1
|
Farmakis IT, Baroutidou A, Patsiou V, Arvanitaki A, Doundoulakis I, Hobohm L, Zafeiropoulos S, Konstantinides SV, D'Alto M, Badagliacca R, Giannakoulas G. Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients. ERJ Open Res 2024; 10:00706-2023. [PMID: 38259812 PMCID: PMC10801731 DOI: 10.1183/23120541.00706-2023] [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: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.
Collapse
Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michele D'Alto
- Department of Cardiology, University “L. Vanvitelli”-Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
2
|
Hu X, Li L, Song Y, Lu Y. Effectiveness and safety of traditional Chinese medicines for pulmonary heart disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24131. [PMID: 33429786 PMCID: PMC7793432 DOI: 10.1097/md.0000000000024131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Previous review indicate that the effect of traditional Chinese medicines (TCM) on pulmonary heart disease (PHD) remains uncertainty. Therefore, we designed this study to systematically evaluate the effectiveness and safety of TCM in the treatment of PHD. METHODS Nine online databases will be searched from inception to October 01, 2021, and we will not restrict the language on included trials. Randomized controlled trials that included patients with PHD receiving TCM therapy vs a control group will be included. Two of us will perform independently the selection of studies, risk of bias assessment, and data extraction. The RevMan V.5.2 software with fixed effects model or random effects model will be used to syntheses the data, according to the heterogeneity test to conduct the data synthesis. The dichotomous data and the continuous data will be presented with risk ratios with 95% confidence intervals and weighted mean differences or standardized mean differences with 95% confidence intervals. And we will use the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the evidence quality. RESULT This study will assess effects and safety for TCM on PHD. CONCLUSION The conclusion of this study will provide evidence to prove the safety and effectiveness of TCM on PHD. TRIAL REGISTRATION NUMBER INPLASY2020120024.
Collapse
Affiliation(s)
- Xinyu Hu
- Chengdu University of Traditional Chinese Medicine, School of Clinical Medicine
| | - Lulu Li
- Chengdu University of Traditional Chinese Medicine, School of Clinical Medicine
| | - Yuanying Song
- Chengdu University of Traditional Chinese Medicine, School of Clinical Medicine
| | - Yun Lu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| |
Collapse
|
3
|
Banerjee J, Bruckbauer A, Thorpe T, Zemel MB. Biphasic Effect of Sildenafil on Energy Sensing is Mediated by Phosphodiesterases 2 and 3 in Adipocytes and Hepatocytes. Int J Mol Sci 2019; 20:ijms20122992. [PMID: 31248114 PMCID: PMC6627652 DOI: 10.3390/ijms20122992] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022] Open
Abstract
Sirt1 (Sirtuin 1), AMPK (AMP-activated protein kinase), and eNOS (endothelial nitric oxide synthase) modulate hepatic energy metabolism and inflammation and play a major role in the development of NASH. Cyclic nucleotide phosphodiesterases (PDEs) play an important role in signal transduction by modulating intracellular levels of cyclic nucleotides. We previously found the PDE5 inhibitor sildenafil to synergize with leucine and leucine-metformin combinations in preclinical studies of NASH and obesity. However, efficacy is diminished at higher sildenafil concentrations. Herein, we have successfully modeled the U-shaped sildenafil dose-response in vitro and utilized this model to assess potential mechanisms of this dose-response relationship. Adipocytes and liver cells were treated with leucine (0.5 mM) and different concentrations of sildenafil (1 nM to 100 µM). cAMP, cGMP, and P-AMPK protein expression were used to demonstrate the biphasic response for increasing concentrations of sildenafil. The reversal with higher sildenafil levels was blunted by PDE2 inhibition. These data indicate that sildenafil-mediated increases in cGMP inhibits PDE3 at lower concentrations, which increases cAMP. However, further increases in cGMP from higher sildenafil concentrations activate PDE2 and consequently decrease cAMP, which demonstrates crosstalk between cAMP and cGMP via PDE2, PDE3, and PDE5. These changes in cAMP concentration are further reflected in downstream effects, including AMPK activation.
Collapse
Affiliation(s)
- Jheelam Banerjee
- NuSirt Biopharma Inc., 11020 Solway School Rd, Knoxville, TN 37931, USA.
| | - Antje Bruckbauer
- NuSirt Biopharma Inc., 11020 Solway School Rd, Knoxville, TN 37931, USA.
| | - Teresa Thorpe
- NuSirt Biopharma Inc., 11020 Solway School Rd, Knoxville, TN 37931, USA.
| | - Michael B Zemel
- NuSirt Biopharma Inc., 11020 Solway School Rd, Knoxville, TN 37931, USA.
| |
Collapse
|
4
|
Use of outcome measures in pulmonary hypertension clinical trials. Am Heart J 2015; 170:419-29.e3. [PMID: 26385024 DOI: 10.1016/j.ahj.2015.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of surrogate measures in pulmonary hypertension (PH) clinical trials and how it relates to clinical practice. BACKGROUND Studies of pulmonary arterial hypertension (PAH) employ a variety of surrogate measures in addition to clinical events because of a small patient population, participant burden, and costs. The use of these measures in PH drug trials is poorly defined. METHODS We searched PubMed/MEDLINE/Embase for randomized or prospective cohort PAH clinical treatment trials from 1985 to 2013. Extracted data included intervention, trial duration, study design, patient characteristics, and primary and secondary outcome measures. To compare with clinical practice, we assessed the use of surrogate measures in a clinical sample of patients on PH medications at Duke University Medical Center between 2003 and 2014. RESULTS Between 1985 and 2013, 126 PAH trials were identified and analyzed. Surrogate measures served as primary endpoints in 119 trials (94.0%). Inclusion of invasive hemodynamics decreased over time (78.6%, 75.0%, 52.2%; P for trend = .02), while functional testing (7.1%, 60.0%, 81.5%; P for trend < .0001) and functional status or quality of life (0%, 47.6%, 62.8%; P for trend < .0001) increased in PAH trials over the same time periods. Echocardiography data were reported as a primary or secondary outcome in 32 trials (25.4%) with increased use from 1985-1994 to 1995-2004 (7.1% vs 35.0%, P = .04), but the trend did not continue to 2005-2013 (25.0%). In comparison, among 450 patients on PAH therapies at our institution between 2003 and 2013, clinical assessments regularly incorporated serial echocardiography and 6-minute walk distance tests (92% and 95% of patients, respectively) and repeat measurement of invasive hemodynamics (46% of patients). CONCLUSIONS The majority of PAH trials have utilized surrogate measures as primary endpoints. The use of these surrogate endpoints has evolved significantly over time with increasing use of patient-centered endpoints and decreasing or stable use of imaging and invasive measures. In contrast, imaging and invasive measures are commonly used in contemporary clinical practice. Further research is needed to validate and standardize currently used measures.
Collapse
|
5
|
Chinello P, Cicalini S, Pichini S, Pacifici R, Tempestilli M, Cicini MP, Pucillo LP, Petrosillo N. Sildenafil and bosentan plasma concentrations in a human immunodeficiency virus- infected patient with pulmonary arterial hypertension treated with ritonavir-boosted protease inhibitor. Infect Dis Rep 2015; 7:5822. [PMID: 25874072 PMCID: PMC4387373 DOI: 10.4081/idr.2015.5822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 02/18/2015] [Accepted: 02/20/2015] [Indexed: 11/22/2022] Open
Abstract
Sildenafil and bosentan are increasingly used for the treatment of pulmonary arterial hypertension (PAH) in HIV-infected patients. However, concerns exist about pharmacokinetic interactions among sildenafil, bosentan and antiretroviral drugs, including protease inhibitors (PI). We describe here the case of an HIV-infected patient with PAH, who was co-administered bosentan 125 mg twice daily and sildenafil 40 mg three times per day, together with a ritonavir-boosted PI-based antiretroviral therapy; plasma levels of bosentan, sildenafil, N-desmethylsildenafil, and PI were measured. The patient had a sildenafil Cthrough and Cmax of 276.94 ng/mL and 1733.19 ng/mL, respectively. The Cthrough and the Cmax of bosentan were 1546.53 ng/mL and 3365.99 ng/mL, respectively. The patient was able to tolerate as high sildenafil blood concentrations as 10 times those usually requested and did not report any significant adverse reaction to sildenafil during the follow-up period. Therapeutic drug monitoring should be considered during sildenafil therapy in patients concomitantly treated with ritonavir-boosted PI.
Collapse
Affiliation(s)
- Pierangelo Chinello
- Second Infectious Diseases Unit, L. Spallanzani National Institute for Infectious Diseases , Rome
| | - Stefania Cicalini
- Second Infectious Diseases Unit, L. Spallanzani National Institute for Infectious Diseases , Rome
| | - Simona Pichini
- Drug Abuse and Doping Unit, Department of Therapeutic Research and Medicines Evaluation, National Institute of Health , Rome
| | - Roberta Pacifici
- Drug Abuse and Doping Unit, Department of Therapeutic Research and Medicines Evaluation, National Institute of Health , Rome
| | - Massimo Tempestilli
- Clinical Biochemistry and Pharmacology Laboratory, L. Spallanzani National Institute for Infectious Diseases , Rome
| | - Maria P Cicini
- III Cardiology Unit, S. Camillo-Forlanini Hospital , Rome, Italy
| | - Leopoldo P Pucillo
- Clinical Biochemistry and Pharmacology Laboratory, L. Spallanzani National Institute for Infectious Diseases , Rome
| | - Nicola Petrosillo
- Second Infectious Diseases Unit, L. Spallanzani National Institute for Infectious Diseases , Rome
| |
Collapse
|
6
|
Strange G, Williams T, Kermeen F, Whyte K, Keogh A. Pulmonary hypertension and breathlessness: is it a combination we can ignore? Intern Med J 2014; 44:114-23. [DOI: 10.1111/imj.12321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/29/2013] [Indexed: 11/27/2022]
Affiliation(s)
- G. Strange
- University of Notre Dame; Fremantle Western Australia
- Pulmonary Research; Pulmonary Hypertension Society ANZ, Inc.; Sydney New South Wales Australia
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - T. Williams
- Allergy, Immunology and Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - F. Kermeen
- Pulmonary Hypertension and Lung Transplantation Unit; The Prince Charles Hospital; Brisbane Queensland Australia
| | - K. Whyte
- Auckland City Hospital; Auckland New Zealand
| | - A. Keogh
- St Vincent's Hospital; Sydney New South Wales Australia
| |
Collapse
|
7
|
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease in infants and children that is associated with significant morbidity and mortality. The disease is characterized by progressive pulmonary vascular functional and structural changes resulting in increased pulmonary vascular resistance and eventual right heart failure and death. In the majority of pediatric patients, PAH is idiopathic or associated with congenital heart disease and rarely is associated with other conditions such as connective tissue or thromboembolic disease. Although treatment of the underlying disease and reversal of advanced structural changes has not yet been achieved with current therapy, quality of life and survival have been improved significantly. Targeted pulmonary vasodilator therapies, including endothelin receptor antagonists, prostacyclin analogs, and phosphodiesterase type 5 inhibitors, have demonstrated hemodynamic and functional improvement in children. The management of pediatric PAH remains challenging, as treatment decisions continue to depend largely on results from evidence-based adult studies and the clinical experience of pediatric experts. This article reviews the current drug therapies and their use in the management of PAH in children.
Collapse
Affiliation(s)
- Erika E Vorhies
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | | |
Collapse
|
8
|
Abstract
Children and adults with pulmonary arterial hypertension (PAH) have similarities and differences in their background characteristics, hemodynamics, and clinical manifestations. Regarding genetic background, mutations in BMPR2-related pathways seem to be pivotal; however, it is likely that other modifier genes and bioactive mediators have roles in the various forms of PAH in children and adults. In pediatric PAH, there are no clear sex differences in incidence, age at onset, disease severity, or prognosis but, as compared with adults, syncope incidence, pulmonary vascular resistance, and mean pulmonary artery pressure are higher, and vasoreactivity to acute drug testing is more frequent, among children. Nevertheless, the pharmacokinetic effects of 3 major pulmonary vasodilators appear to be similar in children and adults with PAH. This review focuses on the specific pathophysiologic features of PAH in children.
Collapse
Affiliation(s)
- Tsutomu Saji
- Division of Pediatric Cardiology & Cardiac Surgery, Omori Hospital Medical Center, Toho University
| |
Collapse
|
9
|
Takatsuki S, Ivy DD. Current challenges in pediatric pulmonary hypertension. Semin Respir Crit Care Med 2013; 34:627-44. [PMID: 24037630 DOI: 10.1055/s-0033-1356461] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pulmonary arterial hypertension (PAH) in the pediatric population is associated with a variety of underlying diseases and causes, significantly morbidity and mortality. In the majority of patients, PAH in children is idiopathic or associated with congenital heart disease (CHD), with pulmonary hypertension (PH) associated with connective tissue disease, a rare cause in children. Classification of pediatric PH has generally followed the WHO classification, but recognition of the importance of fetal origins of PH and developmental abnormalities have led to the formation of a new pediatric-specific classification. Incidence data from the Netherlands has revealed an annual incidence and point prevalence of 0.7 and 4.4 for idiopathic PAH and 2.2 and 15.6 for associated pulmonary arterial hypertension-CHD cases per million children. Although the treatment with new selective pulmonary vasodilators offers hemodynamic and functional improvement in pediatric populations, the treatments in children largely depend on results from evidence-based adult studies and experience of clinicians treating children. A recent randomized clinical trial of sildenafil and its long-term extension has led to disparate recommendations in the United States and Europe.
Collapse
Affiliation(s)
- Shinichi Takatsuki
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | | |
Collapse
|
10
|
Saito Y, Nakamura K, Miyaji K, Akagi S, Mizoguchi H, Ogawa A, Fuke S, Fujio H, Kiyooka T, Nagase S, Kohno K, Morita H, Kusano KF, Matsubara H, Ohe T, Ito H. Acute Vasoreactivity Testing With Nicardipine in Patients With Pulmonary Arterial Hypertension. J Pharmacol Sci 2012; 120:206-12. [DOI: 10.1254/jphs.12114fp] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
11
|
Yanagisawa R, Kataoka M, Taguchi H, Kawakami T, Tamura Y, Fukuda K, Yoshino H, Satoh T. Impact of First-Line Sildenafil Monotreatment for Pulmonary Arterial Hypertension. Circ J 2012; 76:1245-52. [DOI: 10.1253/circj.cj-11-1192] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ryoji Yanagisawa
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Masaharu Kataoka
- Second Department of Internal Medicine, Kyorin University School of Medicine
- Department of Cardiology, Keio University School of Medicine
| | - Hiroki Taguchi
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | | | - Yuichi Tamura
- Department of Cardiology, Keio University School of Medicine
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Hideaki Yoshino
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Toru Satoh
- Second Department of Internal Medicine, Kyorin University School of Medicine
| |
Collapse
|