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Fang X, Chen J, Hu Z, Shu L, Wang J, Dai M, Tan T, Zhang J, Bao M. Carotid Baroreceptor Stimulation Ameliorates Pulmonary Arterial Remodeling in Rats With Hypoxia-Induced Pulmonary Hypertension. J Am Heart Assoc 2024; 13:e035868. [PMID: 39344593 DOI: 10.1161/jaha.124.035868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 08/23/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Sympathetic hyperactivity plays an important role in the initiation and maintenance of pulmonary hypertension. Carotid baroreceptor stimulation (CBS) is an effective autonomic neuromodulation therapy. We aim to investigate the effects of CBS on hypoxia-induced pulmonary hypertension and its underlying mechanisms. METHODS AND RESULTS Rats were randomly assigned into 4 groups, including a Control-sham group (n=7), a Control-CBS group (n=7), a Hypoxia-sham group (n=10) and a Hypoxia-CBS group (n=10). Echocardiography, ECG, and hemodynamics examination were performed. Samples of blood, lung tissue, pulmonary arteries, and right ventricle were collected for the further analysis. In the in vivo study, CBS reduced wall thickness and muscularization degree in pulmonary arterioles, thereby improving pulmonary hemodynamics. Right ventricle hypertrophy, fibrosis and dysfunction were all improved. CBS rebalanced autonomic tone and reduced the density of sympathetic nerves around pulmonary artery trunks and bifurcations. RNA-seq analysis identified BDNF and periostin (POSTN) as key genes involved in hypoxia-induced pulmonary hypertension, and CBS downregulated the mRNA expression of BDNF and POSTN in rat pulmonary arteries. In the in vitro study, norepinephrine was found to promote pulmonary artery smooth muscle cell proliferation while upregulating BDNF and POSTN expression. The proliferative effect was alleviated by silence BDNF or POSTN. CONCLUSIONS Our results showed that CBS could rebalance autonomic tone, inhibit pulmonary arterial remodeling, and improve pulmonary hemodynamics and right ventricle function, thus delaying hypoxia-induced pulmonary hypertension progression. There may be a reciprocal interaction between POSTN and BDNF that is responsible for the underlying mechanism.
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Affiliation(s)
- Xuesheng Fang
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
| | - Jie Chen
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
- Department of Emergency, China-Japan Friendship Hospital Chinese Academy of Medical Sciences & Peking Union Medical College Beijing China
| | - Zhiling Hu
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
| | - Ling Shu
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
| | - Jing Wang
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Mingyan Dai
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
| | - Tuantuan Tan
- Department of Ultrasonography Renmin Hospital of Wuhan University Wuhan China
| | - Junxia Zhang
- Department of Endocrinology Taikang Tongji (Wuhan) Hospital Wuhan China
| | - Mingwei Bao
- Department of Cardiology Renmin Hospital of Wuhan University Wuhan China
- Cardiovascular Research Institute Wuhan University Wuhan China
- Hubei Key Laboratory of Cardiology Wuhan China
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Weatherald J, Hemnes AR, Maron BA, Mielniczuk LM, Gerges C, Price LC, Hoeper MM, Humbert M. Phenotypes in pulmonary hypertension. Eur Respir J 2024; 64:2301633. [PMID: 38964779 DOI: 10.1183/13993003.01633-2023] [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: 09/25/2023] [Accepted: 05/29/2024] [Indexed: 07/06/2024]
Abstract
The clinical classification of pulmonary hypertension (PH) has guided diagnosis and treatment of patients with PH for several decades. Discoveries relating to underlying mechanisms, pathobiology and responses to treatments for PH have informed the evolution in this clinical classification to describe the heterogeneity in PH phenotypes. In more recent years, advances in imaging, computational science and multi-omic approaches have yielded new insights into potential phenotypes and sub-phenotypes within the existing clinical classification. Identification of novel phenotypes in pulmonary arterial hypertension (PAH) with unique molecular profiles, for example, could lead to new precision therapies. Recent phenotyping studies have also identified groups of patients with PAH that more closely resemble patients with left heart disease (group 2 PH) and lung disease (group 3 PH), which has important prognostic and therapeutic implications. Within group 2 and group 3 PH, novel phenotypes have emerged that reflect a persistent and severe pulmonary vasculopathy that is associated with worse prognosis but still distinct from PAH. In group 4 PH (chronic thromboembolic pulmonary disease) and sarcoidosis (group 5 PH), the current approach to patient phenotyping integrates clinical, haemodynamic and imaging characteristics to guide treatment but applications of multi-omic approaches to sub-phenotyping in these areas are sparse. The next iterations of the PH clinical classification are likely to reflect several emerging PH phenotypes and improve the next generation of prognostication tools and clinical trial design, and improve treatment selection in clinical practice.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley A Maron
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Lisa M Mielniczuk
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christian Gerges
- Department of Internal Medicine, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Department of Respiratory and Intensive Care Medicine, Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
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Safaie Qamsari E, Stewart DJ. Cellular senescence in the pathogenesis of pulmonary arterial hypertension: the good, the bad and the uncertain. Front Immunol 2024; 15:1403669. [PMID: 39156894 PMCID: PMC11329925 DOI: 10.3389/fimmu.2024.1403669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/15/2024] [Indexed: 08/20/2024] Open
Abstract
Senescence refers to a cellular state marked by irreversible cell cycle arrest and the secretion of pro-inflammatory and tissue-remodeling factors. The senescence associated secretory phenotype (SASP) impacts the tissue microenvironment and provides cues for the immune system to eliminate senescent cells (SCs). Cellular senescence has a dual nature; it can be beneficial during embryonic development, tissue repair, and tumor suppression, but it can also be detrimental in the context of chronic stress, persistent tissue injury, together with an impairment in SC clearance. Recently, the accumulation of SCs has been implicated in the pathogenesis of pulmonary arterial hypertension (PAH), a progressive condition affecting the pre-capillary pulmonary arterial bed. PAH is characterized by endothelial cell (EC) injury, inflammation, and proliferative arterial remodeling, which leads to right heart failure and premature mortality. While vasodilator therapies can improve symptoms, there are currently no approved treatments capable of reversing the obliterative arterial remodeling. Ongoing endothelial injury and dysfunction is central to the development of PAH, perpetuated by hemodynamic perturbation leading to pathological intimal shear stress. The precise role of senescent ECs in PAH remains unclear. Cellular senescence may facilitate endothelial repair, particularly in the early stages of disease. However, in more advanced disease the accumulation of senescent ECs may promote vascular inflammation and occlusive arterial remodeling. In this review, we will examine the evidence that supports a role of endothelial cell senescence to the pathogenesis of PAH. Furthermore, we will compare and discuss the apparent contradictory outcomes with the use of interventions targeting cellular senescence in the context of experimental models of pulmonary hypertension. Finally, we will attempt to propose a framework for the understanding of the complex interplay between EC injury, senescence, inflammation and arterial remodeling, which can guide further research in this area and the development of effective therapeutic strategies.
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Affiliation(s)
- Elmira Safaie Qamsari
- Sinclair Centre for Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Duncan J. Stewart
- Sinclair Centre for Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Saint-Martin Willer A, Montani D, Capuano V, Antigny F. Orai1/STIMs modulators in pulmonary vascular diseases. Cell Calcium 2024; 121:102892. [PMID: 38735127 DOI: 10.1016/j.ceca.2024.102892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/27/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024]
Abstract
Calcium (Ca2+) is a secondary messenger that regulates various cellular processes. However, Ca2+ mishandling could lead to pathological conditions. Orai1 is a Ca2+channel contributing to the store-operated calcium entry (SOCE) and plays a critical role in Ca2+ homeostasis in several cell types. Dysregulation of Orai1 contributed to severe combined immune deficiency syndrome, some cancers, pulmonary arterial hypertension (PAH), and other cardiorespiratory diseases. During its activation process, Orai1 is mainly regulated by stromal interacting molecule (STIM) proteins, especially STIM1; however, many other regulatory partners have also been recently described. Increasing knowledge about these regulatory partners provides a better view of the downstream signalling pathways of SOCE and offers an excellent opportunity to decipher Orai1 dysregulation in these diseases. These proteins participate in other cellular functions, making them attractive therapeutic targets. This review mainly focuses on Orai1 regulatory partners in the physiological and pathological conditions of the pulmonary circulation and inflammation.
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Affiliation(s)
- Anaïs Saint-Martin Willer
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Véronique Capuano
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Hôptal Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Le Plessis-Robinson, France
| | - Fabrice Antigny
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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Weatherald J, Sitbon O. POINT: Should the Use of Upfront Triple Combination Therapy Be Standard of Care in Pulmonary Arterial Hypertension? Yes. Chest 2024; 165:492-494. [PMID: 38461011 DOI: 10.1016/j.chest.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine University of Alberta, Edmonton, AB, Canada
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
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Novara ME, Di Martino E, Stephens B, Nayrouz M, Vitulo P, Carollo A, Provenzani A. Future Perspectives of Pulmonary Arterial Hypertension: A Review of Novel Pipeline Treatments and Indications. Drugs R D 2024; 24:13-28. [PMID: 38514585 PMCID: PMC11035521 DOI: 10.1007/s40268-024-00453-x] [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] [Accepted: 01/07/2024] [Indexed: 03/23/2024] Open
Abstract
Pulmonary arterial hypertension is characterized by elevated blood pressure and pathological changes in the pulmonary arterioles, leading to the development of right-heart failure and potentially fatal outcomes if left untreated. This review aims to provide an overview of novel drugs or formulations and new drug indications for pulmonary arterial hypertension that are currently in phases II-III of randomized controlled trials, and describe the rationale for the use of these targeted therapies, as well as their efficacy, safety profile, and impact on quality of life and survival. The literature research was conducted using data from ClinicalTrials.gov for the period between 1 January 2016 up to 31 December 2022. The population of interest includes individuals aged ≥ 18 years who have been diagnosed with pulmonary arterial hypertension. The review selection criteria included trials with recruiting, enrolling by invitation, active, terminated or completed status in 2022 and 2023. A total of 24 studies were selected for evaluation based on the inclusion and exclusion criteria. This review summarizes the updated information from randomized clinical trials involving novel therapies for pulmonary arterial hypertension. However, larger clinical trials are required to validate their clinical safety and effects. In the future, clinicians should choose therapies based on the patient's individual situation and requirements when developing treatment strategies.
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Affiliation(s)
- Maria Eugenia Novara
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Enrica Di Martino
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Brandon Stephens
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Mary Nayrouz
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Patrizio Vitulo
- Pneumology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Anna Carollo
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy.
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Goncharova N, Lapshin K, Berezina A, Simakova M, Marichev A, Zlobina I, Marukyan N, Malikov K, Aseeva A, Zaitsev V, Moiseeva O. Elderly Patients with Idiopathic Pulmonary Hypertension: Clinical Characteristics, Survival, and Risk Stratification in a Single-Center Prospective Registry. Life (Basel) 2024; 14:259. [PMID: 38398770 PMCID: PMC10890450 DOI: 10.3390/life14020259] [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: 12/25/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION The predictive value of the risk stratification scales in elderly patients with IPAH might differ from that in younger patients. It is unknown whether young and older IPAH patients have the same survival dependence on PAH-specific therapy numbers. The aim of this study was to evaluate the prognostic relevance of risk stratification scales and PAH medication numbers in elderly IPAH patients in comparison with young IPAH patients. MATERIALS AND METHODS A total of 119 patients from a prospective single-center PAH registry were divided into group I < 60 years old (n = 89) and group II ≥ 60 years old (n = 30). ESC/ERS, REVEAL, and REVEAL 2.0 risk stratification scores were assessed at baseline, as well as H2FpEF score and survival at follow-up. RESULTS During a mean follow-up period of 2.9 years (1.63; 6.0), 42 (35.3%) patients died; at 1, 2, 3, 5, 7, and 10 years, survival was 95%, 88.6%, 78.5%, 61.7%, 48.5%, and 33.7%, respectively. No survival differences were observed between the two groups, despite the use of monotherapy in the elderly patients. The best predictive REVEAL value in elderly patients (IPAH patients ≥ 60 years) was AUC 0.73 (0.56-0.91), p = 0.03; and in patients with LHD comorbidities in the entire cohort, it was AUC 0.73 (0.59-0.87), p < 0.009. Factors independently associated with death in the entire cohort were CKD (p = 0.01, HR 0.2), the right-to-left ventricle dimension ratio (p = 0.0047, HR 5.97), and NT-proBNP > 1400 pg/mL (p = 0.008, HR 3.18). CONCLUSION Risk stratification in the elderly IPAH patients requires a fundamentally different approach than that of younger patients, taking into account the initial limitations in physical performance and comorbidities that interfere with current assessment scores. The REVEAL score reliably stratifies patients at any age and LHD comorbidities. The initial monotherapy seems to be reasonable in patients over 60 years. Selection tools for initial combination PAH therapy in older IPAH patients with comorbidities need to be validated in prospective observational studies.
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Affiliation(s)
- Natalia Goncharova
- Almazov National Medical Research Centre, Ministry of Health of Russia, Saint Petersburg 197341, Russia (A.B.); (A.M.); (I.Z.); (N.M.); (K.M.); (A.A.); (V.Z.); (O.M.)
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Jiang G, Shi LF, Li LJ, Duan XJ, Zheng ZF. Activation of the p62-Keap1-Nrf2 pathway improves pulmonary arterial hypertension in MCT-induced rats by inhibiting autophagy. FASEB J 2024; 38:e23452. [PMID: 38308640 DOI: 10.1096/fj.202301563r] [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: 08/01/2023] [Revised: 11/30/2023] [Accepted: 01/12/2024] [Indexed: 02/05/2024]
Abstract
Autophagy is implicated in the pathogenesis of pulmonary arterial hypertension (PAH). We aimed to investigate whether the p62-Keap1-Nrf2 pathway affects the development of PAH by mediating autophagy. A PAH rat model was established using monocrotaline (MCT). Pulmonary artery smooth muscle cells (PASMCs) were extracted, and the changes in proliferation, migration, autophagy, and oxidative stress were analyzed following overexpression or knockdown of p62. The impact of p62 on the symptoms of PAH rats was assessed by the injection of an adenovirus overexpressing p62. We found that the knockdown of p62 increased the proliferation and migration of PASMCs, elevating the oxidative stress of PASMCs and upregulating gene expression of NADPH oxidases. Co-IP assay results demonstrated that p62 interacted with Keap1. p62 knockdown enhanced Keap1 protein stability and Nrf2 ubiquitination. LC3II/I and ATG5 were expressed more often when p62 was knocked down. Treating with an inhibitor of autophagy reversed the impact of p62 knockdown on PASMCs. Nrf2 inhibitor treatment reduced the expression of Nrf2 and p62, while increasing the expression of Keap1, LC3II/I, and ATG5 in PASMCs. However, overexpressing p62 diminished mRVP, SPAP, and Fulton index in PAH rats and attenuated pulmonary vascular wall thickening. Overexpression of p62 also decreased the expression of Keap1, LC3II/I, and ATG5 and increased the nuclear expression of Nrf2 in PAH rats. Importantly, overexpression of p62 reduced oxidative stress and the NADPH oxidase expression in PAH rats. Overall, activation of the p62-Keap1-Nrf2 positive feedback signaling axis reduces the proliferation and migration of PASMCs and alleviates PAH by inhibiting autophagy and oxidative stress.
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Affiliation(s)
- Gang Jiang
- Department of Respiratory Medicine, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Li-Fang Shi
- Department of Respiratory Medicine, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Ling-Jiao Li
- Department of Respiratory Medicine, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Xiao-Ju Duan
- Department of Respiratory Medicine, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Zhao-Fen Zheng
- Department of Cardiovascular Medicine, Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University), Changsha, China
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Li N, Su S, Xie X, Yang Z, Li Z, Lu D. Tsantan Sumtang, a traditional Tibetan medicine, protects pulmonary vascular endothelial function of hypoxia-induced pulmonary hypertension rats through AKT/eNOS signaling pathway. JOURNAL OF ETHNOPHARMACOLOGY 2024; 320:117436. [PMID: 37979813 DOI: 10.1016/j.jep.2023.117436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Tsantan Sumtang (TS), originated from the Four Tantras, is an empirical Tibetan medicine prescription, which has been widely used for treating cardiovascular diseases in the clinic in Qinghai Province of China. Our previous studies found that TS alleviated hypoxia-induced pulmonary hypertension (HPH) in rats. However, the effect and bioactive fractions of TS on hypoxia-injured pulmonary vascular endothelium are unknown. AIM OF THE STUDY To investigate the effect, bioactive fractions and pharmacological mechanism of TS on hypoxia-injured pulmonary vascular endothelium in vivo and in vitro. MATERIALS AND METHODS In vivo studies, HPH animal model was established, and TS was administrated for four weeks. Then, hemodynamic indexes, ex vivo pulmonary artery perfusion experiment, morphological characteristics, nitric oxide (NO) production, and the protein expression of protein kinase B (AKT)/endothelial nitric oxide synthase (eNOS) and AMP-activated protein kinase (AMPK)/eNOS signaling were determined. In vitro studies, 1% O2-induced pulmonary artery endothelial cells (PAECs) injury model was applied for screening bioactive fractions of TS by cell proliferation assay and NO production measurement. The associated proteins of AKT/eNOS signaling were further measured to elucidate underlying mechanism of bioactive fraction of TS via using phosphatidylinositol-3 kinase (PI3K) inhibitor LY294002. Ultra-high performance liquid chromatography with hybrid quadrupole-orbitrap mass spectrometry (UHPLC-Q-Exactive Orbitrap-MS) was used to reveal the chemical profile of bioactive fraction of TS. RESULTS TS showed protective effect on the integrity of distal pulmonary arterial endothelium in HPH rats. Tsantan Sumtang dilated pulmonary arterial rings in HPH rats. TS enhanced NO bioavailability in lung tissue via regulating AKT/eNOS signaling. Furthermore, in the cellular level, cell viability as well as NO content of hypoxia-injured PAECs were elevated by fraction 17 of water extract of TS (WTS), through activating the AKT/eNOS signaling. Ellagic acid could be one of compositions in fraction 17 of WTS to produce NO in hypoxia-injured PAECs. CONCLUSION TS restored pulmonary arterial endothelial function in HPH rats. The bioactive fraction 17 was screened, which protected hypoxia-injured PAECs via upregulating AKT/eNOS signaling.
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Affiliation(s)
- Na Li
- Research Center for High Altitude Medicine, Key Laboratory of High Altitude Medicine (Ministry of Education), Laboratory for High Altitude Medicine of Qinghai Province, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Qinghai University, Xining, 810001, PR China; Affiliated Hospital of Qinghai University, Xining, 810001, PR China
| | - Shanshan Su
- Technical Center of Xining Customs, Key Laboratory of Food Safety Research in Qinghai Province, Xining, 810003, PR China
| | - Xin Xie
- Research Center for High Altitude Medicine, Key Laboratory of High Altitude Medicine (Ministry of Education), Laboratory for High Altitude Medicine of Qinghai Province, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Qinghai University, Xining, 810001, PR China
| | - Zhanting Yang
- Research Center for High Altitude Medicine, Key Laboratory of High Altitude Medicine (Ministry of Education), Laboratory for High Altitude Medicine of Qinghai Province, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Qinghai University, Xining, 810001, PR China
| | - Zhanqiang Li
- Research Center for High Altitude Medicine, Key Laboratory of High Altitude Medicine (Ministry of Education), Laboratory for High Altitude Medicine of Qinghai Province, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Qinghai University, Xining, 810001, PR China.
| | - Dianxiang Lu
- Research Center for High Altitude Medicine, Key Laboratory of High Altitude Medicine (Ministry of Education), Laboratory for High Altitude Medicine of Qinghai Province, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Qinghai University, Xining, 810001, PR China; Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, 610086, PR China.
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10
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Grünig E, Jansa P, Fan F, Hauser JA, Pannaux M, Morganti A, Rofael H, Chin KM. Randomized Trial of Macitentan/Tadalafil Single-Tablet Combination Therapy for Pulmonary Arterial Hypertension. J Am Coll Cardiol 2024; 83:473-484. [PMID: 38267108 DOI: 10.1016/j.jacc.2023.10.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Endothelin receptor antagonist (ERA) and phosphodiesterase 5 inhibitor (PDE5i) combination therapy is recommended for low-/intermediate-risk pulmonary arterial hypertension (PAH) patients. A fixed-dose combination of the ERA macitentan and PDE5i tadalafil (M/T FDC) in a once-daily, single tablet would simplify treatment. OBJECTIVES The multicenter, double-blind, adaptive phase 3 A DUE study investigated the efficacy and safety of M/T FDC vs macitentan 10 mg and vs tadalafil 40 mg monotherapies in PAH patients, including treatment-naïve and prior ERA or PDE5i monotherapy-treated patients. METHODS World Health Organization functional class II-III patients were randomized to M/T FDC, macitentan, or tadalafil depending on their PAH treatment (treatment-naïve, ERA, or PDE5i monotherapy) at baseline. The primary endpoint was change in pulmonary vascular resistance (PVR) at week 16. RESULTS In total, 187 patients were randomized to single-tablet M/T FDC (n = 108), macitentan (n = 35), or tadalafil (n = 44). PVR reduction with M/T FDC was significantly greater vs macitentan (29%; geometric mean ratio 0.71; 95% CL: 0.61-0.82; P < 0.0001) and vs tadalafil (28%; geometric mean ratio 0.72; 95% CL: 0.64-0.80; P < 0.0001). Three patients died in the M/T FDC arm (judged unrelated to treatment). Adverse events (AEs) leading to discontinuation, serious AEs, and those of special interest (anemia, hypotension, and edema) were more frequent with M/T FDC. CONCLUSIONS Macitentan and tadalafil FDC significantly improved PVR vs monotherapies in PAH patients, with a safety and tolerability profile consistent with the individual components. The A DUE study supports M/T FDC as a once-daily, single-tablet combination for initial therapy and escalation to double combination therapy in patients with PAH. (Clinical Study to Compare the Efficacy and Safety of Macitentan and Tadalafil Monotherapies With the Corresponding Fixed-dose Combination Therapy in Subjects With Pulmonary Arterial Hypertension [PAH]) [A DUE]; NCT03904693).
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Affiliation(s)
- Ekkehard Grünig
- Thoraxklinik at Heidelberg University Hospital and Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany
| | - Pavel Jansa
- Charles University and General University Hospital, Prague, Czech Republic
| | - Fenling Fan
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jakob A Hauser
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Clinical Science, Allschwil, Switzerland
| | | | - Adele Morganti
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Statistical Decision Science, Allschwil, Switzerland
| | - Hany Rofael
- Janssen Research and Development, LLC, Clinical Science, Titusville, New Jersey, USA
| | - Kelly M Chin
- UT Southwestern Medical Center, Dallas, Texas, USA.
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11
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Fauvel C, Liu Y, Correa-Jaque P, Kanwar MK, Vizza CD, Lin S, Benza RL. Do Patients With Low-Risk Pulmonary Arterial Hypertension Really Benefit From Upfront Combination Therapy?: Insight From the AMBITION Trial. Chest 2023; 164:1518-1530. [PMID: 37356711 PMCID: PMC10716797 DOI: 10.1016/j.chest.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Based on results of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial, upfront combination therapy is recommended for treatment-naive patients with low-risk pulmonary arterial hypertension (PAH). However, conflicting data exist whether adopting this treatment strategy in this risk group is beneficial or well tolerated. RESEARCH QUESTION Do patients with low-risk PAH really benefit from upfront combination therapy? STUDY DESIGN AND METHODS Using the data from the original AMBITION trial, patients with PAH were classified as low, intermediate, or high risk using the Registry to Evaluate Early and Long-term PAH Disease Management 2.0 (REVEAL 2.0) score and the Pulmonary Hypertension Outcomes and Risk Assessment (PHORA) tool. The primary end point was time to clinical worsening (including death, hospitalization for PAH worsening, and disease progression) censored at 1- and 3-year post-enrollment. Side effects that led to withdrawal of treatment were also considered. RESULTS Patients with low-risk PAH categorized by REVEAL 2.0 and PHORA did not see a statistically significant benefit of upfront combination therapy vs monotherapy for time to clinical worsening at 1 and 3 years' post-enrollment using Cox proportional analysis (3-year hazard ratio of 0.40 [95% CI, 0.15-1.06; P = .07] and 0.55 [95% CI, 0.26-1.18; P = .12] for REVEAL 2.0 and PHORA, respectively) or considering time to clinical worsening or side effects (3-year hazard ratio of 0.75 [95% CI, 0.39-1.47; P = .4] and 0.87 [95% CI, 0.49-1.54; P = .63] for REVEAL 2.0 and PHORA). Patients with low-risk PAH on upfront combination therapy experienced a higher but not significant incidence of side effects using REVEAL 2.0 and PHORA. In contrast, patients at intermediate or high risk saw a statistically significant benefit of upfront combination therapy considering each of the end points regardless of side effects. INTERPRETATION This analysis suggests that perhaps some patients with low-risk PAH should be further stratified using other modalities prior to committing to upfront combination therapy, especially when the occurrence of side effects is considered. Further prospective data are needed to validate this hypothesis prior to changes in current guideline directed therapy are contemplated.
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Affiliation(s)
- Charles Fauvel
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH; Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Yongqi Liu
- Department of Statistics, The Ohio State University, Columbus, OH
| | - Priscilla Correa-Jaque
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
| | | | - Shili Lin
- Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Raymond L Benza
- ICAHN School of Medicine at Mount Sinai, Mount Sinai Heart, New York, New York.
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12
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Zelt JGE, Weatherald J, Mathai SC. Ambitions for Pulmonary Arterial Hypertension Composite End Points: A Chain Is Only as Strong as Its Weakest Link. Chest 2023; 164:1350-1353. [PMID: 38070956 DOI: 10.1016/j.chest.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Jason G E Zelt
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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13
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Bordag N, Nagy BM, Zügner E, Ludwig H, Foris V, Nagaraj C, Biasin V, Bodenhofer U, Magnes C, Maron BA, Ulrich S, Lange TJ, Hötzenecker K, Pieber T, Olschewski H, Olschewski A. Lipidomics for diagnosis and prognosis of pulmonary hypertension. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.17.23289772. [PMID: 37292870 PMCID: PMC10246148 DOI: 10.1101/2023.05.17.23289772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Pulmonary hypertension (PH) poses a significant health threat with high morbidity and mortality, necessitating improved diagnostic tools for enhanced management. Current biomarkers for PH lack functionality and comprehensive diagnostic and prognostic capabilities. Therefore, there is a critical need to develop biomarkers that address these gaps in PH diagnostics and prognosis. Methods To address this need, we employed a comprehensive metabolomics analysis in 233 blood based samples coupled with machine learning analysis. For functional insights, human pulmonary arteries (PA) of idiopathic pulmonary arterial hypertension (PAH) lungs were investigated and the effect of extrinsic FFAs on human PA endothelial and smooth muscle cells was tested in vitro. Results PA of idiopathic PAH lungs showed lipid accumulation and altered expression of lipid homeostasis-related genes. In PA smooth muscle cells, extrinsic FFAs caused excessive proliferation and endothelial barrier dysfunction in PA endothelial cells, both hallmarks of PAH.In the training cohort of 74 PH patients, 30 disease controls without PH, and 65 healthy controls, diagnostic and prognostic markers were identified and subsequently validated in an independent cohort. Exploratory analysis showed a highly impacted metabolome in PH patients and machine learning confirmed a high diagnostic potential. Fully explainable specific free fatty acid (FFA)/lipid-ratios were derived, providing exceptional diagnostic accuracy with an area under the curve (AUC) of 0.89 in the training and 0.90 in the validation cohort, outperforming machine learning results. These ratios were also prognostic and complemented established clinical prognostic PAH scores (FPHR4p and COMPERA2.0), significantly increasing their hazard ratios (HR) from 2.5 and 3.4 to 4.2 and 6.1, respectively. Conclusion In conclusion, our research confirms the significance of lipidomic alterations in PH, introducing innovative diagnostic and prognostic biomarkers. These findings may have the potential to reshape PH management strategies.
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Affiliation(s)
- Natalie Bordag
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- BioMedTech, Graz, Austria
| | - Bence Miklos Nagy
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elmar Zügner
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Helga Ludwig
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Chandran Nagaraj
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- BioMedTech, Graz, Austria
| | - Valentina Biasin
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Physiology, Otto Loewi Research Centre, Medical University of Graz, Graz, Austria
| | - Ulrich Bodenhofer
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Christoph Magnes
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Bradley A. Maron
- University of Maryland School of Medicine, Baltimore, MD and The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Silvia Ulrich
- Clinic of Pulmonology, University and University Hospital of Zurich, Zürich, Switzerland
| | - Tobias J. Lange
- Department of Internal Medicine II, Pulmonology and Critical Care, Kreisklinik Bad Reichenhall, Bad Reichenhall, Germany
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Konrad Hötzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Pieber
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz Austria
- BioMedTech, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Experimental Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
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14
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Guo J, Wang J, Wang L, Li Y, Xu Y, Li W, Chen C, He J, Yin L, Pu S, Wen B, Han Y, Chen Y. Left ventricular underfilling in PAH: A potential indicator for adaptive-to-maladaptive transition. Pulm Circ 2023; 13:e12309. [PMID: 38045097 PMCID: PMC10689890 DOI: 10.1002/pul2.12309] [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: 05/28/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) still remains a life-threatening disorder with poor prognosis. The right ventricle (RV) adapts to the increased afterload by a series of prognostically significant morphological and functional changes, the adaptive nature should also be understood in the context of ventricular interdependence. We hypothesized that left ventricle (LV) underfilling could serve as an important imaging marker for identifying maladaptive changes and predicting clinical outcomes in PAH patients. We prospectively enrolled patients with PAH who underwent both cardiac magnetic resonance and right heart catheterization between October 2013 and December 2020. Patients were categorized into four groups based on their LV and RV mass/volume ratio (M/V). LV M/V was stratified using the normal value (0.7 g/mL for males and 0.6 g/mL for females) to identify patients with LV underfilling (M/V ≥ normal value), while RV M/V was stratified based on the median value. The primary endpoint was all-cause mortality, and the composite endpoints included all-cause mortality and heart failure-related readmissions. A total of 190 PAH patients (53 male, mean age 37 years) were included in this study. Patients with LV underfilling exhibited higher NT-proBNP levels, increased RV mass, larger RV but smaller LV, lower right ventricular ejection fraction, and shorter 6-min walking distance. Patients with LV underfilling had a 2.7-fold higher risk of mortality than those without and LV M/V (hazard ratio [per 0.1 g/mL increase]: 1.271, 95% confidence interval: 1.082-1.494, p = 0.004) was also independent predictors of all-cause mortality. Moreover, patients with low LV M/V had a better prognosis regardless of the level of RV M/V. Thus, LV underfilling is an independent predictor of adverse clinical outcomes in patients with PAH, and it could be an important imaging marker for identifying maladaptive changes in these patients.
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Affiliation(s)
- Jiajun Guo
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Jiaqi Wang
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yangjie Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Yuanwei Xu
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Weihao Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Chen Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Juan He
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Lidan Yin
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Shoufang Pu
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Bi Wen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Yuchi Han
- Division of Cardiovascular Medicine, Wexner Medical Center, College of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Yucheng Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
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15
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Humbert M, Sitbon O, Guignabert C, Savale L, Boucly A, Gallant-Dewavrin M, McLaughlin V, Hoeper MM, Weatherald J. Treatment of pulmonary arterial hypertension: recent progress and a look to the future. THE LANCET. RESPIRATORY MEDICINE 2023; 11:804-819. [PMID: 37591298 DOI: 10.1016/s2213-2600(23)00264-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe but treatable form of pre-capillary pulmonary hypertension caused by pulmonary vascular remodelling. As a result of basic science discoveries, randomised controlled trials, studies of real-world data, and the development of clinical practice guidelines, considerable progress has been made in the treatment options and outcomes for patients with PAH, underscoring the importance of seamless translation of information from bench to bedside and, ultimately, to patients. However, PAH still carries a high mortality rate, which emphasises the urgent need for transformative innovations in the field. In this Series paper, written by a group of clinicians, researchers, and a patient with PAH, we review therapeutic approaches and treatment options for PAH. We summarise current knowledge of the cellular and molecular mechanisms of PAH, with an emphasis on emerging treatable pathways and optimisation of current management strategies. In considering future directions for the field, our ambition is to identify therapies with the potential to stall or reverse pulmonary vascular remodelling. We highlight novel therapeutic approaches, the important role of patients as partners in research, and innovative approaches to PAH clinical trials.
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Affiliation(s)
- Marc Humbert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France.
| | - Olivier Sitbon
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | | | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), Hannover, Germany
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
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16
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Amann U, Nadine Wentzell, Kollhorst B, Haug U. Prescribing of endothelin receptor antagonists and riociguat in women of childbearing age in a large German claims database study. Reprod Toxicol 2023; 119:108415. [PMID: 37245698 DOI: 10.1016/j.reprotox.2023.108415] [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: 01/24/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
Use of endothelin receptor antagonists (ERAs) and riociguat, approved for treatment of pulmonary hypertension (PH), is contraindicated during pregnancy due to reported teratogenicity in animals. We aimed to investigate prescribing of these drugs in girls/women of childbearing age and to explore - as a secondary aim - the occurrence of pregnancies exposed to these drugs. Using the German Pharmacoepidemiological Research Database (GePaRD, claims data from 20% of the German population) we conducted cross-sectional analyses to determine prescribing prevalence of ERAs and riociguat between 2004 and 2019 and to characterize users and prescribing patterns. In a cohort analysis, we assessed the occurrence of pregnancies exposed to these drugs in the critical time window. Overall, we identified 407 women with ≥ 1 dispensation of bosentan between 2004 and 2019; the respective number was 73 for ambrisentan, 182 for macitentan, 31 for sitaxentan, and 63 for riociguat. In nearly all years, more than 50% of the girls/women were ≤ 40 years. Age-standardized prevalence was highest for bosentan (0.04/1000) in 2012 and 2013, followed by macitentan (0.03/1000) in 2018 and 2019. We observed 10 exposed pregnancies: 5 to bosentan, 3 to ambrisentan, and 2 to macitentan. The increased prevalence of macitentan and riociguat from 2014 onwards might reflect changes in PH treatment. Even though PH is a rare disease and pregnancy should be avoided in women with PH, particularly if they use ERAs, we identified pregnancies exposed to ERAs. Multi-database studies will be needed to assess the risk of these drugs on the unborn child.
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Affiliation(s)
- Ute Amann
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany; Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany.
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17
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Ostad S, Sugarman J, Alkhodair A, Liang J, Mielniczuk LM, Hambly N, Helmersen D, Hirani N, Thakrar M, Varughese R, Norena M, Kularatne M, Swiston JR, Kapasi A, Weatherald J, Brunner NW. Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study. CJC Open 2023; 5:545-553. [PMID: 37496788 PMCID: PMC10366663 DOI: 10.1016/j.cjco.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.
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Affiliation(s)
- Sam Ostad
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Sugarman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Alkhodair
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jiaming Liang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Mielniczuk
- Department of Medicine, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathan Hambly
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naushad Hirani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mitesh Thakrar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John R. Swiston
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan W. Brunner
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Zuin M, Bilato C, Rigatelli G, Quadretti L, Roncon L. Trends in age-specific and sex-specific pulmonary hypertension mortality in Italy between 2005 and 2017. J Cardiovasc Med (Hagerstown) 2023; 24:289-296. [PMID: 36938812 DOI: 10.2459/jcm.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
AIMS Data regarding the pulmonary hypertension (PH)-related mortality and relative trends in the Italian population remain scant. We sought to assess the PH mortality rates and relative trends among the Italian population between 2005 and 2017. METHODS Data regarding the cause-specific mortality and population size by sex in 5-year age groups were extracted from the WHO global mortality database. The age-standardized mortality rates, with relative 95% confidence intervals (CIs), also stratified by sex, were using the direct method. Joinpoint regression analyses were used to identify periods with statistically distinct log linear trends in PH-related death rates. To calculate nationwide annual trends in DCM-related mortality, we assessed the average annual percentage change (AAPC) and relative 95% CIs. RESULTS In Italy, the PH age-standardized annual mortality rate decreased from 2.34 (95% CI: 2.32-2.36) deaths per 100 000 to 1.51 (95% CI: 1.48-1.53) deaths per 100 000 population. Over the entire period, men had higher PH-related mortality rates than women. Moreover, the PH-related mortality trend rose with a seemingly exponential distribution with a similar trend among male and female individuals. Joinpoint regression analysis revealed a linear significant decrease in age-standardized PH-related mortality from 2005 to 2017 [AAPC: -3.1% (95% CI: -3.8 to -2.5), P < 0.001] in the entire Italian population. However, the decline was more pronounced among men [AAPC: -5.0 (95% CI: -6.1 to -3.9), P < 0.001] compared with women [AAPC: -1.5 (95% CI: -2.3 to -0.7), P = 0.001]. CONCLUSION In Italy, the PH-related mortality rates linearly declined from 2005 to 2017.
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Affiliation(s)
- Marco Zuin
- Department of Cardiology, West Vicenza Hospital, Arzignano, Vicenza.,Department of Translational Medicine, University of Ferrara, Ferrara
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Vicenza
| | | | - Laura Quadretti
- Department of Cardiology, Casa di Cura Madonna della Slaute, Porto Viro
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
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19
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Li W, Chen W, Peng H, Xiao Z, Liu J, Zeng Y, Huang T, Song Q, Wang X, Xiao Y. Shikonin improves pulmonary vascular remodeling in monocrotaline‑induced pulmonary arterial hypertension via regulation of PKM2. Mol Med Rep 2023; 27:60. [PMID: 36734266 PMCID: PMC9936259 DOI: 10.3892/mmr.2023.12947] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH), a fatal disease with an insidious onset and rapid progression, shows characteristics such as increases in pulmonary circulatory resistance and pulmonary arterial pressure, and progressive right heart failure. Shikonin can reduce right ventricular systolic pressure in chronically hypoxic mice. However, the mechanisms underlying the protective effect of shikonin against PAH pathogenesis have only been sporadically identified. The present study evaluated whether inhibiting the expression of pyruvate kinase M2 (PKM2) contributed to the improvement of pulmonary vascular remodeling in PAH rats induced by monocrotaline (MCT) treatment. Hemodynamic parameters were assessed using echocardiography and right ventricular catheterization. Right ventricular hypertrophy index analysis and hematoxylin and eosin staining were used to evaluate the degree of pulmonary vascular and right heart remodeling. Moreover, PKM2, p‑PKM2, ERK, p‑ERK, glucose transporter 1 (GLUT1), lactate dehydrogenase A (LDHA) protein expression levels were semi‑quantified using western blotting. The expression and distribution of PKM2 were assessed using immunofluorescence microscopy. The present study demonstrated that MCT treatment caused pulmonary arterial hypertension and pulmonary vascular remodeling in experimental rats. Shikonin improved hemodynamics and pulmonary vascular remodeling in MCT‑induced PAH rats, decreased aerobic glycolysis and downregulated PKM2, p‑PKM2, p‑ERK, GLUT 1 and LDHA protein expression levels. Shikonin improved experimental pulmonary arterial hypertension hemodynamics and pulmonary vascular remodeling at least partly through the inhibition of PKM2 and the resultant suppression of aerobic glycolysis. These results provide a novel understanding of possible new treatment targets for PAH.
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Affiliation(s)
- Wenfeng Li
- Department of Ultrasound, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Wenjuan Chen
- Department of Ultrasound, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Hongyan Peng
- Hunan Children's Research Institute, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Zhenghui Xiao
- Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Jinqiao Liu
- Department of Ultrasound, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Yunhong Zeng
- Department of Cardiology, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Ting Huang
- Department of Ultrasound, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Qingqing Song
- Department of Cardiology, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Xun Wang
- Department of Cardiology, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China
| | - Yunbin Xiao
- Department of Cardiology, Hunan Children's Hospital, Changsha, Hunan 410007, P.R. China,Correspondence to: Dr Yunbin Xiao, Department of Cardiology, Hunan Children's Hospital, 86 Zi Yuan Road, Yuhua, Changsha, Hunan 410007, P.R. China, E-mail:
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20
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Hassan HJ, Naranjo M, Ayoub N, Housten T, Hsu S, Balasubramanian A, Simpson CE, Damico RL, Mathai SC, Kolb TM, Hassoun PM. Improved Survival for Patients with Systemic Sclerosis-associated Pulmonary Arterial Hypertension: The Johns Hopkins Registry. Am J Respir Crit Care Med 2023; 207:312-322. [PMID: 36173815 PMCID: PMC9896646 DOI: 10.1164/rccm.202204-0731oc] [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: 04/15/2022] [Accepted: 09/29/2022] [Indexed: 02/03/2023] Open
Abstract
Rationale: To date, it remains unclear whether recent changes in the management of patients with systemic sclerosis-associated pulmonary hypertension (SSc-PH) have improved survival. Objectives: To describe a cohort of patients with SSc-PH and compare their characteristics and survival between the last two decades. Methods: Patients with SSc-PH prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Center Registry were grouped into two cohorts based on the date of diagnostic right heart catheterization: cohort A included patients whose disease was diagnosed between 1999 and 2010, and cohort B included those whose disease was diagnosed between 2010 and 2021. Patients' characteristics were compared between the two cohorts. Measurements and Main Results: Of 504 patients with SSc-PH distributed almost equally between the two cohorts, 308 (61%) had World Symposium on Pulmonary Hypertension group 1, 43 (9%) had group 2, and 151 (30%) had group 3 disease. Patients with group 1 disease in cohort B had significantly better clinical and hemodynamic characteristics at diagnosis, were more likely to receive upfront combination pulmonary arterial hypertension therapy, and had a nearly 4-year increase in median transplant-free survival in univariable analysis than those in cohort A (P < 0.01). Improved transplant-free survival was still observed after adjusting for patients' baseline characteristics. In contrast, for group 2 or 3 patients with SSc-PH, there were no differences in baseline clinical, hemodynamic, or survival characteristics between the two cohorts. Conclusions: This is the largest single-center study that compares clinical characteristics of patients with SSc-PH between the last two decades. Transplant-free survival has improved significantly for those with group 1 disease over the last decade, possibly secondary to earlier detection and better therapeutic management. Conversely, those with group 2 or 3 disease continue to have dismal prognosis.
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Affiliation(s)
| | - Mario Naranjo
- Division of Pulmonary and Critical Care Medicine and
| | - Nour Ayoub
- Division of Pulmonary and Critical Care Medicine and
| | - Traci Housten
- Division of Pulmonary and Critical Care Medicine and
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine and
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21
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 541] [Impact Index Per Article: 541.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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22
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CTLA-4 Expression Is a Promising Biomarker of Idiopathic Pulmonary Arterial Hypertension and Allows Differentiation of the Type of Pulmonary Hypertension. Int J Mol Sci 2022; 23:ijms232415910. [PMID: 36555549 PMCID: PMC9783197 DOI: 10.3390/ijms232415910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is an increasingly frequently diagnosed disease, the molecular mechanisms of which have not been thoroughly investigated. The aim of our study was to investigate subpopulations of lymphocytes to better understand their role in the molecular pathomechanisms of various types of PAH and to find a suitable biomarker that could be useful in the differential diagnosis of PAH. Using flow cytometry, we measured the frequencies of lymphocyte subpopulations CD4+CTLA-4+, CD8+ CTLA-4+ and CD19+ CTLA-4+ in patients with different types of PAH, namely pulmonary arterial hypertension associated with congenital heart disease (CHD-PAH), pulmonary arterial hypertension associated with connective tissue disorders (CTD-PAH), chronic thromboembolic pulmonary hypertension (CTEPH) and idiopathic pulmonary arterial hypertension (iPAH), and in an age- and sex-matched control group in relation to selected clinical parameters. Patients in the iPAH group had the significantly highest percentage of CD4+CTLA-4+ T lymphocytes among all PAH groups, as compared to those in the control group (p < 0.001), patients with CTEPH (p < 0.001), CTD-PAH (p < 0.001) and CHD-PAH (p < 0.01). In iPAH patients, the percentages of CD4+CTLA-4+ T cells correlated strongly positively with the severity of heart failure New York Heart Association (NYHA) Functional Classification (r = 0.7077, p < 0.001). Moreover, the percentage of B CD19+CTLA-4+ cells strongly positively correlated with the concentration of NT-proBNP (r = 0.8498, p < 0.001). We have shown that statistically significantly higher percentages of CD4+CTLA-4+ (p ≤ 0.01) and CD8+ CTLA-4+ (p ≤ 0.001) T cells, measured at the time of iPAH diagnosis, were found in patients who died within 5 years of the diagnosis, which allows us to consider both of the above lymphocyte subpopulations as a negative prognostic/predictive factor in iPAH. CTLA-4 may be a promising biomarker of noninvasive detection of iPAH, but its role in planning the treatment strategy of PAH remains unclear. Further studies on T and B lymphocyte subsets are needed in different types of PAH to ascertain the relationships that exist between them and the disease.
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23
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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24
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1215] [Impact Index Per Article: 607.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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25
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Boucly A, Humbert M, Sitbon O. To be or not to be… treated with initial combination therapy, that is the (PAH) question. Eur Respir J 2022; 59:59/6/2200390. [PMID: 35654453 DOI: 10.1183/13993003.00390-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France.,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France.,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France .,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
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26
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Chang KY, Duval S, Badesch DB, Bull TM, Chakinala MM, De Marco T, Frantz RP, Hemnes A, Mathai SC, Rosenzweig EB, Ryan JJ, Thenappan T. Mortality in Pulmonary Arterial Hypertension in the Modern Era: Early Insights From the Pulmonary Hypertension Association Registry. J Am Heart Assoc 2022; 11:e024969. [PMID: 35475351 PMCID: PMC9238604 DOI: 10.1161/jaha.121.024969] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Current mortality data for pulmonary arterial hypertension (PAH) in the United States are based on registries that enrolled patients prior to 2010. We sought to determine mortality in PAH in the modern era using the PHAR (Pulmonary Hypertension Association Registry). Methods and Results We identified all adult patients with PAH enrolled in the PHAR between September 2015 and September 2020 (N=935). We used Kaplan-Meier survival analysis and Cox proportional hazards models to assess mortality at 1, 2, and 3 years. Patients were stratified based on disease severity by 3 validated risk scores. In treatment-naïve patients, we compared survival based on initial treatment strategy. The median age was 56 years (44-68 years), and 76% were women. Of the 935 patients, 483 (52%) were ≤6 months from PAH diagnosis. There were 121 deaths (12.9%) during a median follow-up time of 489 days (281-812 days). The 1-, 2-, and 3-year mortality was 8% (95% CI, 6%-10%), 16% (95% CI, 13%-19%), and 21% (95% CI, 17%-25%), respectively. When stratified into low-, intermediate-, and high-risk PAH, the mortality at 1, 2, and 3 years was 1%, 4% to 6%, and 7% to 11% for low risk; 7% to 8%, 11% to 16%, and 18% to 20% for intermediate risk; and 12% to 19%, 22% to 38%, and 28% to 55% for high risk, respectively. In treatment-naïve patients, initial combination therapy was associated with better 1-year survival (adjusted hazard ratio, 0.43 [95% CI, 0.19-0.95]; P=0.037). Conclusions Mortality in the intermediate- and high-risk patients with PAH remains unacceptably high in the PHAR, suggesting the importance for early diagnosis, aggressive use of available therapies, and the need for better therapeutics.
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Affiliation(s)
- Kevin Y. Chang
- Department of MedicineUniversity of MinnesotaMinneapolisMN
| | - Sue Duval
- Department of MedicineUniversity of MinnesotaMinneapolisMN
| | | | - Todd M. Bull
- Department of MedicineUniversity of ColoradoDenverCO
| | | | - Teresa De Marco
- Department of MedicineUniversity of California San FranciscoSan FranciscoCA
| | | | - Anna Hemnes
- Department of MedicineVanderbilt UniversityNashvilleTN
| | | | | | - John J. Ryan
- Department of MedicineUniversity of UtahSalt Lake CityUT
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27
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Prognostic value of improvement endpoints in pulmonary arterial hypertension trials: A COMPERA analysis. J Heart Lung Transplant 2022; 41:971-981. [DOI: 10.1016/j.healun.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
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