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Luo CJ, Qiu HL, Wu CW, He J, Yuan P, Zhao QH, Jiang R, Wu WH, Gong SG, Guo J, Zhang R, Liu JM, Wang L. PeakP ETCO 2 combined with FEV1/FVC predicts vasodilator-responsive patients with idiopathic pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211059713. [PMID: 34881019 PMCID: PMC8647237 DOI: 10.1177/20458940211059713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/01/2021] [Indexed: 11/15/2022] Open
Abstract
Cardiopulmonary exercise testing and pulmonary function test are important methods for detecting human cardio-pulmonary function. Whether they could screen vasoresponsiveness in idiopathic pulmonary artery hypertension (IPAH) patients remains undefined. One hundred thirty-two IPAH patients with complete data were retrospectively enrolled. Patients were classified as vasodilator-responsive (VR) group and vasodilator-nonresponsive (VNR) group on the basis of the acute vasodilator test. Pulmonary function test and cardiopulmonary exercise testing were assessed subsequently and all patients were confirmed by right heart catheterization. We analyzed cardiopulmonary exercise testing and pulmonary function test data and derived a prediction rule to screen vasodilator-responsive patients in IPAH. Nineteen of VR-IPAH and 113 of VNR-IPAH patients were retrospectively enrolled. Compared with VNR-IPAH patients, VR-IPAH patients had less severe hemodynamic effects (lower RAP, m PAP, PAWP, and PVR). And VR-IPAH patients had higher anaerobic threshold (AT), peak partial pressure of end-tidal carbon dioxide (PETCO2), oxygen uptake efficiency (OUEP), and FEV1/FVC (P all <0.05), while lower peak partial pressure of end-tidal oxygen (PETO2) and minute ventilation (VE)/carbon dioxide output (VCO2) slope (P all <0.05). FEV1/FVC (Odds Ratio [OR]: 1.14, 95% confidence interval [CI]: 1.02-1.26, P = 0.02) and PeakPETCO2 (OR: 1.13, 95% CI: 1.01-1.26, P = 0.04) were independent predictors of VR adjusted for age, sex, and body mass index. A novel formula (=-16.17 + 0.123 × PeakPETCO2 + 0.127×FEV1/FVC) reached a high area under the curve value of 0.8 (P = 0.003). Combined with these parameters, the optimal cutoff value of this model for detection of VR is -1.06, with a specificity of 91% and sensitivity of 67%. Compared with VNR-IPAH patients, VR-IPAH patients had less severe hemodynamic effects. Higher FEV1/FVC and higher peak PETCO2 were associated with increased odds for vasoresponsiveness. A novel score combining PeakPETCO2 and FEV1/FVC provides high specificity to predict VR patients among IPAH.
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Affiliation(s)
- Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Chang-Wei Wu
- Department of Respiratory and Critical Care Medicine, Shanghai
Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary
Hospital, Tongji University, Shanghai, China
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2
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Ruffenach G, Hong J, Vaillancourt M, Medzikovic L, Eghbali M. Pulmonary hypertension secondary to pulmonary fibrosis: clinical data, histopathology and molecular insights. Respir Res 2020; 21:303. [PMID: 33208169 PMCID: PMC7677848 DOI: 10.1186/s12931-020-01570-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) developing secondarily in pulmonary fibrosis (PF) patients (PF-PH) is a frequent co-morbidity. The high prevalence of PH in PF patients is very concerning since the presence of PH is a strong predictor of mortality in PF patients. Until recently, PH was thought to arise solely from fibrotic destruction of the lung parenchyma, leading to hypoxic vasoconstriction and loss of vascular bed density. Thus, potential cellular and molecular dysregulation of vascular remodeling as a driver of PF-PH has been under-investigated. The recent demonstrations that there is no correlation between the severity of the fibrosis and development of PH, along with the finding that significant vascular histological and molecular differences exist between patients with and without PH have shifted the etiological paradigm of PF-PH. This review aims to provide a comprehensive translational overview of PH in PF patients from clinical diagnosis and outcome to the latest understanding of the histology and molecular pathophysiology of PF-PH.
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Affiliation(s)
- Grégoire Ruffenach
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA
| | - Jason Hong
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mylène Vaillancourt
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lejla Medzikovic
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA
| | - Mansoureh Eghbali
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA.
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3
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Methods to improve the yield of right heart catheterization in pulmonary hypertension. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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4
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Kaye AD, Baber SR, Sharief MT, Kaye RJ, Cornett EM. Vasodepressor Effects of Adenosine in the Cat are Independent of Cyclooxygenase, Potassium Channels, and Nitric Oxide Pathways. Drugs R D 2019; 19:319-328. [PMID: 31452117 PMCID: PMC6890624 DOI: 10.1007/s40268-019-00283-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension is a hemodynamic disorder. Signs and symptoms are generally difficult to recognize because they are non-specific. The current treatment for pulmonary arterial hypertension offers no cure or prevention; therefore, it is important to explore treatment avenues for novel pulmonary arterial hypertension treatments. In this study, we tested the hypothesis: pulmonary vasodilator responses of adenosine are dependent on the activation of L-type calcium channels, independent of the synthesis of nitric oxide from L-arginine, activation of adenosine triphosphate-sensitive potassium channels, and the release of cyclooxygenase products. METHODS We performed an isolated lobar lung preparation in mongrel cats. The thromboxane A2 analog U-46619 was used to increase lobar arterial pressure to a high steady level. We recorded responses to adenosine and other vasodepressor agents in the pulmonary vascular bed of a cat under conditions of controlled pulmonary blood flow and constant left atrial pressure. RESULTS These data show that adenosine has significant vasodepressor activity in the pulmonary vascular bed of the cat. The data suggest that pulmonary vasodilator responses to adenosine are partially dependent on the activation of adenosine 1 and 2 receptor pathways, and independent of the activation of cyclooxygenase activation, adenosine triphosphate-sensitive K + channels, or synthesis of nitric oxide in the pulmonary vascular bed of the cat. CONCLUSIONS Vasodepressor effects of adenosine are species specific, and this species specificity will impact the development of future testing and treatments for pulmonary arterial hypertension. Clinical studies are warranted to see if adenosine moieties could play a therapeutic role in patients with pulmonary arterial hypertension and/or other pulmonary pathogeneses.
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Affiliation(s)
- Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Ave, Room 656, New Orleans, LA, 70112, USA.
- Department of Pharmacology, Louisiana State University Health Science Center, New Orleans, 70112, LA, USA.
| | - Syed R Baber
- Department of Anesthesiology, LSU School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Ave, Room 656, New Orleans, LA, 70112, USA
| | - Mohammed T Sharief
- Department of Anesthesiology, LSU School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Ave, Room 656, New Orleans, LA, 70112, USA
| | - Rachel J Kaye
- Department of Anesthesiology, LSU School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Ave, Room 656, New Orleans, LA, 70112, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Shreveport, Shreveport, LA, 71103, USA
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5
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Baillie TJ, Sidharta S, Steele PM, Worthley SG, Willoughby S, Teo K, Sanders P, Nicholls SJ, Worthley MI. Noninvasive Assessment of Cardiopulmonary Reserve: Toward Early Detection of Pulmonary Vascular Disease. Am J Respir Crit Care Med 2017; 195:398-401. [PMID: 28145761 DOI: 10.1164/rccm.201607-1366le] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Timothy J Baillie
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and
| | - Samuel Sidharta
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and
| | - Peter M Steele
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia
| | - Stephen G Worthley
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and
| | - Scott Willoughby
- 3 South Australian Health and Medical Research Institute Adelaide, South Australia, Australia
| | - Karen Teo
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and
| | - Stephen J Nicholls
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and.,3 South Australian Health and Medical Research Institute Adelaide, South Australia, Australia
| | - Matthew I Worthley
- 1 Royal Adelaide Hospital Adelaide, South Australia, Australia.,2 University of Adelaide Adelaide, South Australia, Australia and
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Alencar AKN, Montes GC, Barreiro EJ, Sudo RT, Zapata-Sudo G. Adenosine Receptors As Drug Targets for Treatment of Pulmonary Arterial Hypertension. Front Pharmacol 2017; 8:858. [PMID: 29255415 PMCID: PMC5722832 DOI: 10.3389/fphar.2017.00858] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/09/2017] [Indexed: 01/05/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a clinical condition characterized by pulmonary arterial remodeling and vasoconstriction, which promote chronic vessel obstruction and elevation of pulmonary vascular resistance. Long-term right ventricular (RV) overload leads to RV dysfunction and failure, which are the main determinants of life expectancy in PAH subjects. Therapeutic options for PAH remain limited, despite the introduction of prostacyclin analogs, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and soluble guanylyl cyclase stimulators within the last 15 years. Through addressing the pulmonary endothelial and smooth muscle cell dysfunctions associated with PAH, these interventions delay disease progression but do not offer a cure. Emerging approaches to improve treatment efficacy have focused on beneficial actions to both the pulmonary vasculature and myocardium, and several new targets have been investigated and validated in experimental PAH models. Herein, we review the effects of adenosine and adenosine receptors (A1, A2A, A2B, and A3) on the cardiovascular system, focusing on the A2A receptor as a pharmacological target. This receptor induces pulmonary vascular and heart protection in experimental models, specifically models of PAH. Targeting the A2A receptor could potentially serve as a novel and efficient approach for treating PAH and concomitant RV failure. A2A receptor activation induces pulmonary endothelial nitric oxide synthesis, smooth muscle cell hyperpolarization, and vasodilation, with important antiproliferative activities through the inhibition of collagen deposition and vessel wall remodeling in the pulmonary arterioles. The pleiotropic potential of A2A receptor activation is highlighted by its additional expression in the heart tissue, where it participates in the regulation of intracellular calcium handling and maintenance of heart chamber structure and function. In this way, the activation of A2A receptor could prevent the production of a hypertrophic and dysfunctional phenotype in animal models of cardiovascular diseases.
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Affiliation(s)
- Allan K N Alencar
- Programa de Pesquisa em Desenvolvimento de Fármacos, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Guilherme C Montes
- Programa de Pesquisa em Desenvolvimento de Fármacos, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliezer J Barreiro
- Programa de Pesquisa em Desenvolvimento de Fármacos, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberto T Sudo
- Programa de Pesquisa em Desenvolvimento de Fármacos, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gisele Zapata-Sudo
- Programa de Pesquisa em Desenvolvimento de Fármacos, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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7
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Langleben D, Orfanos S. Vasodilator responsiveness in idiopathic pulmonary arterial hypertension: identifying a distinct phenotype with distinct physiology and distinct prognosis. Pulm Circ 2017; 7:588-597. [PMID: 28632001 PMCID: PMC5841907 DOI: 10.1177/2045893217714231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/17/2017] [Indexed: 01/03/2023] Open
Abstract
Within the cohort of patients suffering from idiopathic pulmonary arterial hypertension (IPAH) is a group that responds dramatically (VR-PAH) to an acute vasodilator challenge and that has excellent long-term hemodynamic improvement and prognosis on high dose calcium channel blockers compared with vasodilator non-responders (VN-PAH). For the purposes of diagnosing VR-PAH, there is to date no test to replace the acute vasodilator challenge. However, recent studies have identified markers that may aid in the identification of VR-PAH, including peripheral blood lymphocyte RNA expression levels of desmogelin-2 and Ras homolog gene family member Q, and plasma levels of provirus integration site for Moloney murine leukemia virus. Genome wide-array studies of peripheral blood DNA have demonstrated differences in disease specific genetic variants between VR-PAH and NR-PAH, with particular convergence on cytoskeletal function pathways and Wnt signaling pathways. These studies offer hope for future non-invasive identification of VR-PAH, and insights into pathogenesis that may lead to novel therapies. Examination of the degree of pulmonary microvascular perfusion in PAH has offered additional insights. During the acute vasodilator challenge, VR-PAH patients demonstrate true vasodilation with recruitment and increased perfusion of the capillary bed, while VN-PAH patients are unable to recruit vasculature. In the very few reports of lung histology, VR-PAH has more medial thickening in the precapillary arterioles, while VN-PAH has the classic histology of PAH, including intimal thickening. VR-PAH is a disorder with a phenotype distinct from VN-PAH and other types of PAH, and should be considered separately in the classification of PAH.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec Canada
| | - Stylianos Orfanos
- Pulmonary Hypertension Clinic, Department of Critical Care, Attikon Hospital, National and Kapodistirian University of Athens, Athens, Greece
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8
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Edelman JD. Clinical Presentation, Differential Diagnosis, and Vasodilator Testing of Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2016; 11:110-8. [PMID: 17536115 DOI: 10.1177/1089253207301355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinicians should be cognizant of the symptoms and risk factors associated with pulmonary hypertension (PH). While known PH poses significant therapeutic challenges, occult PH carries the added potential for unanticipated complications when treating concurrent medical illnesses. PH may occur with underlying medical conditions and risk factors or may occur de novo as idiopathic pulmonary arterial hypertension (IPAH). Symptoms of PH are frequently attributed to more common conditions, and their nonspecific nature and insidious onset may lead to delay in presentation, evaluation, and diagnosis. Initial symptoms are dyspnea, fatigue, chest pain, and palpitations. Lower extremity edema, presyncope, and syncope are symptoms of more advanced disease. Thorough evaluation of symptoms and identification of patients with risk factors for PH are critical in making a timely diagnosis. History and physical examination can identify patients with suspected PH. Further testing is necessary for definitive diagnosis, classification, assessment of severity, and guiding therapeutic decisions.
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Affiliation(s)
- Jeffrey D Edelman
- Department of Medicine, University of Washington, Seattle, Washington 98195, USA.
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9
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Gomberg-Maitland M, Schilz R, Mediratta A, Addetia K, Coslet S, Thomeas V, Gillies H, Oudiz RJ. Phase I safety study of ranolazine in pulmonary arterial hypertension. Pulm Circ 2015; 5:691-700. [PMID: 26697176 DOI: 10.1086/683813] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
UNLABELLED Pulmonary arterial hypertension (PAH) causes right ventricular ischemia, dysfunction, and failure. PAH patients may benefit from antianginal agents based on a shared pathophysiology with left ventricular ischemia. A single-center, randomized, placebo-controlled trial (1∶1) to assess the acute vasoreactivity and safety of ranolazine in PAH was conducted. Plasma samples for pharmacokinetic (PK) studies were drawn during hemodynamic measurements at 0, 60, 90, 120, 240, and 360 minutes from a Swan-Ganz catheter. All patients received 500-mg doses, uptitrated to 1,000 mg at week 4, monthly evaluations, and a complete objective assessment after 12 weeks, followed by an open-label extension. Thirteen patients were randomized and 12 enrolled (6 ranolazine, 6 placebo). All patients completed the acute phase; 10 completed the 12-week study. There were no acute changes in invasive hemodynamics. At 12 weeks ranolazine was well tolerated. Only 1 of the 5 patients on ranolazine had a serum concentration considered to be in the therapeutic range. Two serious adverse events required early withdrawal (both in the ranolazine group); gastrointestinal complaints were the most common adverse event. Efficacy measures did not demonstrate any differences between treatment groups. During the open-label trial, 2 additional patients reached a therapeutic concentration. Ranolazine in PAH appears safe, without acute hemodynamic effects after a 500-mg dose. Ranolazine administrated to PAH patients receiving background PAH therapies did not consistently reach therapeutic levels. Future studies should first perform PK analysis in PAH patients receiving PAH therapies and explore the safety and tolerability of the higher doses perhaps necessary to achieve therapeutic levels in PAH patients. ( TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01757808.).
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Affiliation(s)
- Mardi Gomberg-Maitland
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA ; Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Robert Schilz
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, Case Western University, Cleveland, Ohio, USA
| | - Anuj Mediratta
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Karima Addetia
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Sandra Coslet
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Vasiliki Thomeas
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA ; Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | - Ronald J Oudiz
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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10
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McNamara MJ, Sayanlar JJ, Dooley DJ, Srichai MB, Taylor AJ. A randomized pilot study on the effect of niacin on pulmonary arterial pressure. Trials 2015; 16:530. [PMID: 26590128 PMCID: PMC4654874 DOI: 10.1186/s13063-015-1013-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 10/15/2015] [Indexed: 11/11/2022] Open
Abstract
Background Niacin induces the release of vasodilating prostaglandins, for which receptors are present within the pulmonary arterial circulation. We hypothesized that immediate-release niacin would reduce right ventricular systolic pressure in patients with pulmonary hypertension in a randomized, double-blinded, single-dose provocation study. Methods We recruited inpatient subjects with a Doppler echocardiogram showing a peak tricuspid regurgitation (TR) jet velocity of 2.7 m/s or greater, and who were free of known pulmonary vascular disease. Subjects were randomized in a 1:2:2 ratio to receive a single dose of either placebo, niacin 100 mg or niacin 500 mg, respectively. TR jet velocities were measured immediately before, and 1 hour post dose, corresponding to peak niacin absorption and prostaglandin release. The primary endpoint was the change in mean TR jet velocity measured over ten successive cardiac cycles. Results The baseline mean estimated right ventricular systolic pressure (RVSP) for all 49 subjects (25 male) was 51.9 ± 12.1 mm Hg. The primary endpoint of mean change in TR jet velocity was 0.016 ± 0.065 m/s in the placebo group, compared to −0.017 ± 0.065 m/s with niacin 100 mg, and −0.063 ± 0.038 m/s with niacin 500 mg (P = 0.63). The change in maximum estimated RVSP across the three drug groups was 0.2 ± 1.6 mm Hg, −1.3 ± 1.8 mm Hg and −2.2 ± 1.2 mm Hg (P = 0.62). In exploratory pairwise analysis in the high-dose niacin group (500 mg), the reduction in mean RVSP was from 50.9 ± 9.4 mm Hg to 48.7 ± 10.0 mm Hg (P = 0.09). Conclusions A single dose of immediate-release niacin (100 mg or 500 mg) had no significant effect on RVSP 1 hour post administration. A nonsignificant dose-dependent trend for a modest reduction in RVSP, most notable in the 500 mg group, was noted. (ISRCTN number 12353191, registered April 23, 2015). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1013-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin J McNamara
- Cardiology Division, Medstar Heart and Vascular Institute at Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 3800 Reservoir Rd., NW, 5 PHC, Washington, DC, 20007, USA.
| | - Jason J Sayanlar
- Cardiology Division, Medstar Heart and Vascular Institute at Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 3800 Reservoir Rd., NW, 5 PHC, Washington, DC, 20007, USA.
| | - Daniel J Dooley
- Cardiology Division, Medstar Heart and Vascular Institute at Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 3800 Reservoir Rd., NW, 5 PHC, Washington, DC, 20007, USA.
| | - Monvadi B Srichai
- Cardiology Division, Medstar Heart and Vascular Institute at Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 3800 Reservoir Rd., NW, 5 PHC, Washington, DC, 20007, USA.
| | - Allen J Taylor
- Cardiology Division, Medstar Heart and Vascular Institute at Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 3800 Reservoir Rd., NW, 5 PHC, Washington, DC, 20007, USA.
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
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12
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Sileshi B, Haglund NA, Davis ME, Tricarico NM, Stulak JM, Khalpey Z, Danter MR, Deegan R, Kennedy J, Keebler ME, Maltais S. In-hospital outcomes of a minimally invasive off-pump left thoracotomy approach using a centrifugal continuous-flow left ventricular assist device. J Heart Lung Transplant 2015; 34:107-112. [DOI: 10.1016/j.healun.2014.09.023] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 09/04/2014] [Accepted: 09/18/2014] [Indexed: 11/17/2022] Open
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Maltais S, Davis ME, Haglund N. Minimally invasive and alternative approaches for long-term LVAD placement: the Vanderbilt strategy. Ann Cardiothorac Surg 2014; 3:563-9. [PMID: 25512895 DOI: 10.3978/j.issn.2225-319x.2014.10.02] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 08/25/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Minimally invasive and alternative strategies for implantation have been anecdotally reported for contemporary continuous-flow left ventricular assist device (CF-LVAD) placement. METHODS We reviewed our experience at a single center with alternative strategies for implantation of the HeartMate II and HeartWare CF-LVADs, in patients with advanced heart failure (HF). This featured article focuses on the associated surgical techniques and patient management pitfalls. RESULTS For appropriately selected cases, our group believes that these alternative strategies allow for the development of novel and less traumatic surgical approaches for CF-LVAD implantation. With reproducible outcomes, these approaches also promise the possibility of increasing the number of high-risk surgical patients who could benefit from CF-LVAD therapies. CONCLUSIONS This work has detailed a variety of less invasive alternative strategies for implantation of long-term LVADs. These newer approaches have the potential for significant advancements in the field of cardiothoracic surgery. Large-scale collaborative studies will be needed to clarify the potential advantages and disadvantages of these novel techniques on patient outcomes.
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Affiliation(s)
- Simon Maltais
- 1 Department of Cardiothoracic Surgery, 2 Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN 37232-8808, USA
| | - Mary E Davis
- 1 Department of Cardiothoracic Surgery, 2 Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN 37232-8808, USA
| | - Nicholas Haglund
- 1 Department of Cardiothoracic Surgery, 2 Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN 37232-8808, USA
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Taichman DB, Ornelas J, Chung L, Klinger JR, Lewis S, Mandel J, Palevsky HI, Rich S, Sood N, Rosenzweig EB, Trow TK, Yung R, Elliott CG, Badesch DB. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest 2014; 146:449-475. [PMID: 24937180 PMCID: PMC4137591 DOI: 10.1378/chest.14-0793] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/05/2014] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Choices of pharmacologic therapies for pulmonary arterial hypertension (PAH) are ideally guided by high-level evidence. The objective of this guideline is to provide clinicians advice regarding pharmacologic therapy for adult patients with PAH as informed by available evidence. METHODS This guideline was based on systematic reviews of English language evidence published between 1990 and November 2013, identified using the MEDLINE and Cochrane Library databases. The strength of available evidence was graded using the Grades of Recommendations, Assessment, Development, and Evaluation methodology. Guideline recommendations, or consensus statements when available evidence was insufficient to support recommendations, were developed using a modified Delphi technique to achieve consensus. RESULTS Available evidence is limited in its ability to support high-level recommendations. Therefore, we drafted consensus statements to address many clinical questions regarding pharmacotherapy for patients with PAH. A total of 79 recommendations or consensus statements were adopted and graded. CONCLUSIONS Clinical decisions regarding pharmacotherapy for PAH should be guided by high-level recommendations when sufficient evidence is available. Absent higher level evidence, consensus statements based upon available information must be used. Further studies are needed to address the gaps in available knowledge regarding optimal pharmacotherapy for PAH.
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Affiliation(s)
| | | | - Lorinda Chung
- Stanford University and Palo Alto VA Health Care System, Palo Alto, CA
| | | | | | | | | | | | | | | | | | - Rex Yung
- Johns Hopkins University, Baltimore, MD
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16
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Maltais S, Danter MR, Haglund NA, Schmitto JD, Stulak JM. Nonsternotomy Approaches for Left Ventricular Assist Device Placement. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.optechstcvs.2014.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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18
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Zuo XR, Zhang R, Jiang X, Li XL, Zong F, Xie WP, Wang H, Jing ZC. Usefulness of intravenous adenosine in idiopathic pulmonary arterial hypertension as a screening agent for identifying long-term responders to calcium channel blockers. Am J Cardiol 2012; 109:1801-6. [PMID: 22459309 DOI: 10.1016/j.amjcard.2012.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 02/07/2012] [Accepted: 02/07/2012] [Indexed: 10/28/2022]
Abstract
Although intravenous adenosine is recommended for acute vasodilator testing in patients with pulmonary hypertension, long-term outcomes in acute responders treated with calcium channel blockers (CCBs) who are identified by adenosine remain unknown. In this study, the value of adenosine for identifying long-term responders to CCBs was investigated in patients with idiopathic pulmonary arterial hypertension (IPAH). All acute responders were subsequently treated with high-dose CCB monotherapy, and 6-minute walk distances, hemodynamic data, and World Health Organization functional classifications were followed. Nine of 104 patients exhibited an acute response with intravenous adenosine (8.7%, 95% confidence interval 3.2 to 14.2). After 12 months of follow-up, all acute responders were still alive; however, only 6 patients showed sustained hemodynamic improvement (5.8%, 95% confidence interval 2 to 13). Three patients had failed CCB monotherapy and bosentan was added to their treatment. Mean tolerated dose of intravenous adenosine was 142 ± 49 μg/kg/min. No life-threatening adverse events were observed and only 2 patients of the nonresponders exhibited a 20% decrease in mean systemic arterial pressure. In nonresponders, 1- and 3-year survival rates were 89% and 75%, respectively. In conclusion, acute vasodilator testing with intravenous adenosine was safe and able to screen responders to CCB therapy in patients with IPAH. Long-term CCB responders accounted for about 5.8% of patients with IPAH.
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19
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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
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20
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Prevalence of acute vasoresponsiveness in patients with pulmonary hypertension: treatment implications. South Med J 2010; 103:630-4. [PMID: 20531064 DOI: 10.1097/smj.0b013e3181e1a8af] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) is a serious and often progressive disorder that results in right ventricular dysfunction. The general reported rate of patients who are responders is 10%-26%. More recently, using the current criteria, the rate of acute vasodilator response was as low as 6%. This study used the most current guidelines to assess the prevalence of acute vasoresponsiveness in patients with PH. METHODS A retrospective chart review of 618 patients seen in the PH clinic at the Mayo Clinic Jacksonville from 1991 to June 2008 was conducted. We assessed the prevalence of acute vasoresponsiveness in patients with PH who had undergone vasodilator trial with epoprostenol or nitric oxide, using the current accepted criteria. RESULTS One hundred and seventy-six patients who underwent a vasodilator trial that had complete hemodynamic data were identified. The average age was 61 +/- 14 years and most were women (67%). The PH was severe with most patients in the World Health Organization (WHO) functional class III-IV (82%), and an average mean pulmonary artery pressure of 48 +/- 11 mm Hg. Although the study group included all WHO diagnostic groups, 69% were diagnosed as Group I pulmonary arterial hypertension. We found an overall prevalence of response to acute vasodilator therapy to be 26%. CONCLUSION Using the most current criteria to identify acute responders to vasodilator therapy in PH patients, we found a slightly higher rate of "responders" than previously reported. Acute vasodilator testing identifies a clinically important group who may benefit from calcium channel blockers (CCBs), and this study confirms that a significant percentage of PH patients are acutely vasoresponsive.
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21
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Pulmonary vasodilator testing and use of calcium channel blockers in pulmonary arterial hypertension. Respir Med 2009; 104:481-96. [PMID: 20004088 DOI: 10.1016/j.rmed.2009.11.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 11/07/2009] [Accepted: 11/21/2009] [Indexed: 11/21/2022]
Abstract
Pulmonary arterial hypertension (PAH) encompasses a number of diseases responsible for a specific set of hemodynamic findings during right heart catheterization. During initial workup, pulmonary vasodilator testing is performed. A positive acute pulmonary vasodilator test predicts better survival and response to calcium channel blocker (CCB) therapy. There is lack of consensus on the preferred agent for determining acute pulmonary vasoreactivity. The ACCP guidelines and the 4(th) World Symposium on Pulmonary Hypertension support the use of intravenous epoprostenol or nitric oxide (NO) as the preferred agents for pulmonary vasodilator testing. A decrease in the mean pulmonary artery pressure by at least 10 mmHg to reach an absolute value of 40 mmHg or less without a decrease in cardiac output is currently considered a positive pulmonary vasodilator test. A positive test by the current recommended criteria is observed in about 10-15% of patients with idiopathic PAH. Approximately half of these patients will experience long-term benefits with CCBs. A positive test may select patients with an earlier or less aggressive form of disease, which may carry a better prognosis. A positive vasodilator test is observed very infrequently in patients with pulmonary arterial hypertension other than idiopathic PAH or anorexigen associated PAH. This article reviews the literature regarding pulmonary vasodilator testing and use of CCB therapy in patients with PAH, while identifying the gaps in knowledge concerning this diagnostic procedure.
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22
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Adenosine for vasoreactivity testing in pulmonary hypertension: a head-to-head comparison with inhaled nitric oxide. Respir Med 2009; 104:606-11. [PMID: 19962292 DOI: 10.1016/j.rmed.2009.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 11/16/2009] [Accepted: 11/17/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND APVT is an invasive method recommended for symptomatic patients with PAH that permits the identification of the minority of patients (<20%) that may benefit from long-term calcium channel blockers. Adenosine has been indicated in guidelines as a vasodilator agent of choice for APVT, although it has not been directly compared with iNO, the gold standard for this test. The objective of the study was to compare adenosine with inhaled nitric oxide (iNO) for acute pulmonary vasoreactivity testing (APVT) in pulmonary arterial hypertension (PAH), in order to determine the efficacy and safety of the first in the clinical setting. METHODS The measurements of cardiac output, pulmonary and systemic resistance were done in the basal state and with a stepwise increase of the dose of each drug until either maximum dosage (adenosine: 500 microg/kg/min or iNO: 80 ppm) or side effects observed or a positive response were reached, according to current guidelines. The order of drugs used in each test was consecutively alternated during the study. RESULTS Six of the 39 studied patients (15%) presented a positive response to iNO; none to adenosine (p = 0.047, McNemar's test). Twenty-three patients (59%) did not reach the maximum dose of adenosine due to side effects, including bronchospasm, thoracic pain and bradycardia. CONCLUSIONS APVT testing with adenosine was not able to detect PAH patients responsive to iNo and provoked frequent adverse effects. Adenosine should not be used as a vasodilator drug in APVT.
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23
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Tofovic SP, Jackson EK, Rafikova O. Adenosine deaminase-adenosine pathway in hemolysis-associated pulmonary hypertension. Med Hypotheses 2009; 72:713-9. [PMID: 19237250 DOI: 10.1016/j.mehy.2008.12.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 12/02/2008] [Accepted: 12/07/2008] [Indexed: 11/16/2022]
Abstract
Hemolysis-associated pulmonary hypertension (HA-PH) is a serious clinical complication of various hemolytic disorders, and pulmonary hypertension (PH) is considered the greatest risk factor for death in patients with a hemolytic disorder. It is now well established that hemolysis causes the release of soluble hemoglobin and arginase from injured erythrocytes into plasma. This leads to nitric oxide (NO) deficiency, oxidative stress and a state of endothelial dysfunction that is associated with clinical development of PH. We challenge this concept and propose that in addition to the NO-arginase pathway, the adenosine deaminase-adenosine pathway plays a significant role in HA-PH and that modulation of this pathway may offer protective/therapeutic effects in HA-PH. Our preliminary data suggest that in HA-PH adenosine deaminase (ADA) is released from injured erythrocytes into plasma and that metabolic conversion of adenosine (ADO) to inosine by ADA reduces extracellular ADO levels. Adenosine, mainly via activation of adenosine A(2A) receptors, mediates a number of biological responses that may reduce hemolysis-induced vasculopathy and the risk of PH. Hypoxia is the strongest stimulus for ADO synthesis, and this increased ADO production counteracts some of the tissue/vascular injury caused by hypoxia itself. Unfortunately, under hypoxic conditions (anemia, vasoconstriction, and vaso-occlusion) in HA-PH, this "ADO negative-feed back" is abolished and the vascular protective effects of ADO are severely diminished by ADA released from injured erythrocytes. We hypothesize that in hemolytic anemia the repetitive release of ADA increases the risk for vaso-occlusive events and PH. We also propose that increase in extracellular ADO levels or activation of adenosine A(2A) receptors attenuates HA-PH, and we suggest further preclinical and clinical investigation of ADA inhibitors and ADO agonists in HA-PH.
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Affiliation(s)
- Stevan P Tofovic
- Center for Clinical Pharmacology, University of Pittsburgh School of Medicine, 100 Technology Drive, Suite 450, Pittsburgh, PA 15219, USA.
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24
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Shah SJ, Thenappan T, Rich S, Tian L, Archer SL, Gomberg-Maitland M. Association of Serum Creatinine With Abnormal Hemodynamics and Mortality in Pulmonary Arterial Hypertension. Circulation 2008; 117:2475-83. [DOI: 10.1161/circulationaha.107.719500] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Renal dysfunction predicts mortality in patients with cardiovascular disease. How renal dysfunction relates to hemodynamics and mortality in pulmonary arterial hypertension (PAH) remains unclear.
Methods and Results—
We performed a cohort study of 500 patients with World Health Organization group I PAH from 1982 to 2006 with data on demographics, comorbidities, medications, functional class, laboratory tests, exercise testing results, and hemodynamics. Serum creatinine (SCr) was determined on entry into the study (initial PAH clinic visit). Vital status was determined from hospital records and the Social Security Death Index. We used a Cox proportional hazards analysis to determine whether SCr was an independent predictor of mortality. Mean age on entry into the study was 48±14 years, and 79% of subjects were female. Mean SCr was 1.05±0.35 mg/dL. Elevated SCr was associated with higher right atrial pressure and lower cardiac index. During a median follow-up of 3.5 years, 279 deaths (55.8% of the cohort) occurred. Compared with patients with SCr <1.0 mg/dL, those with SCr 1.0 to 1.4 mg/dL and SCr >1.4 mg/dL had an increased hazard ratio of death (unadjusted hazard ratio 1.65, 95% confidence interval 1.26 to 2.17,
P
<0.0001 for SCr 1.0 to 1.4 mg/dL; unadjusted hazard ratio 2.54, 95% confidence interval 1.73 to 3.71,
P
<0.0001 for SCr >1.4 mg/dL). On multivariable analysis, we found a significant interaction between SCr and right atrial pressures (interaction
P
<0.0001); increased SCr best predicted death in patients with right atrial pressure <10 mm Hg.
Conclusions—
Renal dysfunction is associated with a worse hemodynamic profile and is an independent predictor of mortality in PAH. Measurement of SCr is practical and offers a simple way to noninvasively predict outcome.
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Affiliation(s)
- Sanjiv J. Shah
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
| | - Thenappan Thenappan
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
| | - Stuart Rich
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
| | - Lu Tian
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
| | - Stephen L. Archer
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
| | - Mardi Gomberg-Maitland
- From the Division of Cardiology, Department of Medicine (S.J.S.) and Department of Preventive Medicine (L.T.), Northwestern University Feinberg School of Medicine, Chicago, Ill; and Section of Cardiology, Department of Medicine (T.T., S.R., S.L.A., M.G.-M.), University of Chicago, Chicago, Ill
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Abstract
Adenosine, a ubiquitous metabolic intermediate in the body, is involved in nearly every aspect of cell function, including neuromodulation and neurotransmission. Adenosine A(1) and A(2) receptors are widely distributed in the brain and spinal cord, and are a novel, non-opiate target for pain management. The potential of adenosine as a non-narcotic analgesic in anesthetized patients has been explored in clinical trials, including double-blind studies versus placebo and remifentanil infusion. These studies suggest that, compared to placebo or remifentanil, an intraoperative adenosine infusion stabilizes core hemodynamics and reduces the requirement for anesthesia during surgery. Further, adenosine improves postoperative recovery, as indicated by lower pain scores and less opioid consumption. The safety profile of adenosine has been well characterized based on use of currently approved adenosine products. The most common adverse events associated with its use include flushing, chest discomfort, dyspnea, headache, gastrointestinal discomfort, and lightheadedness. These effects are generally well tolerated and transient. Further studies are warranted to investigate the full potential of adenosine as a non-opioid analgesic in the perioperative setting.
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Affiliation(s)
- Tong J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Progress in understanding the basic biology and the development of new therapies for pulmonary arterial hypertension have led to improvements in survival. This article reviews clinically important changes in the classification of the pulmonary hypertensive diseases, as well as the epidemiology of various forms of pulmonary hypertension. The risk factors for the development of pulmonary arterial hypertension, prognostic markers, and the effects of current therapies on survival are discussed.
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Affiliation(s)
- Darren B Taichman
- University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, 441 PHI Building, Philadelphia, PA 19104, USA.
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27
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Sitbon O, Humbert M, Simonneau G. Les traitements de l’hypertension artérielle pulmonaire à l’heure de la T2A. Recommandations du groupe de travail “Maladies vasculaires pulmonaires” de la Société de pneumologie de langue française. Presse Med 2005; 34:1456-64. [PMID: 16301977 DOI: 10.1016/s0755-4982(05)84207-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Activity-based financing (that is, casemix-based hospital payments, known as T2A) is intended to harmonize and improve the fairness of remuneration of public and private hospitals. T2A will ultimately rely mainly on a flat rate per admission, set according to the diagnosis-related group (DRG). Although payment for drugs is usually included in the DRG price, some expensive drugs will be reimbursed on an additional cost basis after implementation of a "best practices" agreement. Four drugs used for treatment of pulmonary arterial hypertension are eligible for this additional reimbursement: 3 prostacyclin derivatives (intravenous epoprostenol, inhaled iloprost, and subcutaneous treprostinil), and oral bosentan, an endothelin receptor antagonist. The Pulmonary Vascular Diseases working group of the French Society of Pulmonary Medicine has developed guidelines for the best practices in use of these drugs.
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Affiliation(s)
- O Sitbon
- Centre de référence national sur l'HTAP, service de pneumologie et réanimation, UPRES EA2705, Université Paris-Sud, Hôpital Antoine Béclère, AP-HP, Clamart.
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28
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Sulica R, Dinh HV, Dunsky K, Fuster V, Poon M. The acute hemodynamic effect of IV nitroglycerin and dipyridamole in patients with pulmonary arterial hypertension: comparison with IV epoprostenol. ACTA ACUST UNITED AC 2005; 11:139-44; quiz 145-6. [PMID: 15947535 DOI: 10.1111/j.1527-5299.2005.03885.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nitroglycerin and dipyridamole are two commonly available and well tolerated vasoactive medications. Their acute hemodynamic effects in patients with pulmonary arterial hypertension are not well defined in the current literature. The authors retrospectively analyzed the acute hemodynamic effects of IV nitroglycerin, dipyridamole, and epoprostenol in 59 patients with pulmonary arterial hypertension as determined by changes from baseline in systemic and pulmonary hemodynamic parameters. Statistical analysis was performed using the independent sample t test. A p value <0.05 was considered significant. Nitroglycerin is predominantly a vasodilator of the pulmonary vasculature with moderate systemic vasodilator effect, while dipyridamole is primarily a positive inotropic agent. Epoprostenol is a potent vasodilator of both pulmonary and systemic vessels and a strong positive inotropic agent. Nitroglycerin and dipyridamole may be useful in the acute management of pulmonary arterial hypertension.
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Affiliation(s)
- Roxana Sulica
- Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY, USA
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29
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Costa ELV, Jardim C, Bogossian HB, Amato MBP, Carvalho CRR, Souza R. Acute vasodilator test in pulmonary arterial hypertension: Evaluation of two response criteria. Vascul Pharmacol 2005; 43:143-7. [PMID: 16061423 DOI: 10.1016/j.vph.2005.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 04/05/2005] [Accepted: 05/11/2005] [Indexed: 11/23/2022]
Abstract
The rationale for the acute vasodilator test in idiopathic pulmonary arterial hypertension (IPAH) is to identify patients who have a vasoreactive component that justifies the use of non-selective vasodilators. We tested the ability of two different response criteria to identify such patients studying 34 patients with IPAH. The hemodynamic data from the right heart catheterization were collected at baseline and post-administration of inhaled nitric oxide. We describe the results obtained by two different response criteria: (A) a 20% decrease in indexed pulmonary vascular resistance (PVRi) and in mean pulmonary artery pressure(PAPm)(classic criterion); (B) a fall in PAPm of at least 10 mm Hg to a pressure level of 40 mm Hg or lower (revised criterion). Patients who responded according to the revised criterion showed a higher cardiac index (CI) (3.45+/-1.94 vs. 1.99+/-0.44 L/min/m2; p=0.05) and lower PVRi (1247+/-746 vs. 2437+/-1105 dyn cm-5 s m2; p=0.02) compared to non-responders. Responders according to the classic criterion had a statistically significant lower CI (1.59+/-0.40 vs. 2.43+/-1.14 L/min/m2; p=0.03) and higher PVRI (3130+/-1173 vs. 1958+/-980 dyn cm-5 s m2; p=0.04) also compared to non-responders. We conclude that the revised criterion seems to reflect the degree of vascular remodeling more accurately, identifying patients with better preserved cardiac function, possibly in an earlier phase of the disease.
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30
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Broadley KJ. Drugs modulating adenosine receptors as potential therapeutic agents for cardiovascular diseases. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.10.11.1669] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Souza R, Amato MBP, Demarzo SE, Deheinzelin D, Barbas CSV, Caruso P, Carvalho CRR. Ação da adenosina na circulação pulmonar de pacientes com hipertensão pulmonar primária. J Bras Pneumol 2005. [DOI: 10.1590/s1806-37132005000100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUÇÃO: A adenosina é um nucleosídeo com potente ação vasodilatadora. Apesar de seus efeitos sobre o território arterial pulmonar ser conhecido, seu efeito sobre o território capilar/venoso ainda não foi descrito. OBJETIVO: Estudar o comportamento das resistências arterial e venosa da circulação pulmonar de pacientes com hipertensão pulmonar primária antes e depois da administração de adenosina. MÉTODO: Foram estudados sete pacientes com hipertensão pulmonar primária que apresentaram resposta positiva durante o teste agudo com adenosina. Resistência arterial e resistência venosa foram determinadas pela estimativa da pressão capilar pulmonar realizada através da análise da curva de decaimento da pressão arterial pulmonar, antes e depois da administração da adenosina. RESULTADOS: Após a administração da adenosina, houve um aumento do índice cardíaco (1,71 ± 0,23 para 2,72 ± 0,74 L.min-1.m-2) com concomitante diminuição da resistência vascular pulmonar (2.924 ± 1.060 para 1.975 ± 764 dina.s.cm-5.m-2), sem variações significativas da pressão arterial pulmonar média (75,6 ± 16,8 para 78,1 ± 18,8 mmHg), da pressão de oclusão da artéria pulmonar (15,3 ± 1,5 para 15,4 ± 1,9 mmHg) e da pressão capilar pulmonar (43,8 ± 5,8 para 44,5 ± 4,9 mmHg). A proporção entre a resistência arterial e a resistência vascular pulmonar total também apresentou variação não significativa (50 ± 15 para 49 ± 17%). Estes achados sugerem que a adenosina teve ação não somente sobre o território arterial mas também sobre o território capilar/venoso. CONCLUSÃO: Os autores concluem que o mecanismo de ação da adenosina não é restrito ao território arterial da circulação pulmonar e que este tipo de análise, através da determinação da pressão capilar pulmonar, pode ser útil no estudo das diversas drogas que agem sobre a circulação pulmonar.
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Morales-Blanhir J, Santos S, de Jover L, Sala E, Paré C, Roca J, Rodriguez-Roisin R, Barberà JA. Clinical value of vasodilator test with inhaled nitric oxide for predicting long-term response to oral vasodilators in pulmonary hypertension. Respir Med 2004; 98:225-34. [PMID: 15002758 DOI: 10.1016/j.rmed.2003.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute vasodilator tests with prostacyclin (PGI2) or inhaled nitric oxide (iNO) are used to select patients with pulmonary arterial hypertension (PAH) who should be treated with oral vasodilators. The haemodynamic effects of PGI2 and iNO are different, and the limits for considering a vasodilator response as significant are controversial. The study was aimed to investigate the diagnostic performance of acute vasodilator testing with iNO and PGI2 in predicting the clinical outcome after 1 year treatment with oral vasodilators. Twenty-seven patients with severe PAH were studied. Nineteen patients were treated with oral vasodilators and their outcome after 1 year was qualified as favourable or unfavourable. The diagnostic performance of vasodilator tests in predicting this outcome was evaluated using receiver operating characteristics (ROC) curves. The acute effects of iNO and PGI2 on pulmonary artery pressure (PAP) were similar. By contrast, PGI2 produced more marked changes on cardiac output and pulmonary vascular resistance than iNO (P<0.05). The evolution at 1 year was favourable in 11 patients and unfavourable in 8. Patients with favourable evolution showed greater decrease of PAP with iNO than with PGI2 (P<0.05). The decrease of PAP with iNO had the greatest predictive value on the clinical outcome (area under ROC curve, 0.83). We conclude that in patients with PAH, acute vasodilator testing with iNO is preferable to PGI2 because it reflects more consistently the changes in pulmonary vascular tone. The acute decrease of PAP with iNO is the best predictor of the long-term response to oral vasodilator treatment.
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Affiliation(s)
- Jaime Morales-Blanhir
- Department of Pulmonary Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
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33
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Fischer LG, Aken HV, Bürkle H. Management of pulmonary hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96:1603-1616. [PMID: 12760982 DOI: 10.1213/01.ane.0000062523.67426.0b] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lars G Fischer
- Department of Anesthesiology and Intensive Care, Universita[Combining Diaeresis]tsklinikum Mu[Combining Diaeresis]nster, Mu[Combining Diaeresis]nster, Germany
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34
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Abstract
Primary pulmonary hypertension and cor pulmonale represent forms of precapillary pulmonary hypertension due to intrinsic lung disease. In the case of primary pulmonary hypertension, this is due to disease of the pulmonary vasculature while cor pulmonale is related to diseases of the pulmonary vasculature, airways, or interstitium. Patients present with signs and symptoms of right ventricular dysfunction and low cardiac output including dyspnea, chest pain and peripheral edema. Therapy is directed at the underlying disease and may include supplemental oxygen for diseases causing chronic hypoxemia and anticoagulation for thrombotic disease. Vasodilator therapy has variable efficacy for pulmonary vascular disorders. Postacyclin by continuous infusion has been a major advance in the therapy of primary pulmonary hypertension and has prolonged survival and delayed the need for lung transplantation. Bosentan, an endothelin receptor blocking agent is the first oral medication approved for the therapy of pulmonary hypertension.
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Affiliation(s)
- Stuart Lehrman
- Departments of Pulmonary Medicine, General Internal Medicine, and Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York 10595, USA
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35
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Abstract
Because the causes of primary pulmonary hypertension (PPH) remains unknown, the therapeutic approach of the disease can be only empirical, based on the pathology and pathobiology of pulmonary circulation. Despite the inability to cure the disease, therapeutic advances over the past 20 years have contributed to an improvement of quality of life and prolonged survival in PPH patients. Current therapeutic approach of PPH mostly includes limitation of physical activity, long-term anticoagulation, and vasodilator therapy. Among all tested oral vasodilators, calcium-channel blockers are the most efficient long-term therapies by improving symptoms and hemodynamics in a subset of PPH patients (10% to 15%) who acutely respond to such drugs. Acute pulmonary vasodilator response to inhalation of nitric oxide can predict acute and chronic responses to oral calcium-channel blockers. A better understanding of the pathogenesis of PPH has changed the focus of medical treatments from purely chronic vasodilator therapy to the evaluation of agents, such as prostaglandins, that may reverse the proliferation of pulmonary vascular cells and result in regression of the pulmonary vascular hypertrophy and remodeling. Long-term treatment with intravenous epoprostenol (prostaglandin I(2) or prostacyclin) improves exercise capacity, hemodynamics and survival in most patients with PPH in functional class NYHA III or IV, and may be currently considered as the "gold standard" therapy for severe patients. However, response to long-term epoprostenol therapy may be incomplete, adverse effects are common, and survival remains unsatisfactory (55% at 5 years). In such patients with severe pulmonary hypertension refractory to medical therapy, atrioseptostomy and lung transplantation can be indicated.
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Affiliation(s)
- Olivier Sitbon
- Service de Pneumologie et Réanimation Respiratoire, Pulmonary Vascular Center, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Clamart, France
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36
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Hoeper MM, Galiè N, Simonneau G, Rubin LJ. New treatments for pulmonary arterial hypertension. Am J Respir Crit Care Med 2002; 165:1209-16. [PMID: 11991870 DOI: 10.1164/rccm.200110-028pp] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
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37
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Abstract
Primary pulmonary hypertension (PPH) is a rare disorder of the lung vasculature characterised by an increase in pulmonary artery pressure. Although the aetiology of this disease remains unknown, knowledge of the pathophysiology of the disease has advanced considerably. Diagnosis of PPH is largely by exclusion. The clinical symptoms associated with PPH are aspecific and similar to those seen in other cardiovascular and pulmonary diseases. Electrocardiography, echocardiography, pulmonary function tests, and a lung perfusion scan are necessary to exclude secondary forms of pulmonary hypertension and also help to confirm the diagnosis of PPH. A definite diagnosis of PPH is established by right-heart catheterisation which gives a precise measure of the blood pressure in the right side of the heart and the pulmonary artery, right ventricular function and cardiac output. Once a diagnosis of PPH is established, treatment involving drug therapy or surgery is commenced on the basis of the New York Heart Association functional class. Conventional treatment consists of lifetime administration of anticoagulants, oxygen, diuretics, and digoxin. Vasodilator therapy with calcium channel antagonists is indicated in patients who are 'vasoreactive' to acute vasodilator challenge as assessed by right-heart catheterisation. Promising results are obtained by continuous intravenous administration of epoprostenol (prostacyclin). Newer therapies for PPH include prostacyclin analogues, endothelin receptor antagonists, nitric oxide, phosphodiesterase-5 inhibitors, elastase inhibitors, and gene therapy. Surgical treatment consists of atrial septostomy, thromboendarterectomy, and lung or heart-lung transplantation.
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Affiliation(s)
- T L De Backer
- Department of Cardiology, Thoraxcentre, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
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38
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Abstract
Until recently, many physicians considered pulmonary hypertension a rare and esoteric condition that is difficult to diagnose and nearly impossible to treat. However, pulmonary hypertension can complicate a variety of relatively common diseases and, with the development of new and effective therapies, there is a need for greater awareness of this condition. Pulmonary hypertension should be considered when patients present with unexplained shortness of breath, chest pain, or syncope. The usual delay of 1 to 2 years between onset of symptoms and diagnosis underscores the importance of considering pulmonary hypertension in the differential diagnosis of patients who present with atypical cardiorespiratory symptoms.
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Affiliation(s)
- G L Yung
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego School of Medicine, La Jolla, CA, USA
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39
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Glenny RW, Robertson HT, Hlastala MP. Vasomotor tone does not affect perfusion heterogeneity and gas exchange in normal primate lungs during normoxia. J Appl Physiol (1985) 2000; 89:2263-7. [PMID: 11090577 DOI: 10.1152/jappl.2000.89.6.2263] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
To determine whether vasoregulation is an important cause of pulmonary perfusion heterogeneity, we measured regional blood flow and gas exchange before and after giving prostacyclin (PGI(2)) to baboons. Four animals were anesthetized with ketamine and mechanically ventilated. Fluorescent microspheres were used to mark regional perfusion before and after PGI(2) infusion. The lungs were subsequently excised, dried inflated, and diced into approximately 2-cm(3) pieces (n = 1,208-1,629 per animal) with the spatial coordinates recorded for each piece. Blood flow to each piece was determined for each condition from the fluorescent signals. Blood flow heterogeneity did not change with PGI(2) infusion. Two other measures of spatial blood flow distribution, the fractal dimension and the spatial correlation, did not change with PGI(2) infusion. Alveolar-arterial O(2) differences did not change with PGI(2) infusion. We conclude that, in normal primate lungs during normoxia, vasomotor tone is not a significant cause of perfusion heterogeneity. Despite the heterogeneous distribution of blood flow, active regulation of regional perfusion is not required for efficient gas exchange.
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Affiliation(s)
- R W Glenny
- Department of Medicine, University of Washington 98195, USA.
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40
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Saadjian AY, Paganelli F, Juin MA, Devaux C, Lévy S, Guieu RP. Plasma beta-endorphin and adenosine concentration in pulmonary hypertension. Am J Cardiol 2000; 85:858-63. [PMID: 10758927 DOI: 10.1016/s0002-9149(99)00881-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To determine whether beta-endorphin plays a role in the regulation of pulmonary vascular tone in patients with pulmonary hypertension, we investigated the relations between hemodynamics and beta-endorphin and adenosine concentrations in 3 clinical situations: (1) normal hemodynamics (7 subjects, mean pulmonary artery [PA] pressure 18.5 +/- 1 mm Hg); (2) moderate pulmonary hypertension secondary to chronic obstructive pulmonary disease (COPD) (8 patients, mean PA pressure 31 +/- 3 mm Hg); and (3) severe primary pulmonary hypertension (PPH) (8 patients, mean PA pressure 70 +/-5 mm Hg). Plasma beta-endorphin and adenosine were measured in a distal PA and in the femoral artery in room air and during oxygen inhalation. Beta-endorphin levels were similar in the pulmonary and systemic circulations. No difference was observed between patients with COPD and PPH, but relative to controls, both had significantly higher beta-endorphin levels. Pulmonary adenosine was significantly lower in patients with pulmonary hypertension than in controls (-60% in COPD [p <0.005] and -70% in PPH [p <0.001]). Pure oxygen administration significantly decreased adenosine and beta-endorphin levels, much more so in patients with COPD and PPH. We found a negative correlation between beta-endorphin and adenosine concentrations (r = -0.751, p <0.001): the higher the adenosine, the lower the beta-endorphin level. These observations suggest that because adenosine release by pulmonary vascular endothelium is reduced in pulmonary hypertension, the resulting worsened hypoperfusion and tissue oxygenation may cause increased beta-endorphin release.
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Affiliation(s)
- A Y Saadjian
- Cardiology Department, Institut National de la Santé et de la Recherche Médicale, Service de Cardiologie, CHU Nord, Marseille, France
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41
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Abstract
The goals of treatment of cor pulmonale are 1) to reduce pulmonary arterial hypertension; 2) to optimize gas-exchange efficiency; and 3) to improve survival. These goals are achieved through long-term oxygen therapy, bronchodilator and vasodilator therapy, aggressive treatment of pulmonary infection, and anticoagulation. Selected patients may benefit from available surgical options.
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Affiliation(s)
- ED Missov
- Division of Cardiology, University of California at San Francisco, 1180 Moffitt Hospital, 505 Parnassus Avenue, San Francisco, CA 94143-0124, USA.
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42
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Affiliation(s)
- A J Peacock
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow G11 6NT, UK
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43
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Krowka MJ, Frantz RP, McGoon MD, Severson C, Plevak DJ, Wiesner RH. Improvement in pulmonary hemodynamics during intravenous epoprostenol (prostacyclin): A study of 15 patients with moderate to severe portopulmonary hypertension. Hepatology 1999; 30:641-8. [PMID: 10462369 DOI: 10.1002/hep.510300307] [Citation(s) in RCA: 215] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pulmonary hypertension associated with increased pulmonary vascular resistance (PVR) and occurring in the setting of portal hypertension is referred to as "portopulmonary hypertension." Intravenous epoprostenol (prostacyclin) is a potent pulmonary and systemic vasodilator with antithrombotic properties. It can decrease PVR and pulmonary artery pressure in patients with primary (idiopathic) pulmonary hypertension. Using right-heart catheterization, we evaluated the acute pulmonary hemodynamic effects of intravenous epoprostenol in patients with moderate to severe pulmonary hypertension (mean pulmonary artery pressure [MPAP] >/=35 mm Hg) associated with clinical manifestations of portal hypertension. Effects of long-term infusion of epoprostenol were also evaluated. We studied 15 consecutive patients with portopulmonary hypertension; 14 underwent acute administration of epoprostenol, and no significant side effects were noted. Ten patients received continuous epoprostenol (range, 8 days-30 months). Acute changes in PVR (-34% +/- 18%), MPAP (-16% +/- 10%), and cardiac output (CO) (+21 +/- 18%), were statistically significant (P <.01). Long-term use of epoprostenol further lowered PVR (-47% +/- 12% from baseline and -31% +/- 22% from the acute change; P <.05) in the 6 patients restudied by right-heart catheterization. Death occurred in 6 of 10 (60%) of those receiving long-term epoprostenol. In moderate to severe portopulmonary hypertension, intravenous epoprostenol resulted in a significant improvement (both acute and long-term) in PVR, MPAP, and CO. Potential adverse effects on portal hypertension and implications for orthotopic liver transplantation (OLT), however, require further study.
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Affiliation(s)
- M J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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44
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Affiliation(s)
- S Brij
- Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, UK
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45
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Aranda M, Bradford KK, Pearl RG. Combined Therapy with Inhaled Nitric Oxide and Intravenous Vasodilators During Acute and Chronic Experimental Pulmonary Hypertension. Anesth Analg 1999. [DOI: 10.1213/00000539-199907000-00027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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46
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Aranda M, Bradford KK, Pearl RG. Combined therapy with inhaled nitric oxide and intravenous vasodilators during acute and chronic experimental pulmonary hypertension. Anesth Analg 1999; 89:152-8. [PMID: 10389795 DOI: 10.1097/00000539-199907000-00027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Both inhaled nitric oxide (NO) and IV vasodilators decrease pulmonary hypertension, but the effects of combination therapy are unknown. We studied the response to inhaled NO (100 ppm) alone, IV vasodilator alone, and combined therapy during acute (U46619-induced) and chronic (monocrotaline-induced) pulmonary hypertension in the pentobarbital-anesthetized rat. Vasodilator doses were 1.0, 3.2, 10, and 32 microg x kg(-1) x min(-1) sodium nitroprusside (SNP); 50, 100, 150, 200, and 300 microg x kg(-1) x min(-1) adenosine; or 25, 50, 150, 200, and 300 ng x kg(-1) x min(-1) prostacyclin. In the absence of IV vasodilator therapy, inhaled NO decreased mean pulmonary artery pressure without decreasing mean systemic arterial pressure. In both acute and chronic pulmonary hypertension, the addition of inhaled NO to the largest dose of adenosine or prostacyclin, but not of SNP, decreased pulmonary artery pressure. Because inhaled NO and SNP activate guanylyl cyclase and adenosine and prostacyclin activate adenylyl cyclase, the results suggest that adding inhaled NO to a vasodilator not dependent on guanylyl cyclase may produce additional selective pulmonary vasodilation. IMPLICATIONS In therapy of pulmonary hypertension, inhaled nitric oxide should produce additional selective pulmonary vasodilation when combined with a vasodilator whose mechanism of action is not dependent on cyclic guanosine 3',5'-monophosphate.
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Affiliation(s)
- M Aranda
- Department of Anesthesia, Stanford University Medical Center, California 94305-5117, USA
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47
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Palevsky HI, Gurughagavatula I. Pulmonary hypertension in collagen vascular disease. COMPREHENSIVE THERAPY 1999; 25:133-43. [PMID: 10200902 DOI: 10.1007/bf02889609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension associated with collagen vascular disease often eludes diagnosis, sometimes causing considerable morbidity or even death before being identified. This review details its characteristic clinical features, appropriate diagnostic and treatment approaches, and expected outcomes.
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Affiliation(s)
- H I Palevsky
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Health System, Philadelphia 19104-2699, USA
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48
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Abstract
Pulmonary hypertension (mean pulmonary arterial pressure > 20mm Hg at rest or > 30mm Hg during exercise) occurs (i) as primary pulmonary hypertension (no known underlying cause), (ii) as persistent pulmonary hypertension of the newborn or (iii) secondary to a variety of lung and cardiovascular diseases. In the last 10 to 15 years there have been significant advances in the medical management of this debilitating and life-threatening disorder. The main drugs in current use are anticoagulants (warfarin, heparin) and vasodilators, especially oral calcium antagonists, intravenous prostacyclin (prostaglandin I2; epoprostenol) and inhaled nitric oxide. Calcium antagonists, (e.g. nifedipine, diltiazem) are used chiefly in primary pulmonary hypertension. They are effective in patients who give a pulmonary vasodilator response to an acute challenge with a short acting vasodilator (e.g. prostacyclin, nitric oxide or adenosine), and are used in doses greater than are usual in the treatment of other cardiovascular disorders. Prostacyclin, given by continuous intravenous infusion, is effective in patients even if they do not respond to an acute vasodilator challenge. The long term benefit in these patients is thought to reflect the antiproliferative effects of the drug and/or its ability to inhibit platelet aggregation. It is used either as long term therapy or as a bridge to transplantation. Inhaled nitric oxide, which is used mainly in persistent pulmonary hypertension of the newborn, has the particular benefit of being pulmonary selective, due to its route of administration and rapid inactivation. Anticoagulants have a specific role in the treatment of pulmonary thromboembolic pulmonary hypertension and are also used routinely in patients with primary pulmonary hypertension. Nondrug treatments for pulmonary hypertension include (i) supplemental oxygen (> or = 15 h/day), which is the primary therapy in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease and (ii) heart-lung or lung transplantation, which nowadays is regarded as a last resort. Different types of pulmonary hypertension require different treatment strategies. Future advances in the treatment of pulmonary hypertension may come from the use of drug combinations, the development of new drugs, such as endothelin antagonists, nitric oxide donors and potassium channel openers, or the application of gene therapy.
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Affiliation(s)
- J C Wanstall
- Department of Physiology and Pharmacology, University of Queensland, Brisbane, Australia.
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49
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Parsons S, Celermajer D, Savidis E, Miller O, Young I. The effect of inhaled nitric oxide on 6-minute walk distance in patients with pulmonary hypertension. Chest 1998; 114:70S-72S. [PMID: 9676643 DOI: 10.1378/chest.114.1_supplement.70s] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- S Parsons
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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50
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Saadjian A, Philip-Joët F, Paganelli F, Arnaud A, Levy S. Long-term effects of cicletanine on secondary pulmonary hypertension. J Cardiovasc Pharmacol 1998; 31:364-71. [PMID: 9514180 DOI: 10.1097/00005344-199803000-00006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cicletanine, a furopyridine-derivative drug, was shown to enhance the production of endogenous prostacyclin. The potent vasodilating properties of prostacyclin are used to treat severe primary pulmonary hypertension. Prostacyclin has a short half-life and can be administered only as an i.v. infusion. The aim of this study was to evaluate the effects of cicletanine on pulmonary artery hypertension (PAH) resulting from chronic obstructive lung disease (COLD). In a double-blind controlled study, we evaluated the effects of short- and long-term administration of cicletanine (50 mg daily, orally) on hemodynamics and blood gases of patients with PAH resulting from COLD. The initial dose of 50 mg of cicletanine had no effect. A significant decrease in the mean pulmonary artery pressure (15%) and in total pulmonary resistance (20%) was observed after 3 or 12 months of treatment in the cicletanine group (11 patients), when compared with placebo (12 patients). PaO2 decreased slightly in the cicletanine group, but the difference from the control group was not significant. These results suggest that long-term treatment with cicletanine can induce effective pulmonary vasodilation in patients with PAH caused by COLD and that this is probably responsible for a small venous admixture.
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Affiliation(s)
- A Saadjian
- Department of Cardiology, Institut National de la Santé et de la Recherche Mëdicale, CHU Nord, Marseille, France
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