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Pavasini R, Sanguettoli F, Deserio MA, Bianchi N, Zanarelli L, Fabbri G, Tonet E, Passarini G, Serenelli M, Campo G. Drug-based cardiovascular prevention in patients with Marfan Syndrome: a systematic review. Minerva Cardiol Angiol 2023; 71:611-621. [PMID: 36939732 DOI: 10.23736/s2724-5683.23.06184-7] [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: 03/21/2023]
Abstract
INTRODUCTION Marfan Syndrome (MFS) is a rare and complex genetic disorder associated with increased aortic growth and aortic disease. The effectiveness of cardiovascular medical therapies aiming to slow down aortic growth has been tested in several trials, particularly beta-blockers and angiotensin receptor blockers, however showing conflicting results. EVIDENCE ACQUISITION We conducted a systematic review on PubMed (Medline), Cochrane library, Google Scholar, and Biomed Central databases between January and February 2022. We selected relevant articles focusing on patients with MFS treated with beta-blockers, angiotensin receptors blockers, or both, and reporting data on the effect of the drugs on 1) slowing down aortic dilatation; 2) the reduction of aortic complication (aortic dissection, mortality, aortic surgery); and with a 3) follow-up length of at least two years. A total of 16 studies were selected. EVIDENCE SYNTHESIS Beta-blockers remain the mainstay of therapy as they have proven to slow aortic enlargement. Angiotensin receptor blockers are a useful alternative and with proven benefit as an add-on therapy to limit aortic growth. Neither beta-blockers, nor angiotensin receptor blockers have shown meaningful results on clinical aortic endpoints. CONCLUSIONS The current evidence of pharmacological treatment for MFS patients is conflicting due to the lack of large, randomized clinical trials with adequate follow-up studies and homogeneous age grouping. Beta-blockers and angiotensin receptor blockers are the only available treatments to reduce aortic growth. A recently published patient-level meta-analysis confirmed that angiotensin receptor blockers and beta-blockers have a similar effect on reducing the rate of increase of the aortic root Z score, used singularly or as add-on therapy. Considering the current evidence on new features related with MFS (such as mitral annular disjunction - MAD) bearing a potential additional increased arrhythmic risk, it is of paramount importance to establish the role of beta-blockers and angiotensin receptor blockers in clinical endpoints of this population as well.
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Affiliation(s)
- Rita Pavasini
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | | | - Maria A Deserio
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Nicola Bianchi
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Luca Zanarelli
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Gioele Fabbri
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Elisabetta Tonet
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Giulia Passarini
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Matteo Serenelli
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Unit of Cardiology, University Hospital of Ferrara, Ferrara, Italy -
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Iskandar Z, Dodd M, Huang J, Chin CWL, Stuart G, Caputo M, Clayton T, Child A, Jin XY, Aragon-Martin JA, Gibb J, Flather M, Choy AM. Exaggerated elastin turnover in young individuals with Marfan syndrome: new insights from the AIMS trial. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead095. [PMID: 37829559 PMCID: PMC10567063 DOI: 10.1093/ehjopen/oead095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023]
Abstract
Aims The fragmentation and loss of elastic fibre in the tunica media of the aorta are pathological hallmarks of Marfan syndrome (MFS) but the dynamics of elastin degradation and its relationship to aortic size and physiological growth remain poorly understood. Methods and results In this post hoc analysis of the AIMS randomized controlled trial, the association of plasma desmosine (pDES)-a specific biomarker of mature elastin degradation-with age and aortic size was analysed in 113 patients with MFS and compared to 109 healthy controls. There was a strong association between age and pDES in both groups, with higher pDES levels in the lower age groups compared to adults. During childhood, pDES increased and peaked during early adolescence, and thereafter decreased to lower adult levels. This trend was exaggerated in young individuals with MFS but in those above 25 years of age, pDES levels were comparable to controls despite the presence of aortic root dilation. In MFS children, increased aortic diameter relative to controls was seen at an early age and although the increase in diameter was less after adolescence, aortic root size continued to increase steadily with age. In MFS participants, there was an indication of a positive association between baseline pDES levels and aortic root dilatation during up to 5 years of follow-up. Conclusion This study has shown that developmental age has a significant effect on levels of elastin turnover as measured by pDES in MFS individuals as well as healthy controls. This effect is exaggerated in those with MFS with increased levels seen during the period of physiologic development that plateaus towards adulthood. This suggests an early onset of pathophysiology that may present an important opportunity for disease-modifying intervention.
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Affiliation(s)
| | - Matthew Dodd
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Calvin W L Chin
- National Heart Center Singapore, Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Graham Stuart
- University Hospitals Bristol NHS Foundation Trust/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Anne Child
- Royal Brompton and Harefield Clinical Group, Guy’s and St Thomas’ Trust, King’s College, London, UK
| | - Xu Yu Jin
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
| | | | - Jack Gibb
- Bristol Royal Hospital for Children/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
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Rodrigues Bento J, Meester J, Luyckx I, Peeters S, Verstraeten A, Loeys B. The Genetics and Typical Traits of Thoracic Aortic Aneurysm and Dissection. Annu Rev Genomics Hum Genet 2022; 23:223-253. [PMID: 36044906 DOI: 10.1146/annurev-genom-111521-104455] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Genetic predisposition and risk factors such as hypertension and smoking can instigate the development of thoracic aortic aneurysm (TAA), which can lead to highly lethal aortic wall dissection and/or rupture. Monogenic defects in multiple genes involved in the elastin-contractile unit and the TGFβ signaling pathway have been associated with TAA in recent years, along with several genetic modifiers and risk-conferring polymorphisms. Advances in omics technology have also provided significant insights into the processes behind aortic wall degeneration: inflammation, epigenetics, vascular smooth muscle phenotype change and depletion, reactive oxygen species generation, mitochondrial dysfunction, and angiotensin signaling dysregulation. These recent advances and findings might pave the way for a therapy that is capable of stopping and perhaps even reversing aneurysm progression.
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Affiliation(s)
- Jotte Rodrigues Bento
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium;
| | - Josephina Meester
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium;
| | - Ilse Luyckx
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; .,Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Silke Peeters
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium;
| | - Aline Verstraeten
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium;
| | - Bart Loeys
- Centre of Medical Genetics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; .,Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
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Wang Z, Deng X, Kang X, Hu A. Angiotensin Receptor Blockers vs. Beta-Blocker Therapy for Marfan Syndrome: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2022; 82:347-361. [PMID: 34998935 DOI: 10.1016/j.avsg.2021.12.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 12/05/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Several RCTs have been conducted to assess the efficacy and safety of angiotensin receptor blocker (ARB) and beta-blocker (BB) therapy for Marfan syndrome (MFS), but the existing evidence is limited and conflicting. This study aimed to compare the efficacy and safety of different therapies. APPROACH The PubMed, Embase, Web of Science, and Cochrane Library databases were electronically searched up to March 2021 to retrieve randomized controlled trials regarding the efficacy and safety of ARB-related (including ARB-only and ARB+BB treatment) and BB-only treatment for treating patients with MFS. The revised risk-of-bias tool was used for quality assessment. The odds ratio (OR) and standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the pooled effect size. RESULTS Fourteen reports of nine trials involving 1,449 patients were included in the meta-analysis. Regarding aortic root dilation, the ARB-related regimen has efficacy comparable with that of the BB-only regimen in patients with MFS (pooled SMD = -0.16, 95% CI [-0.33; 0.01]; p = 0.06), while in the ARB+BB vs. BB-only subgroup, a significant difference was observed (pooled SMD = -0.26; 95% CI [-0.40; -0.11]; p < 0.01). In addition, there were no significant differences in other aortic dilation-related measures (aortic root Z scores, ascending aorta, pulmonary artery, aortic annulus, sinotubular junction, aortic arch, thoracic aorta, and abdominal aorta diameter change) or cardiovascular events (aortic dissection, aortic surgery, and death) between the two regimens. CONCLUSION Our results showed that the clinical efficacy of ARB-only therapy is not inferior to that of BB-only therapy. Moreover, ARB+BB therapy showed superior therapeutic effects without significant adverse effects.
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Affiliation(s)
- Zhong Wang
- M.N., School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Xiaohong Deng
- M.N., Nursing Department, Lingnan Branch of the Third Affiliated Hospital of Sun Yat-sen University, No. 2693 Kaichuang Street, Huangpu District, Guangzhou, China
| | - Xianmei Kang
- B.D., Nursing Department, Lingnan Branch of the Third Affiliated Hospital of Sun Yat-sen University, No. 2693 Kaichuang Street, Huangpu District, Guangzhou, China
| | - Ailing Hu
- M.N., Nursing Department, Lingnan Branch of the Third Affiliated Hospital of Sun Yat-sen University, No. 2693 Kaichuang Street, Huangpu District, Guangzhou, China.
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Creamer TJ, Bramel EE, MacFarlane EG. Insights on the Pathogenesis of Aneurysm through the Study of Hereditary Aortopathies. Genes (Basel) 2021; 12:183. [PMID: 33514025 PMCID: PMC7912671 DOI: 10.3390/genes12020183] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
Thoracic aortic aneurysms (TAA) are permanent and localized dilations of the aorta that predispose patients to a life-threatening risk of aortic dissection or rupture. The identification of pathogenic variants that cause hereditary forms of TAA has delineated fundamental molecular processes required to maintain aortic homeostasis. Vascular smooth muscle cells (VSMCs) elaborate and remodel the extracellular matrix (ECM) in response to mechanical and biochemical cues from their environment. Causal variants for hereditary forms of aneurysm compromise the function of gene products involved in the transmission or interpretation of these signals, initiating processes that eventually lead to degeneration and mechanical failure of the vessel. These include mutations that interfere with transduction of stimuli from the matrix to the actin-myosin cytoskeleton through integrins, and those that impair signaling pathways activated by transforming growth factor-β (TGF-β). In this review, we summarize the features of the healthy aortic wall, the major pathways involved in the modulation of VSMC phenotypes, and the basic molecular functions impaired by TAA-associated mutations. We also discuss how the heterogeneity and balance of adaptive and maladaptive responses to the initial genetic insult might contribute to disease.
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Affiliation(s)
- Tyler J. Creamer
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Emily E. Bramel
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Predoctoral Training in Human Genetics and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Elena Gallo MacFarlane
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Nuche J, Palomino-Doza J, Ynsaurriaga FA, Delgado JF, Ibáñez B, Oliver E, Subías PE. Potential Molecular Pathways Related to Pulmonary Artery Aneurysm Development: Lessons to Learn from the Aorta. Int J Mol Sci 2020; 21:ijms21072509. [PMID: 32260370 PMCID: PMC7177585 DOI: 10.3390/ijms21072509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 12/20/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease caused by pulmonary vascular remodeling. Current vasodilator treatments have substantially improved patients’ survival. This improved survival has led to the appearance of complications related to conditions previously underdiagnosed or even ignored, such as pulmonary artery aneurysm (PAA). The presence of a dilated pulmonary artery has been shown to be related to an increased risk of sudden cardiac death among PAH patients. This increased risk could be associated to the development of left main coronary artery compression or pulmonary artery dissection. Nevertheless, very little is currently known about the molecular mechanisms related to PAA. Thoracic aortic aneurysm (TAA) is a well-known condition with an increased risk of sudden death caused by acute aortic dissection. TAA may be secondary to chronic exposure to classic cardiovascular risk factors. In addition, a number of genetic variants have been shown to be related to a marked risk of TAA and dissection as part of multisystemic syndromes or isolated familial TAA. The molecular pathways implied in the development of TAA have been widely studied and described. Many of these molecular pathways are involved in the pathogenesis of PAH and could be involved in PAA. This review aims to describe all these common pathways to open new research lines that could help lead to a better understanding of the pathophysiology of PAH and PAA and their clinical implications.
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Affiliation(s)
- Jorge Nuche
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Julián Palomino-Doza
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
| | - Fernando Arribas Ynsaurriaga
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Juan F. Delgado
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Borja Ibáñez
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - Eduardo Oliver
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- Correspondence: (E.O.); (P.E.S.)
| | - Pilar Escribano Subías
- Centro de Investigaciones Biomédicas en Red de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.N.); (J.P.-D.); (F.A.Y.); (J.F.D.); (B.I.)
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Correspondence: (E.O.); (P.E.S.)
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Muiño-Mosquera L, De Backer J. Angiotensin-II receptor blockade in Marfan syndrome. Lancet 2019; 394:2206-2207. [PMID: 31836197 DOI: 10.1016/s0140-6736(19)32536-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Laura Muiño-Mosquera
- Department of Paediatrics, Division of Paediatric Cardiology, Ghent University Hospital, Ghent 9000, Belgium; Centre for Medical Genetics, Ghent University Hospital, Ghent 9000, Belgium.
| | - Julie De Backer
- Centre for Medical Genetics, Ghent University Hospital, Ghent 9000, Belgium; Department of Cardiology, Ghent University Hospital, Ghent 9000, Belgium
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