Survival with sildenafil and inhaled iloprost in a cohort with pulmonary hypertension: an observational study

Preventive effects of nitrate-rich beetroot juice supplementation on monocrotaline-induced pulmonary hypertension in rats

Beetroot (Beta vulgaris L.) has a high level of nitrate; therefore, its dietary intake could increase nitric oxide (NO) level in the body, possibly preventing the development of pulmonary hypertension (PH). In this study, we examined the effects of beetroot juice (BJ) supplementation on PH and the contribution of nitrate to such effects using a rat model of monocrotaline (MCT, 60 mg/kg s.c.)-induced PH. Rats were injected subcutaneously with saline or 60 mg/kg MCT and were sacrificed 28 days after the injection. In some rats injected with MCT, BJ was supplemented from the day of MCT injection to the day of sacrifice. First, MCT-induced right ventricular systolic pressure elevation, pulmonary arterial medial thickening and muscularization, and right ventricular hypertrophy were suppressed by supplementation with low-dose BJ (nitrate: 1.3 mmol/L) but not high-dose BJ (nitrate: 4.3 mmol/L). Of the plasma nitrite, nitrate, and their sum (NOx) levels, only the nitrate levels were found to be increased by the high-dose BJ supplementation. Second, in order to clarify the possible involvement of nitrate in the preventive effects of BJ on PH symptoms, the effects of nitrate-rich BJ (nitrate: 0.9 mmol/L) supplementation were compared with those of the nitrate-depleted BJ. While the former exerted preventive effects on PH symptoms, such effects were not observed in rats supplemented with nitrate-depleted BJ. Neither supplementation with nitrate-rich nor nitrate-depleted BJ affected plasma nitrite, nitrate, and NOx levels. These findings suggest that a suitable amount of BJ ingestion, which does not affect systemic NO levels, can prevent the development of PH in a nitrate-dependent manner. Therefore, BJ could be highly useful as a therapy in patients with PH.

[Advantages and limitations of initial combination therapy in pulmonary arterial hypertension patients in Russia]

Pulmonary arterial hypertension (PAH) is severe and often times rapidly progressive disease with fatal outcome. The concept of initial combination of PAH-specific therapies in high risk patients at baseline was first described in the European guidelines on pulmonary hypertension (PH) in 2009, and in low or intermediate risk patients at baseline in 2015. Interestingly, that in Cologne Experts Consensus, and then in the 6th World Symposium on PH medical community started considering initial combination therapy as one of the most important pillars in PAH treatment algorithms in 2018. As of August 2020, as many as 8 formulations of 7 reference PAH-specific drugs are licensed for medical use in the Russian Federation. On top of that, 6 abbreviated drugs (generics) have also become available few years ago. Unfortunately, intravenous and subcutaneous prostacyclin analogs (PCA) and tadalafil are not approved for PH patients treatment in the Russian Federation. In this narrative review paper we attempted to describe studies on initial dual combination therapy with PAH-specific drugs registered in Russia, i.e. ambrisentan and riociguat, macitentan and riociguat, macitentan and sildenafil in low or intermediate risk patients at baseline, as well as iloprost inhaled and sildenafil, iloprost inhaled and bosentan in high risk patients. Some beneficial pharmacological effects due to the synergy between ambrisentan plus riociguat, and inhaled iloprost plus sildenafil appear to be interesting and require further clinical confirmation. Other initial combinations of PAH-specific agents require large-scale clinical trials as well.

Current state and future perspective of cardiovascular medicines derived from natural products

The contribution of natural products (NPs) to cardiovascular medicine has been extensively documented, and many have been used for centuries. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Over the past 40 years, approximately 50% of newly developed cardiovascular drugs were based on NPs, suggesting that NPs provide essential skeletal structures for the discovery of novel medicines. After a period of lower productivity since the 1990s, NPs have recently regained scientific and commercial attention, leveraging the wealth of knowledge provided by multi-omics, combinatorial biosynthesis, synthetic biology, integrative pharmacology, analytical and computational technologies. In addition, as a crucial part of complementary and alternative medicine, Traditional Chinese Medicine has increasingly drawn attention as an important source of NPs for cardiovascular drug discovery. Given their structural diversity and biological activity NPs are one of the most valuable sources of drugs and drug leads. In this review, we briefly described the characteristics and classification of NPs in CVDs. Then, we provide an up to date summary on the therapeutic potential and the underlying mechanisms of action of NPs in CVDs, and the current view and future prospect of developing safer and more effective cardiovascular drugs based on NPs.

Inhaled Iloprost and Oral Sildenafil Combination Therapy: Is it a Chance for Heart Transplant Candidacy?

BACKGROUND

Severe pulmonary hypertension is a risk factor for mortality, due to increased postoperative right ventricular failure, in a heart transplant patient. Elevated pulmonary vascular resistance (PVR) in heart transplant candidates can be reduced using a left ventricular assist device or medical therapy. This study analysed the effect of inhaled iloprost and oral sildenafil combination therapy (ilo-sil) on pulmonary haemodynamic parameters in patients with secondary pulmonary hypertension.

METHODS

Between May 2011 and April 2014, 25 patients who were unresponsive to reversibility test and PVR >3.5 Wood units (WU) during right heart catheterisation were included in this study. After 6 months of oral sildenafil (3 × 20 mg/day) and inhaled iloprost (6 × 5 μg/day) combination therapy, second right heart catheterisations were performed and eligibility for heart transplant was evaluated.

RESULTS

Repeat right heart catheterisation revealed that there was a significant decrease in the PVR from 5.4 ± 1.6 WU to 3.54 ± 2.5 WU (p<0.001), with trans-pulmonary gradient from 13.7 ± 5.6 to 11.46 ± 6.64 (p=0.042), and mean cardiac index (CI) increasing non-significantly from 1.45 ± 0.51 L/min/m2 to 1.82 ± 0.60 (p=0.157). The mean sPAP was initially 57.54 ± 14.79 mmHg and fell to 52.93 ± 16.83 mm Hg (p=0.03). Twenty (20) (80%) patients were enrolled in the waiting list since their PVR values decreased to <3.5 WU. Of these 20 patients, one had undergone heart transplant and four were bridged to transplant with mechanical circulatory support devices.

CONCLUSIONS

After a decrease in PVR with ilo-sil combination therapy for patients with severe pulmonary hypertension, these patients may become candidates for heart transplant without bearing additional risk. Ilo-sil combination therapy could be a viable option with which to evaluate the reversibility of PVR.

Does Portopulmonary Hypertension Impede Liver Transplantation in Cirrhotic Patients? A French Multicentric Retrospective Study

BACKGROUND

Portopulmonary hypertension is defined by the presence of pulmonary arterial hypertension associated with portal hypertension. Its presence is a major stake for cirrhotic patients requiring liver transplantation (LT), with increased postoperative mortality and unpredictable evolution after transplantation. The aim was to study outcomes after liver transplantation in patients with portopulmonary hypertension and to identify factors associated with normalization of pulmonary hypertension.

METHODS

Patients with portopulmonary hypertension who underwent LT between 2008 and 2016 in 8 French centers were retrospectively included. Pulmonary artery pressure was established by right heart catheterization before and after LT. Primary endpoint was the normalization of pulmonary artery pressure after LT.

RESULTS

Twenty-three patients who received liver transplant between 2008 and 2016 were included. Two (8.7%) patients died in the immediate posttransplant period from right heart failure. With appropriate vasoactive medical treatment and LT, pulmonary arterial pressure was normalized in 14 patients (60.8%), demonstrating recovery from portopulmonary hypertension. In univariate analysis, the use of vasoactive combination therapy was the only prognostic factor for pulmonary arterial hypertension normalization after LT.

CONCLUSIONS

Treatment of portopulmonary hypertension with a combination of vasoactive drugs allows LT with acceptable postoperative cardiovascular-related mortality and normalization of pulmonary hypertension in the majority of the patients.

Real-life experience of inhaled iloprost for patients with pulmonary arterial hypertension: Insights from the Spanish REHAP registry

INTRODUCTION

REHAP is a voluntary, observational Spanish registry of patients with pulmonary arterial hypertension. We analyzed the experience (use and effectiveness) with inhaled iloprost (inh-ILO) in real-life conditions during a 3-year period.

METHODS

Patients included were those with PAH ≥14 years recruited during 1998-2016 who had received inh-ILO. Variables were collected at the beginning of treatment (0 ± 3 months) and 12 ± 3/36 ± 6 months follow-up. Effectiveness was assessed in the intent-to-treat population as changes in functional class and/or physical performance and transplant-free survival from the beginning of treatment. Stopping inh-ILO-related survival was also assessed. Subanalyses included treatment strategy (first-line therapy -monotherapy or upfront combination- or sequential therapy) and risk of clinical worsening/death.

RESULTS

Inh-ILO was the most frequently used prostanoid in Spain, rendering 267 patients eligible for analysis. Median age was 54 years; 61% were WHO FC III. Sixty (23%) patients started inh-ILO as monotherapy, 27 (10%) as upfront combination and 180 (67%) sequentially. At 3-year follow-up significant clinical improvements were observed; however, transplant-free survival rate was 54%, being poorer in patients at high risk (63% vs. 85% in low risk patients; P < 0.001) and similar in the three treatment strategies. Only 25% patients remained on inh-ILO. Three-year after stopping inh-ILO-related survival rate was 24.7%.

CONCLUSION

Data from the REHAP collected during 3 years shows that inh-ILO has low effectiveness independently of the treatment strategy used, with a 3-year survival rate of 54% despite significant clinical improvements, probably due to the use in high-risk patients. Discontinuation rate was as high as 75%.

The safety and pharmacokinetics of rapid iloprost aerosol delivery via the BREELIB nebulizer in pulmonary arterial hypertension

The BREELIB nebulizer was developed for iloprost to reduce inhalation times for patients with pulmonary arterial hypertension (PAH). This multicenter, randomized, unblinded, four-part study compared inhalation time, pharmacokinetics, and acute tolerability of iloprost 5 µg at mouthpiece delivered via BREELIB versus the standard I-Neb nebulizer in 27 patients with PAH. The primary safety outcome was the proportion of patients with a maximum increase in heart rate (HR) ≥ 25% and/or a maximum decrease in systolic blood pressure ≥ 20% within 30 min after inhalation. Other safety outcomes included systolic, diastolic, and mean blood pressure, HR, oxygen saturation, and adverse events (AEs). Median inhalation times were considerably shorter with BREELIB versus I-Neb (2.6 versus 10.9 min; n = 24). Maximum iloprost plasma concentration and systemic exposure (area under the plasma concentration–time curve) were 77% and 42% higher, respectively, with BREELIB versus I-Neb. Five patients experienced a maximum systolic blood pressure decrease ≥ 20%, four with BREELIB (one mildly and transiently symptomatic), and one with I-Neb; none required medical intervention. AEs reported during the study were consistent with the known safety profile of iloprost. The BREELIB nebulizer offers reduced inhalation time, good tolerability, and may improve iloprost aerosol therapy convenience and thus compliance for patients with PAH.

Clinical study of right ventricular longitudinal strain for assessing right ventricular dysfunction and hemodynamics in pulmonary hypertension

This study aimed to appraise the application of right ventricular longitudinal strain for assessing right ventricular dysfunction and severe hemodynamic changes in pulmonary hypertension. The study included 53 patients clinically diagnosed with PH. Tissue Doppler-derived tricuspid lateral annular systolic velocity (s'), early diastolic peak velocity (e'), late diastolic peak velocity (a'), tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), and right ventricular fractional area change (FAC) were determined. The STI parameter was RV free wall longitudinal peak systolic strain (RV LPSS). The patients were assigned into two groups based on a RV LPSS value of - 19%.RV LPSS, s', TAPSE, RIMP, FAC, a' and e'/a' showed significant differences. PH patients with an RV LPSS≥ -19% exhibited a lower RV function (P < 0.05). RV LPSS was negatively correlated with TAPSE (r = -0.326, P < 0.05) and FAC (r = -0.495, P < 0.001) and positively correlated with RIMP (r = 0.508, P < 0.001). The optimal cut-off value of RV LPSS to reveal an mPAP ≥ 45 mmHg defined based on the receiver operating characteristic curve analysis was - 19.26% with a sensitivity of 83.9% and a specificity of 73.4%.Distinguishing the degree of RV dysfunction by 2D-STI may help physicians to determine the state of cardiac function and degree of PH in patients and offer a basis for subsequent clinical diagnosis and therapy. Our study demonstrates the superiority of RV LPSS for uncovering severe PH over the traditional echocardiographic parameters.