinese-language databases (China National Knowledge Infrastructure, WanFang Data, and Chongqing VIP) to identify studies assessing the cost-effectiveness of bosentan for PAH treatments. Results A total of 8 published studies were selected for inclusion. Among them were two studies comparing bosentan with epoprostenol and treprostinil. Both results indicated that bosentan was more cost-effective than epoprostenol, while the results of bosentan and treprostinil were not consistent. Four studies compared bosentan with other endothelin receptor antagonists, which indicated ambrisentan might be the drug of choice for its economic advantages and improved safety profile. Only two economic evaluations provided data to compare bosentan versus sildenafil, and the results favored the use of sildenafil in PAH patients. Four studies compared bosentan with conventional, supportive, or palliative therapy, and whether bosentan was cost-effective was uncertain. Conclusions Bosentan may represent a more cost-effective option compared with epoprostenol and conventional or palliative therapy. There was unanimous agreement that bosentan was not a cost-effective front-line therapy compared with sildenafil and other endothelin receptor antagonists. However, high-quality cost-effectiveness analyses that utilize long-term follow-up data and have no conflicts of interest are still needed.
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50
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Hui M, Zhao J, Tian Z, Wang J, Qian J, Yang X, Wang Q, Li M, Zhao Y, Zeng X. Red blood cell distribution width as a potential predictor of survival of pulmonary arterial hypertension associated with primary Sjogren's syndrome: a retrospective cohort study. Clin Rheumatol 2018; 38:477-485. [PMID: 30218288 DOI: 10.1007/s10067-018-4281-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/26/2018] [Accepted: 08/27/2018] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication and leading cause of mortality in patients with primary Sjogren's syndrome (pSS). This study was to investigate the overall survival rates and the utility of red blood cell distribution width (RDW) as a potential prognostic factor of pSS-PAH. This cohort study retrospectively enrolled 55 patients with pSS-PAH who were followed up at the Department of Rheumatology of Peking Union Medical College Hospital (PUMCH) between August 2007 and May 2017. The patients were stratified according to the level of RDW (≤ 15.0 and > 15.0%). Baseline demographics, laboratory results, pulmonary function conditions, hemodynamic assessments, and treatment regimens were analyzed. Cox proportional hazards regression analysis was used to identify whether RDW level is a factor related to adverse outcome. A total of 55 patients were recruited, with an average age of 38.9 ± 9.3 years. Fifty-four were female (98.2%), and the average duration at the time of PAH diagnosis was 25.5 ± 33.2 months. Higher RDW levels were found in patients who deceased in follow-up (13.8 ± 2.6 vs 16.5 ± 1.6%, p = 0.003) and with higher NYHA classes (13.8 ± 1.8 vs 16.5 ± 2.9%, p < 0.001). Patients with RDW > 15% had a significantly worse overall survival than patients with RDW ≤ 15% (3-year survival rate 59.5 vs. 88.7% log-rank p = 0.015). Cox regression analysis identified RDW > 15% as a prognostic factor for adverse outcome (HR 1.786, 95% CI 1.137-2.803, p = 0.012). RDW can serve as a potential negative prognostic factor of pSS-PAH.
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Affiliation(s)
- Min Hui
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Beijing, 100730, China
| | - Jieying Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Junyan Qian
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiaoxi Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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