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Chao HY, Yee BJ, Hsu CH, Chen HM, Lau EM. Sleep-related disorders in patients with precapillary pulmonary hypertension. Sleep Med Rev 2024; 77:101972. [PMID: 39032322 DOI: 10.1016/j.smrv.2024.101972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/12/2024] [Accepted: 06/27/2024] [Indexed: 07/23/2024]
Abstract
Precapillary pulmonary hypertension (PcPH) is associated with the development of sleep-related disorders and impairment of sleep quality. With growing recognition of the clinical relevance of sleep-related conditions in PcPH, this narrative review seeks to discuss the spectrum of disorders encountered in clinical practice, pathophysiological mechanisms linking PcPH with sleep-related disorders, and potential therapeutic considerations. Current evidence demonstrates a higher prevalence of impaired sleep quality, sleep-disordered breathing, sleep-related hypoxia, and restless leg syndrome in patients with PcPH. These sleep-related disorders could further lead to impairment of quality of life in a patient population with already a high symptom burden. Recent data suggest that sleep-related hypoxia is strongly linked to worse right ventricular function and higher risk of transplantation or death. However, limited studies have investigated the role of oxygen therapy or positive airway pressure therapy improving symptoms or outcomes. Abnormal iron homeostasis is highly prevalent in PcPH and may contribute to the development of restless legs syndrome/periodic limb movement of sleep. To improve sleep management in PcPH, we highlight future research agenda and advocate close collaboration between pulmonary hypertension specialists and sleep physicians.
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Affiliation(s)
- Hsin-Yu Chao
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Brendon J Yee
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; Woolcock Institute of Medical Research, Macquarie University, Sydney, Australia
| | - Chih-Hsin Hsu
- Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Hsing-Mei Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Edmund M Lau
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia.
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2
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Sahay S, Chakinala MM, Kim NH, Preston IR, Thenappan T, Mclaughlin VV. Contemporary Treatment of Pulmonary Arterial Hypertension: A U.S. Perspective. Am J Respir Crit Care Med 2024; 210:581-592. [PMID: 38984912 DOI: 10.1164/rccm.202405-0914so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a complex fatal condition that requires aggressive treatment with close monitoring. Significant progress has been made over the last three decades in the treatment of PAH, but, despite this progress, survival has remained unacceptably low. In the quest to improve survival, therapeutic interventions play a central role. In the last few years, there have been remarkable attempts to identify novel treatments. Finally, we have had a breakthrough with the discovery of the fourth treatment pathway in PAH. Activin signaling inhibition distinguishes itself as a potential antiproliferative intervention as opposed to the traditional therapies, which mediate their effect primarily by vasodilatation. With this novel treatment pathway, we stand at an important milestone with an exciting future ahead and the natural question of when to use an activin signaling inhibitor for the treatment of PAH. In this state-of-the-art review, we focus on the placement of this novel agent in the PAH treatment paradigm, based on the available evidence, with special focus on the U.S. patient population. This review also provides an expert opinion of the current treatment algorithm in important subgroups of patients with comorbidities from the U.S. perspective.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary, Critical Care and Sleep Medicine, Houston Methodist Hospital, Houston, Texas
| | - Murali M Chakinala
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, California
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Division, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Thenappan Thenappan
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and
| | - Vallerie V Mclaughlin
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
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3
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Biener L, Kohli J, Marggraf V, Nickenig G, Skowasch D, Pizarro C. Intravenous iron supplementation in pulmonary hypertension groups 1 to 4. Int J Med Sci 2024; 21:2011-2020. [PMID: 39239538 PMCID: PMC11373552 DOI: 10.7150/ijms.92904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 07/16/2024] [Indexed: 09/07/2024] Open
Abstract
Background: Iron deficiency (ID) is common in patients with pulmonary arterial hypertension and has been associated with increased morbidity and mortality. We aimed to evaluate the therapeutic effects of iron supplementation in iron deficient patients with group 1 to 4 pulmonary hypertension (PH). Methods: A total of 85 PH patients (mean age 69.8 ± 12.0 years, 56.5% female) were included in this prospective trial. Patients were screened for ID at baseline. PH patients with ID received intravenous iron supplementation (500-1000 mg ferric carboxymaltose). PH patients without ID served as control group. At baseline and 16-week follow up, six-minute walk test (6MWT), laboratory testing and echocardiography were performed. Additionally, World Health Organization (WHO) functional class, fatigue score and quality of life (QoL) by the SF-36 questionnaire were assessed. Results: Overall, ID was present in 26.7% (n=8/30), 37.5% (n=9/24), 45.5% (n=10/22) and 44.4% (n=4/9) of patients in PH groups 1-4, respectively. In the total study population, iron restoration led to a significant mitigation of fatigue (p=0.01). However, 6MWT, WHO function class, NT-proBNP levels, QoL and right ventricular function did not change significantly. With regard to the underlying PH group, only PH group 3 patients experienced significant improvements in 6MWT distance (p=0.019), WHO functional class (p=0.017), fatigue (p=0.009) and some QoL domains, as compared to controls. Conclusions: ID was common in PH groups 1 to 4. Though intravenous iron supplementation adequately restored iron status and improved fatigue throughout all patients, in the underlying PH groups treatment was accompanied by improvements in exercise capacity, WHO function class and fatigue only in group 3 PH.
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Affiliation(s)
- Leonie Biener
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
| | - Josna Kohli
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
| | - Vanessa Marggraf
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
| | - Dirk Skowasch
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
| | - Carmen Pizarro
- Department of Internal Medicine II - Pneumology/Cardiology, University Hospital Bonn, Bonn, Germany
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4
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Albulushi A, Kashoub M, Al-Saidi K, Al-Farhan H. Iron Deficiency in Pulmonary Hypertension. Int Heart J 2024; 65:593-600. [PMID: 39010221 DOI: 10.1536/ihj.24-055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Pulmonary hypertension (PH) is a complex cardiovascular condition that is characterized by elevated pulmonary arterial pressure, which leads to significant morbidity and mortality. Among the various factors that influence the pathophysiology and progression of PH, iron deficiency has become a critical, yet often overlooked, element. In this review, the prevalence, implications, and therapeutic potential of addressing iron deficiency in patients with PH are elucidated.Iron deficiency, which is prevalent in a significant proportion of patients with PH, has been associated with worsened clinical outcomes, including diminished exercise capacity, impaired oxygen transport and utilization, and compromised right ventricular function. The pathophysiological linkages between iron deficiency and PH are multifaceted and involve alterations in oxygen sensing, endothelial function, and metabolic disturbances.In this review, the evidence from recent clinical trials and studies that assess the impact of iron supplementation, both oral and intravenous, on PH outcomes is critically analyzed. Although some studies suggest improvements in exercise capacity and hemodynamic parameters following iron repletion, the responses appear variable and are not universally beneficial. This review highlights the complexities of iron metabolism in PH and the challenges in effectively diagnosing and treating iron deficiency in this patient population.Furthermore, the potential mechanisms through which iron supplementation might influence pulmonary vascular and right ventricular function, emphasizing the need for personalized treatment approaches are discussed. In this review, the importance of recognizing iron deficiency in the management of patients with PH is highlighted, and further research is warranted to establish comprehensive, evidence-based guidelines for iron supplementation in this unique patient cohort. The ultimate goal of this review is to improve clinical outcomes and quality of life for patients suffering from this debilitating condition.
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Affiliation(s)
- Arif Albulushi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center
- Division of Adult Cardiology, National Heart Center, Royal Hospital
| | - Masoud Kashoub
- Department of Medicine, Sultan Qaboos University Hospital
| | - Khalid Al-Saidi
- Division of Adult Cardiology, National Heart Center, Royal Hospital
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5
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Kido K, Beavers CJ, Dulnuan K, Fida N, Guglin M, Ilonze OJ, Mentz RJ, Narang N, Rajagopalan N, Ramu B, Sattar Y, Sokos G, Jankowska EA. Management of Iron Deficiency in Heart Failure: Practical Considerations and Implementation of Evidence-Based Iron Supplementation. JACC. HEART FAILURE 2024:S2213-1779(24)00433-5. [PMID: 39001744 DOI: 10.1016/j.jchf.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 07/15/2024]
Abstract
Iron deficiency (ID) is present in approximately 50% of patients with heart failure (HF) and even higher prevalence rate up to 80% in post-acute HF setting. The current guidelines for HF recommend intravenous (IV) iron replacement in HF with reduced or mildly reduced ejection fraction and ID based on clinical trials showing improvements in quality of life and exercise capacity, and an overall treatment benefit for recurrent HF hospitalization. However, several barriers cause challenges in implementing IV iron supplementation in practice due, in part, to clinician knowledge gaps and limited resource availability to protocolize routine utilization in appropriate patients. Thus, the current review will discuss practical considerations in ID treatment, implementation of evidence-based ID treatment to improve regional health disparities with toolkits, inclusion/exclusion criteria of IV iron supplementation, and clinical controversies in ID treatment, as well as gaps in evidence and questions to be answered.
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Affiliation(s)
- Kazuhiko Kido
- West Virginia University School of Pharmacy, Morgantown, West Virginia, USA.
| | - Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Kenneth Dulnuan
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | | | - Maya Guglin
- Krannert Cardiovascular Research Center, Indiana University Health School of Medicine, Indianapolis, Indiana, USA
| | - Onyedika J Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, Indiana, USA
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Nikhil Narang
- Advocate Heart Institute, Oak Lawn, Illinois, USA; Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Navin Rajagopalan
- Division of Cardiology, University of Kentucky, Lexington, Kentucky, USA
| | | | - Yasar Sattar
- West Virginia University Medicine, Morgantown, West Virginia, USA
| | - George Sokos
- West Virginia University Medicine, Morgantown, West Virginia, USA
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6
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Brownstein AJ, Wilkinson JD, Liang LL, Channick RN, Saggar R, Kim A. Immature reticulocyte fraction: A novel biomarker of hemodynamic severity in pulmonary arterial hypertension. Pulm Circ 2024; 14:e12421. [PMID: 39105130 PMCID: PMC11298897 DOI: 10.1002/pul2.12421] [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: 05/03/2024] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 08/07/2024] Open
Abstract
Various erythropoietic abnormalities are highly prevalent among patients with pulmonary arterial hypertension (PAH) and associated with worse disease severity. Given the poorly understood yet important roles of dysregulated erythropoiesis and iron metabolism in PAH, we sought to further characterize the hematologic and iron profiles in PAH and their relationship to PAH severity. We recruited 67 patients with PAH and 13 healthy controls. Hemodynamics attained within 1 year of blood sample collection were available for 36 patients. Multiple hematologic, iron, and inflammatory parameters were evaluated for their association with hemodynamics. The subset with hemodynamic data consisted of 29 females (81%). The most common etiologies were idiopathic PAH (47%) and connective tissue disease-related PAH (33%). 19 (53%) had functional class 3 or 4 symptomatology, and 12 (33%) were on triple pulmonary vasodilator therapy. Immature reticulocyte fraction (IRF) had significant positive correlations with mean pulmonary artery (PA) pressure (mPAP) (0.59, p < 0.001), pulmonary vascular resistance (0.52, p = 0.001), and right atrial pressure (0.46, p = 0.005), and significant negative correlations with cardiac index (-0.43, p = 0.009), PA compliance (PAC) (-0.60, p < 0.001), stroke volume index (SVI) (-0.57, p < 0.001), and mixed venous oxygen saturation (-0.51, p = 0.003). IRF correlated with markers of iron deficiency (ID) and erythropoiesis. On multivariable linear regression, IRF was associated with elevated mPAP and reduced SVI and PAC independent of EPO levels, transferrin saturation, and soluble transferrin receptor levels. We identified IRF as a novel and potent biomarker of PAH hemodynamic severity, possibly related to its associations with erythropoiesis, ID, and tissue hypoxia.
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Affiliation(s)
- Adam J. Brownstein
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Jared D. Wilkinson
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Lloyd L. Liang
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Richard N. Channick
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Rajan Saggar
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Airie Kim
- Division of Pulmonary and Critical Care MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
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7
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Lakhal-Littleton S, Cleland JGF. Iron deficiency and supplementation in heart failure. Nat Rev Cardiol 2024; 21:463-486. [PMID: 38326440 DOI: 10.1038/s41569-024-00988-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.
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Affiliation(s)
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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8
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Mousavi Mele M, Tahavorgar A, Salimi Z, Shaker A, Askarpour SA, Mohammadian MK, Mirshafaei SR, Saeedirad Z, Torkaman M, Mahmoudi Z, Tajadod S, Khoshdooz S, Doaei S, Kooshki A, Gholamalizadeh M. The Association of Iron Intake and Hypertension, Does Iron Intake Decrease Blood Pressure? Cardiovasc Toxicol 2024; 24:345-350. [PMID: 38561455 DOI: 10.1007/s12012-024-09848-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/02/2024] [Indexed: 04/04/2024]
Abstract
Previous studies reported that iron may have an indispensable role in the risk of hypertension (HTN). However, the result of the studies on the relationship between iron and risk of HTN is inconsistent. This study aimed to assess the association between the association of dietary iron intake and HTN in the Iranian population. This case-control study was conducted on 4184 people aged 35 to 70, including 1239 people with HTN and 2945 people with normal blood pressure (BP) in Sabzevar, Iran. Dietary intake was assessed using a food frequency questionnaire (FFQ). The Nutritionist IV software was used in terms of the assessment of dietary intake of iron. An inverse association was found between iron intake and HTN (OR = 0.97, CI 95%: 0.94-0.99, P = 0.04). The association remained significant after adjustment for age, gender, smoking, drinking alcohol, calorie intake, and BMI (OR = 0.94, CI 95%: 0.89-0.98, P = 0.01). As a conclusion, iron intake was inversely associated with HTN. Further longitudinal studies on the effect of iron intake on BP are required to confirm this finding.
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Affiliation(s)
- Mahdi Mousavi Mele
- Department of Nutrition, School of Public Health, International Campus, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Atefeh Tahavorgar
- School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Salimi
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Shaker
- Cellular and Molecular Biology, Islamic Azad University of Mashhad, Mashhad, Iran
| | - Seyed Ali Askarpour
- Division of Food Safety and Hygiene, Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Seyed Reza Mirshafaei
- Department of Applied Mathematics, Faculty of Mathematical Sciences, Roudsar & Amlash Branch, Islamic Azad University, Roudsar, Iran
| | - Zahra Saeedirad
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdie Torkaman
- Department of Chemical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Zahra Mahmoudi
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Shirin Tajadod
- Department of nutrition, School of Public health, International campus, Iran University of Medical Sciences, International Campus, Tehran, Iran
| | | | - Saeid Doaei
- Department of Community Nutrition, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Akram Kooshki
- Non-Communicable Diseases Research Center, Department of Nutrition & Biochemistry, Faculty of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
| | - Maryam Gholamalizadeh
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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9
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Rose SW, Highland KB, Kelkar AA. Clinical Utility of Patient-Reported Outcome Instruments in the Management of Pulmonary Hypertension: A Systematic Review. JACC. HEART FAILURE 2024; 12:366-376. [PMID: 37897461 DOI: 10.1016/j.jchf.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Despite the greater sensitivity and specificity of disease-specific patient-reported outcome measures (PROM) to detect clinical change, only recently have such instruments been developed for pulmonary hypertension (PH), specifically pulmonary arterial hypertension (PAH) and chronic thromboembolic disease (CTEPH). Although these valuable tools are now being incorporated into clinical studies of PH, they have not yet reached widespread integration into routine clinical care. OBJECTIVES In this systematic review, the authors assess the psychometric properties of PROM developed for PH, compare PROM with other clinical outcomes in PH, and address the utility of PROM in clinical care. METHODS The authors performed a systematic search of papers published between January 1, 2006, and October 1, 2022, using the MEDLINE database to identify PROM developed and validated for PH. The identified PROM were found to have been developed only in groups with PAH and CTEPH. The authors evaluated the identified instruments according to established psychometric criteria. An additional search was performed to identify randomized controlled trials (RCTs) utilizing these PROM for comparison with clinical outcomes. RESULTS From 527 papers retrieved, a total of 35 PROM were identified. Of these, 5 disease-specific instruments were included in the final analysis. While both CAMPHOR (Cambridge Pulmonary Hypertension Outcome Review) and emPHasis-10 performed well in patients with PAH and CTEPH with regard to their psychometric properties, emPHasis-10 demonstrated superior feasibility for use in clinical practice due to its concise format. The Pulmonary Arterial Hypertension-Symptoms and Impacts Questionnaire performed well in the authors' analysis, though additional data is needed regarding interpretability and feasibility. CONCLUSIONS EmPHasis-10 demonstrated strong psychometric properties and the greatest feasibility for clinical use. Further study assessing the integration of PROM into routine clinical care for PH is needed.
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Affiliation(s)
- Scott W Rose
- Sections of Critical Care and Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | | | - Anita A Kelkar
- Section of Cardiovascular Medicine, Department of Veterans Affairs, Kernersville, North Carolina, USA.
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10
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Oknińska M, Zajda K, Zambrowska Z, Grzanka M, Paterek A, Mackiewicz U, Szczylik C, Kurzyna M, Piekiełko-Witkowska A, Torbicki A, Kieda C, Mączewski M. Role of Oxygen Starvation in Right Ventricular Decompensation and Failure in Pulmonary Arterial Hypertension. JACC. HEART FAILURE 2024; 12:235-247. [PMID: 37140511 DOI: 10.1016/j.jchf.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/22/2023] [Accepted: 03/16/2023] [Indexed: 05/05/2023]
Abstract
Right ventricular (RV) function and eventually failure determine outcome in patients with pulmonary arterial hypertension (PAH). Initially, RV responds to an increased load caused by PAH with adaptive hypertrophy; however, eventually RV failure ensues. Unfortunately, it is unclear what causes the transition from compensated RV hypertrophy to decompensated RV failure. Moreover, at present, there are no therapies for RV failure; those for left ventricular (LV) failure are ineffective, and no therapies specifically targeting RV are available. Thus there is a clear need for understanding the biology of RV failure and differences in physiology and pathophysiology between RV and LV that can ultimately lead to development of such therapies. In this paper, we discuss RV adaptation and maladaptation in PAH, with a particular focus of oxygen delivery and hypoxia as the principal drivers of RV hypertrophy and failure, and attempt to pinpoint potential sites for therapy.
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Affiliation(s)
- Marta Oknińska
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Karolina Zajda
- Laboratory of Molecular Oncology and Innovative Therapies, Military Medical Institute, Warsaw, Poland
| | - Zuzanna Zambrowska
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Małgorzata Grzanka
- Department of Biochemistry and Molecular Biology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Aleksandra Paterek
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Urszula Mackiewicz
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Cezary Szczylik
- Department of Oncology at ECZ-Otwock, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at ECZ-Otwock, ERN-LUNG Member, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at ECZ-Otwock, ERN-LUNG Member, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Claudine Kieda
- Laboratory of Molecular Oncology and Innovative Therapies, Military Medical Institute, Warsaw, Poland; Centre for Molecular Biophysics, UPR, CNRS 4301, Orléans CEDEX 2, France; Department of Molecular and Translational Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Mączewski
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland.
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11
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Hopkins CD, Wessel C, Chen O, El-Kersh K, Cathey D, Cave MC, Cai L, Huang J. A hypothesis: Potential contributions of metals to the pathogenesis of pulmonary artery hypertension. Life Sci 2024; 336:122289. [PMID: 38007143 PMCID: PMC10872724 DOI: 10.1016/j.lfs.2023.122289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023]
Abstract
Pulmonary artery hypertension (PAH) is characterized by vasoconstriction and vascular remodeling resulting in both increased pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP). The chronic and high-pressure stress experienced by endothelial cells can give rise to inflammation, oxidative stress, and infiltration by immune cells. However, there is no clearly defined mechanism for PAH and available treatment options only provide limited symptomatic relief. Due to the far-reaching effects of metal exposures, the interaction between metals and the pulmonary vasculature is of particular interest. This review will briefly introduce the pathophysiology of PAH and then focus on the potential roles of metals, including essential and non-essential metals in the pathogenic process in the pulmonary arteries and right heart, which may be linked to PAH. Based on available data from human studies of occupational or environmental metal exposure, including lead, antimony, iron, and copper, the hypothesis of metals contributing to the pathogenesis of PAH is proposed as potential risk factors and underlying mechanisms for PAH. We propose that metals may initiate or exacerbate the pathogenesis of PAH, by providing potential mechanism by which metals interact with hypoxia-inducible factor and tumor suppressor p53 to modulate their downstream cellular proliferation pathways. These need further investigation. Additionally, we present future research directions on roles of metals in PAH.
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Affiliation(s)
- C Danielle Hopkins
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Caitlin Wessel
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Oscar Chen
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Karim El-Kersh
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Dakotah Cathey
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; Pediatric Research Institute, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - Matthew C Cave
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA; The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY 40202, USA; Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, KY, USA; The Transplant Program at University of Louisville Health - Jewish Hospital Trager Transplant Center, Louisville, KY, USA
| | - Lu Cai
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY 40202, USA; Pediatric Research Institute, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA; Department of Radiation Oncology, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, KY, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY 40202, USA; The Transplant Program at University of Louisville Health - Jewish Hospital Trager Transplant Center, Louisville, KY, USA; Cardiovascular Innovation Institute, Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
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12
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Xiong J, Peng Y, Li J, Cai S, Wu R. Total iron binding capacity: an independent predictor of prognosis for pulmonary arterial hypertension in systemic lupus erythematosus. Scand J Rheumatol 2024; 53:44-48. [PMID: 37605880 DOI: 10.1080/03009742.2023.2240586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/21/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE To investigate the role of parameters of iron metabolism in systemic lupus erythematosus (SLE) patients with pulmonary arterial hypertension (PAH). METHOD This was a prospective observational study recruiting patients diagnosed with systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH). Patients with other factors that might lead to PAH were excluded from the study. All patients were assessed for PAH every 1-3 months and were followed up for 6 months. The primary outcome was considered improved if the grade of risk stratification declined at the endpoint; otherwise, it was considered unimproved. RESULTS In total, 29 patients with SLE-PAH were included in this study. The mean of serum ferritin was higher than normal, and total iron binding capacity (TIBC) decreased in 48% of patients. Correlation analyses showed that serum iron (SI) was negatively correlated with World Health Organization functional class (WHO-FC) (r = -0.409, p = 0.028), and positively correlated with Six-Minute Walk Test distance (6MWD) (r = 0.427, p = 0.021) and tricuspid annular plane systolic excursion (TAPSE) (r = 0.388, p = 0.037). Primary outcomes improved in 12 patients at the endpoint, and univariate logistic regression analyses indicated that TIBC was associated with improved primary outcomes in patients with SLE-PAH (odds ratio 12.00, 95% confidence interval 1.90-75.72). CONCLUSION SI was negatively correlated with WHO-FC, and positively correlated with 6MWD and TAPSE. Furthermore, TIBC was associated with improved outcomes of patients with SLE-PAH, which could be an independent predictor of prognosis. Further research is needed to verify the findings.
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Affiliation(s)
- J Xiong
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Y Peng
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - J Li
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - S Cai
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - R Wu
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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13
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Lichtblau M, Harutyunova S, Nechwatal R, Mayer L, Kabitz HJ, Wilkens FM, Uiker S, Grünig E, Ritter D, Florea A, Benjamin N. [General measures and management of pulmonary arterial hypertension]. Pneumologie 2023; 77:907-915. [PMID: 37963480 DOI: 10.1055/a-2145-4741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Care of patients with pulmonary arterial hypertension (PAH) needs a multi-facetet concept and measures, including management of adverse reactions, right heart insufficiency as well as information on pregnancy, travels by air, psychosocial support, physical exercise training and prophylaxis by vaccination.Positive study results led to an higher recommendation of specialized exercise training in pulmonary hypertension. Also, the recommendation on iron substitution was amended according to the current evidence.In the current guidelines, special focus was given to the elaboration of recommendations regarding pregnancy, including patient information, contraception and patient management in case of pregnancy.This article aims to provide an overview on the recommendations of general measuremes, special circumstances and patient management according to the ESC/ERS guidelines. Amendments to the guideline recommendations are given as comments from the authors of this article.
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Affiliation(s)
- Mona Lichtblau
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | | | - Laura Mayer
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Schweiz
| | - Finn Moritz Wilkens
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Sören Uiker
- Rehaklinik Heidelberg Königstuhl, Heidelberg, Deutschland
| | - Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Daniel Ritter
- Klinikum Würzburg Mitte, Standort Missionsärztliche Klinik, Würzburg, Deutschland
| | - Andreea Florea
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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14
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Slingo ME. Oxygen-sensing pathways and the pulmonary circulation. J Physiol 2023. [PMID: 37843154 DOI: 10.1113/jp284591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
The unique property of the pulmonary circulation to constrict in response to hypoxia, rather than dilate, brings advantages in both health and disease. Hypoxic pulmonary vasoconstriction (HPV) acts to optimise ventilation-perfusion matching - this is important clinically both in focal disease (such as pneumonia) and in one-lung ventilation during anaesthesia for thoracic surgery. However, during global hypoxia such as that encountered at high altitude, generalised pulmonary vasoconstriction can lead to pulmonary hypertension. There is now a growing body of evidence that links the hypoxia-inducible factor (HIF) pathway and pulmonary vascular tone - in both acute and chronic settings. Genetic and pharmacological alterations to all key components of this pathway (VHL - von Hippel-Lindau ubiquitin E3 ligase; PHD2 - prolyl hydroxylase domain protein 2; HIF1 and HIF2) have clear effects on the pulmonary circulation, particularly in hypoxia. Furthermore, knowledge of the molecular biology of the prolyl hydroxylase enzymes has led to an extensive and ongoing body of research into the importance of iron in both HPV and pulmonary hypertension. This review will explore these relationships in more detail and discuss future avenues of research.
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Affiliation(s)
- Mary E Slingo
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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15
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Khangoora V, Bernstein EJ, King CS, Shlobin OA. Connective tissue disease-associated pulmonary hypertension: A comprehensive review. Pulm Circ 2023; 13:e12276. [PMID: 38088955 PMCID: PMC10711418 DOI: 10.1002/pul2.12276] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/13/2023] [Accepted: 07/30/2023] [Indexed: 10/16/2024] Open
Abstract
Connective tissue diseases (CTDs) can be associated with various forms of pulmonary hypertension, including pulmonary arterial hypertension (PAH), pulmonary veno-occlusive disease, pulmonary venous hypertension, interstitial lung disease-associated pulmonary hypertension, chronic thromboembolic pulmonary hypertension, and sometimes a combination of several processes. The prevalence of PAH varies among the different CTDs, with systemic sclerosis (SSc) having the highest at 8%-12%. The most recent European Society of Cardiology/European Respiratory Society guidelines recommend routine annual screening for PAH in SSc and CTDs with SSc features. As CTDs can be associated with a myriad of presentations of pulmonary hypertension, a thorough evaluation to include a right heart catheterization to clearly delineate the hemodynamic profile is essential in developing an appropriate treatment plan. Treatment strategies will depend on the predominant phenotype of pulmonary vasculopathy. In general, management approach to CTD-PAH mirrors that of idiopathic PAH. Despite this, outcomes of CTD-PAH are inferior to those of idiopathic PAH, with those of SSc-PAH being particularly poor. Reasons for this may include extrapulmonary manifestations of CTDs, including renal disease and gastrointestinal involvement, concurrent interstitial lung disease, and differences in the innate response of the right ventricle to increased pulmonary vascular resistance. Early referral for lung transplant evaluation of patients with CTD-PAH, particularly SSc-PAH, is recommended. It is hoped that in the near future, additional therapies may be added to the armamentarium of effective treatments for CTD-PAH. Ultimately, a better understanding of the pathogenesis of CTD-PAH will be required to develop targeted therapies for this morbid condition.
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Affiliation(s)
- Vikramjit Khangoora
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Elana J. Bernstein
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Christopher S. King
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
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16
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Kido K, Fang W, Broscious R, Colvin BM, Kamal KM, Bianco C, Caccamo M, Felpel K, Sokos G. Evaluation of a pharmacist-provider collaborative clinic for treatment of iron deficiency in patients with heart failure. Am J Health Syst Pharm 2023; 80:1326-1335. [PMID: 37368751 PMCID: PMC10516710 DOI: 10.1093/ajhp/zxad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE Intravenous iron therapy is recommended to improve symptoms and exercise tolerance in patients with heart failure (HF) with -reduced ejection fraction and iron deficiency (ID), but there are limited published data on the implementation of intravenous iron therapy in practice. A pharmacist-provider collaborative ID treatment clinic was established within an advanced HF and pulmonary hypertension service to optimize IV iron therapy. The objective was to evaluate the clinical impacts of the pharmacist-provider collaborative ID treatment clinic. METHODS A retrospective cohort study was performed to compare clinical outcomes among patients of the collaborative ID treatment clinic (the postimplementation group) and a cohort of patients who received usual care (the preimplementation group). The study included patients 18 years of age or older with diagnosed HF or pulmonary hypertension who met prespecified criteria for ID. The primary outcome was adherence to institutional intravenous iron therapy guidance. A key secondary outcome was ID treatment goal achievement. RESULTS A total of 42 patients in the preimplementation group and 81 in the postimplementation group were included in the study. The rate of adherence to the institutional guidance was significantly improved in the postimplementation group (93%) compared to the preimplementation group (40%). There was no significant difference in the ID therapeutic target achievement rate between the pre- and postimplementation groups (38% vs 48%). CONCLUSION Implementing a pharmacist-provider collaborative ID treatment clinic significantly increased the number of patients who adhered to intravenous iron therapy guidance compared to usual care.
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Affiliation(s)
- Kazuhiko Kido
- West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Wei Fang
- West Virginia Center for Translational Science Institute, Morgantown, WV, USA
| | - Rachael Broscious
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Bailey M Colvin
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Khalid M Kamal
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Christopher Bianco
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - Marco Caccamo
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - Kevin Felpel
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - George Sokos
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
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17
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Cleland JGF, Pellicori P, Graham FJ. Redefining both iron deficiency and anaemia in cardiovascular disease. Eur Heart J 2023; 44:1992-1994. [PMID: 36879446 PMCID: PMC10256186 DOI: 10.1093/eurheartj/ehad154] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Affiliation(s)
- John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
| | - Pierpaolo Pellicori
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
| | - Fraser J Graham
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
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18
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Jin Q, Chen D, Zhang X, Zhang F, Zhong D, Lin D, Guan L, Pan W, Zhou D, Ge J. Medical Management of Pulmonary Arterial Hypertension: Current Approaches and Investigational Drugs. Pharmaceutics 2023; 15:1579. [PMID: 37376028 DOI: 10.3390/pharmaceutics15061579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a malignant pulmonary vascular syndrome characterized by a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, which eventually leads to right heart failure and even death. Although the exact mechanism of PAH is not fully understood, pulmonary vasoconstriction, vascular remodeling, immune and inflammatory responses, and thrombosis are thought to be involved in the development and progression of PAH. In the era of non-targeted agents, PAH had a very dismal prognosis with a median survival time of only 2.8 years. With the deep understanding of the pathophysiological mechanism of PAH as well as advances in drug research, PAH-specific therapeutic drugs have developed rapidly in the past 30 years, but they primarily focus on the three classical signaling pathways, namely the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. These drugs dramatically improved pulmonary hemodynamics, cardiac function, exercise tolerance, quality of life, and prognosis in PAH patients, but could only reduce pulmonary arterial pressure and right ventricular afterload to a limited extent. Current targeted agents delay the progression of PAH but cannot fundamentally reverse pulmonary vascular remodeling. Through unremitting efforts, new therapeutic drugs such as sotatercept have emerged, injecting new vitality into this field. This review comprehensively summarizes the general treatments for PAH, including inotropes and vasopressors, diuretics, anticoagulants, general vasodilators, and anemia management. Additionally, this review elaborates the pharmacological properties and recent research progress of twelve specific drugs targeting three classical signaling pathways, as well as dual-, sequential triple-, and initial triple-therapy strategies based on the aforementioned targeted agents. More crucially, the search for novel therapeutic targets for PAH has never stopped, with great progress in recent years, and this review outlines the potential PAH therapeutic agents currently in the exploratory stage to provide new directions for the treatment of PAH and improve the long-term prognosis of PAH patients.
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Affiliation(s)
- Qi Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Dandan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai 201508, China
| | - Dongxiang Zhong
- Department of Cardiology, Shanghai East Hospital, Shanghai Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China
| | - Dawei Lin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Lihua Guan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
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19
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Theobald V, Grünig E, Benjamin N, Seyfarth H, Halank M, Schneider MA, Richtmann S, Kazdal D, Hinderhofer K, Xanthouli P, Egenlauf B, Harutyunova S, Hoeper MM, Jonigk D, Sparla R, Muckenthaler MU, Eichstaedt CA. Is iron deficiency caused by BMPR2 mutations or dysfunction in pulmonary arterial hypertension patients? Pulm Circ 2023; 13:e12242. [PMID: 37292089 PMCID: PMC10247310 DOI: 10.1002/pul2.12242] [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: 03/03/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
Iron deficiency is common in idiopathic and heritable pulmonary arterial hypertension patients (I/HPAH). A previous report suggested a dysregulation of the iron hormone hepcidin, which is controlled by BMP/SMAD signaling involving the bone morphogenetic protein receptor 2 (BMPR-II). Pathogenic variants in the BMPR2 gene are the most common cause of HPAH. Their effect on patients' hepcidin levels has not been investigated. The aim of this study was to assess whether iron metabolism and regulation of the iron regulatory hormone hepcidin was disturbed in I/HPAH patients with and without a pathogenic variant in the gene BMPR2 compared to healthy controls. In this explorative, cross-sectional study hepcidin serum levels were quantified by enzyme-linked immunosorbent assay. We measured iron status, inflammatory parameters and hepcidin modifying proteins such as IL6, erythropoietin, and BMP2, BMP6 in addition to BMPR-II protein and mRNA levels. Clinical routine parameters were correlated with hepcidin levels. In total 109 I/HPAH patients and controls, separated into three groups, 23 BMPR2 variant-carriers, 56 BMPR2 noncarriers and 30 healthy controls were enrolled. Of these, 84% had iron deficiency requiring iron supplementation. Hepcidin levels were not different between groups and corresponded to the degree of iron deficiency. The levels of IL6, erythropoietin, BMP2, or BMP6 showed no correlation with hepcidin expression. Hence, iron homeostasis and hepcidin regulation was largely independent from these parameters. I/HPAH patients had a physiologically normal iron regulation and no false elevation of hepcidin levels. Iron deficiency was prevalent albeit independent of pathogenic variants in the BMPR2 gene.
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Affiliation(s)
- Vivienne Theobald
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Ekkehard Grünig
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Nicola Benjamin
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Hans‐Jürgen Seyfarth
- Department of Pneumology, Medical Clinic IIUniversity Hospital of LeipzigLeipzigGermany
| | - Michael Halank
- Medical Clinic IUniversity Hospital of DresdenDresdenGermany
| | - Marc A. Schneider
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Translational Research UnitThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
| | - Sarah Richtmann
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Translational Research UnitThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
| | - Daniel Kazdal
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Institute of PathologyHeidelberg University HospitalHeidelbergGermany
| | - Katrin Hinderhofer
- Laboratory for Molecular Diagnostics, Institute of Human GeneticsHeidelberg UniversityHeidelbergGermany
| | - Panagiota Xanthouli
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Benjamin Egenlauf
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Satenik Harutyunova
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
| | - Marius M. Hoeper
- Department of Pneumology, Hannover Medical School, Biomedical Research in End‐stage and Obstructive Lung Disease Hannover (BREATH)German Center for Lung Research (DZL)HannoverGermany
| | - Danny Jonigk
- Hannover Medical School, Institute for Pathology, German Center for Lung Research (DZL)Biomedical Research in End‐stage and Obstructive Lung Disease Hannover (BREATH)HannoverGermany
- Institute of PathologyRWTH Aachen University HospitalAachenGermany
| | - Richard Sparla
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Centre for Translational Biomedical Iron Research, Hematology, Immunology and PulmonologyUniversity Hospital HeidelbergHeidelbergGermany
| | - Martina U. Muckenthaler
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Centre for Translational Biomedical Iron Research, Hematology, Immunology and PulmonologyUniversity Hospital HeidelbergHeidelbergGermany
- German Centre for Cardiovascular Research (DZHK)Partner Site Heidelberg/MannheimHeidelbergGermany
| | - Christina A. Eichstaedt
- Center for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
- Translational Lung Research Center Heidelberg (TLRC)German Center for Lung Research (DZL)HeidelbergGermany
- Laboratory for Molecular Diagnostics, Institute of Human GeneticsHeidelberg UniversityHeidelbergGermany
- German Centre for Cardiovascular Research (DZHK)Partner Site Heidelberg/MannheimHeidelbergGermany
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20
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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21
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Benjamin N, Resag C, Weinstock K, Grünig E. Allgemeine Therapie der pulmonalarteriellen Hypertonie nach den neuen Leitlinien. AKTUELLE KARDIOLOGIE 2023. [DOI: 10.1055/a-1968-9488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
ZusammenfassungIn den neuen Leitlinien (LL) für pulmonalarterielle Hypertonie (PAH) sind die allgemeinen Maßnahmen ein integraler Bestandteil der Behandlung der Patienten. Auch die systemischen
Auswirkungen der pulmonalen Hypertonie und Rechtsherzinsuffizienz sollten angemessen berücksichtigt und behandelt werden. Im folgenden Artikel werden die in den LL genannten Maßnahmen unter
Berücksichtigung des bestehenden Empfehlungsgrads und der Evidenzen beschrieben. Leider sind die meisten Allgemeinmaßnahmen, wie die Gabe von Diuretika, Sauerstoff, psychosozialer Support
und Impfungen, nicht oder unzureichend in randomisierten, kontrollierten Studien untersucht worden. So haben sie zwar einen hohen I-Empfehlungsgrad, aber einen niedrigen Evidenzgrad C. Nur
bei dem spezialisierten körperlichen Training liegen bislang insgesamt 7 randomisierte, kontrollierte Studien und 5 Metaanalysen vor, die eine Verbesserung der Sauerstoffaufnahme,
körperlichen Belastbarkeit, der Beschwerden (WHO-Funktionsklasse), Lebensqualität und Hämodynamik nachgewiesen haben (daher neu IA-Empfehlung). Auch weitere Maßnahmen wie die
Antikoagulation, Eisensubstitution und andere werden im Folgenden besprochen.
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Affiliation(s)
- Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
| | - Carolin Resag
- Zentrum für pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
| | - Kilian Weinstock
- Zentrum für pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
| | - Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
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22
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 543] [Impact Index Per Article: 543.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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23
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Savarese G, von Haehling S, Butler J, Cleland JGF, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease. Eur Heart J 2023; 44:14-27. [PMID: 36282723 PMCID: PMC9805408 DOI: 10.1093/eurheartj/ehac569] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/11/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Iron deficiency (ID) is common in patients with cardiovascular disease. Up to 60% of patients with coronary artery disease, and an even higher proportion of those with heart failure (HF) or pulmonary hypertension have ID; the evidence for cerebrovascular disease, aortic stenosis and atrial fibrillation is less robust. The prevalence of ID increases with the severity of cardiac and renal dysfunction and is probably more common amongst women. Insufficient dietary iron, reduced iron absorption due to increases in hepcidin secondary to the low-grade inflammation associated with atherosclerosis and congestion or reduced gastric acidity, and increased blood loss due to anti-thrombotic therapy or gastro-intestinal or renal disease may all cause ID. For older people in the general population and patients with HF with reduced ejection fraction (HFrEF), both anaemia and ID are associated with a poor prognosis; each may confer independent risk. There is growing evidence that ID is an important therapeutic target for patients with HFrEF, even if they do not have anaemia. Whether this is also true for other HF phenotypes or patients with cardiovascular disease in general is currently unknown. Randomized trials showed that intravenous ferric carboxymaltose improved symptoms, health-related quality of life and exercise capacity and reduced hospitalizations for worsening HF in patients with HFrEF and mildly reduced ejection fraction (<50%). Since ID is easy to treat and is effective for patients with HFrEF, such patients should be investigated for possible ID. This recommendation may extend to other populations in the light of evidence from future trials.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas TX, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Wellebing, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Centre for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
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24
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Influence of Iron Deficiency on Clinical and Haemodynamic Parameters in Pulmonary Arterial Hypertension Cohorts. Heart Lung Circ 2022; 31:1594-1603. [PMID: 36402703 DOI: 10.1016/j.hlc.2022.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/16/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Iron deficiency (Fedef) has been shown to be common in patients with group 1 or pulmonary arterial hypertension (PAH). Several studies have shown a negative impact of Fedef on clinical and haemodynamic parameters of the disease, but data from individual studies have not been strong enough to lead to incorporation of the finding of Fedef into prognostic or therapeutic algorithms. The goal of this meta-analysis was to combine data from available studies to better define any associations between Fedef and established variables of prognostic importance in PAH. METHODS A literature search identified nine studies with extractable data relevant to the study questions. The impact of Fedef upon the following parameters was evaluated: 6-minute walk distance (6MWD), WHO-functional class, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, echocardiography, and findings from right heart catheterisation (RHC). Pooled results were reported as mean difference or risk difference with 95% confidence intervals utilising a random effects modeling approach. RESULTS Fedef in the PAH population was common (47% of cases) and was associated with cardiovascular dysfunction (lower tricuspid annular plane systolic excursion [TAPSE], elevated NT-proBNP, and lower mixed venous oxygen saturation) and with reduction in functional capacity (lower 6MWD and higher functional class). CONCLUSION This meta-analysis strengthens the relationships between Fedef and several markers of poor outcome in PAH. Fedef in patients with PAH warrants further scrutiny and merits consideration as a cause of clinical deterioration. Even though causation and longitudinal relationships between Fedef and PAH could not be identified, effect of Fedef on factors that affect disease prognosis is noteworthy and worthy of more focussed studies.
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25
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1230] [Impact Index Per Article: 615.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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26
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Medrek S, Melendres-Groves L. Evolving nonvasodilator treatment options for pulmonary arterial hypertension. Curr Opin Pulm Med 2022; 28:361-368. [PMID: 35838352 DOI: 10.1097/mcp.0000000000000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With the establishment of vasodilator therapy as a mainstay of treatment for pulmonary arterial hypertension (PAH), new therapeutic approaches are needed to prevent the development of the vasculopathy associated with this disease. Many studies are currently underway to investigate nonvasodilator treatment options. RECENT FINDINGS Modulation of bone morphogenic protein receptor type 2 (BMPR2) signaling with sotatercept showed promising results in phase 2 studies. Rituximab, an anti-CD20 monoclonal antibody, showed some signal for beneficial effect in patients with scleroderma-associated PAH. Studies evaluating agents including tocilizumab, selonsertib, bardoxolone, 10-nitro-9(E)-enoic acid (CXA-10) and intravenous iron have not shown acceptable efficacy in treating PAH. SUMMARY Pharmacologic approaches for the treatment of PAH include altering of transforming growth factor β/BMPR2 signaling, proliferation via growth factors, immune response, oxidative stress, estrogen signaling, metabolism, and neurohormonal modulation. Other treatment modalities including pulmonary artery nerve denervation, stem cell therapy, and inter-atrial shunt formation are also being explored.
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Affiliation(s)
- Sarah Medrek
- Division of Pulmonary Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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27
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Yarlas A, Mathai SC, Nathan SD, DuBrock HM, Morland K, Anderson N, Kosinski M, Lin X, Classi P. Considerations When Selecting Patient-Reported Outcome Measures for Assessment of Health-Related Quality of Life in Patients With Pulmonary Hypertension. Chest 2022; 162:1163-1175. [DOI: 10.1016/j.chest.2022.08.2206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022] Open
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28
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Lan M, Wu S, Fernandes TM. Iron deficiency and pulmonary arterial hypertension. Nutr Clin Pract 2022; 37:1059-1073. [PMID: 35748341 DOI: 10.1002/ncp.10884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/11/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
The purpose of this review article is to provide a comprehensive review of iron deficiency in the setting of pulmonary arterial hypertension (PAH) and to evaluate the utility of iron supplementation in PAH. Iron deficiency is present in 33%-46% of patients with PAH and has been associated with reduced exercise capacity, compromised oxygen handling, deterioration of right ventricular function, and even mortality. Iron homeostasis and the pathophysiology of PAH are highly intertwined, which has inspired the use of iron supplementation in patients with iron deficiency and PAH. A literature search was performed to identify all available evidence on iron supplementation for PAH. Limited evidence has suggested poor oral bioavailability of oral iron dosed three times a day, but newer formulations such as ferrous maltol may provide better absorption and clinical benefit, especially when dosed less frequently, such as every other day. Intravenous (IV) iron has been shown in observational studies to improve outcomes, but the single randomized control trial in patients without anemia has failed to show benefits in any measure of exercise tolerance. Larger randomized control studies on oral iron with good bioavailability or IV iron in patients with anemia are warranted to explore the potential utility of iron supplementation in patients with PAH.
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Affiliation(s)
- Michelle Lan
- Internal Medicine Pharmacy Residency Program, UC San Diego Health, La Jolla, California, USA
| | - Sheryl Wu
- Pulmonary Arterial Hypertension Pharmacy Program, UC San Diego Health, La Jolla, California, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, California, USA
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29
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Rhodes CJ, Sweatt AJ, Maron BA. Harnessing Big Data to Advance Treatment and Understanding of Pulmonary Hypertension. Circ Res 2022; 130:1423-1444. [PMID: 35482840 PMCID: PMC9070103 DOI: 10.1161/circresaha.121.319969] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension is a complex disease with multiple causes, corresponding to phenotypic heterogeneity and variable therapeutic responses. Advancing understanding of pulmonary hypertension pathogenesis is likely to hinge on integrated methods that leverage data from health records, imaging, novel molecular -omics profiling, and other modalities. In this review, we summarize key data sets generated thus far in the field and describe analytical methods that hold promise for deciphering the molecular mechanisms that underpin pulmonary vascular remodeling, including machine learning, network medicine, and functional genetics. We also detail how genetic and subphenotyping approaches enable earlier diagnosis, refined prognostication, and optimized treatment prediction. We propose strategies that identify functionally important molecular pathways, bolstered by findings across multi-omics platforms, which are well-positioned to individualize drug therapy selection and advance precision medicine in this highly morbid disease.
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Affiliation(s)
- Christopher J Rhodes
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Andrew J Sweatt
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.M.).,Division of Cardiology, VA Boston Healthcare System, West Roxbury, MA (B.A.M.)
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30
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Erratum: Supplementation with Iron in Pulmonary Arterial Hypertension: Two Randomized Crossover Trials. Ann Am Thorac Soc 2022; 19:704. [PMID: 35363128 DOI: 10.1513/v19erratum1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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31
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Naito Y, Tsujino T, Masuyama T, Ishihara M. Crosstalk between Iron and Arteriosclerosis. J Atheroscler Thromb 2022; 29:308-314. [PMID: 34421089 PMCID: PMC8894107 DOI: 10.5551/jat.rv17060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/25/2021] [Indexed: 11/11/2022] Open
Abstract
Iron is an important element for life; however, intracellular labile iron overload can lead to the generation of reactive oxygen species and cellular damage. Although iron is mainly utilized for heme synthesis and is incorporated into hemoglobin, body iron status is often implicated in the pathogenesis of cardiovascular diseases. In a cell, iron is used for basic processes such as cell growth, maintenance, and repair. Thus, iron is considered to be involved in the pathogenesis of arteriosclerosis. In fact, clinical and experimental studies have shown an association between iron and arteriosclerosis. These data suggest the crosstalk between iron and arteriosclerosis. However, iron metabolism in arteriosclerosis is often complicated, and the systemic and cellular mechanisms of iron homeostasis in arteriosclerosis remain completely unsolved. Thus, in this review, we aimed to examine the role of iron in arteriosclerosis.
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Affiliation(s)
- Yoshiro Naito
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Tsujino
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Division of Pharmaceutical Therapeutics, Department of Pharmacy, School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan
| | - Tohru Masuyama
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Japan Community Health Care Organization, Hoshigaoka Medical Center, Hirakata, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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32
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Gomes MT, Bai Y, Potje SR, Zhang L, Lockett AD, Machado RF. Signal Transduction during Metabolic and Inflammatory Reprogramming in Pulmonary Vascular Remodeling. Int J Mol Sci 2022; 23:2410. [PMID: 35269553 PMCID: PMC8910500 DOI: 10.3390/ijms23052410] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease characterized by (mal)adaptive remodeling of the pulmonary vasculature, which is associated with inflammation, fibrosis, thrombosis, and neovascularization. Vascular remodeling in PAH is associated with cellular metabolic and inflammatory reprogramming that induce profound endothelial and smooth muscle cell phenotypic changes. Multiple signaling pathways and regulatory loops act on metabolic and inflammatory mediators which influence cellular behavior and trigger pulmonary vascular remodeling in vivo. This review discusses the role of bioenergetic and inflammatory impairments in PAH development.
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Affiliation(s)
- Marta T. Gomes
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA; (Y.B.); (S.R.P.); (A.D.L.)
| | - Yang Bai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA; (Y.B.); (S.R.P.); (A.D.L.)
- Department of Clinical Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China
| | - Simone R. Potje
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA; (Y.B.); (S.R.P.); (A.D.L.)
- Department of Biological Science, Minas Gerais State University (UEMG), Passos 37900-106, Brazil
| | - Lu Zhang
- Department of Ion Channel Pharmacology, School of Pharmacy, China Medical University, Shenyang 110122, China;
| | - Angelia D. Lockett
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA; (Y.B.); (S.R.P.); (A.D.L.)
| | - Roberto F. Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA; (Y.B.); (S.R.P.); (A.D.L.)
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33
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Tatah J, Keen JL, Prisco SZ, Pritzker M, Thenappan T, Prins KW. Iron Deficiency Is Associated With More Severe Pulmonary Vascular Disease in Pulmonary Hypertension Caused by Chronic Lung Disease. Chest 2022; 161:232-236. [PMID: 34352277 PMCID: PMC8783028 DOI: 10.1016/j.chest.2021.07.2159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jasmine Tatah
- Department of Medicine, Cardiovascular Division, Lillehei Clinical Research Unit, Minneapolis, MN
| | - Jennifer L. Keen
- Department of Medicine, Pulmonary and Critical Care, Minneapolis, MN
| | - Sasha Z. Prisco
- Department of Medicine, Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, MN
| | - Marc Pritzker
- Department of Medicine, Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, MN
| | - Thenappan Thenappan
- Department of Medicine, Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, MN
| | - Kurt W. Prins
- Department of Medicine, Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, MN,CORRESPONDENCE TO: Kurt W. Prins, MD, PhD
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34
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Slingo ME, Pandit JJ. Oxygen sensing, anaesthesia and critical care: a narrative review. Anaesthesia 2021; 77:213-223. [PMID: 34555179 DOI: 10.1111/anae.15582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/01/2022]
Abstract
In 2019, the scientists who discovered how cells sense and adapt to oxygen availability were awarded the Nobel Prize. This elegant sensing pathway is conserved throughout evolution, and it underpins the physiology and pathology that we, as clinicians in anaesthesia and critical care, encounter on a daily basis. The purpose of this review is to bring hypoxia-inducible factor, and the oxygen-sensing pathway as a whole, to the wider clinical community. We describe how this unifying mechanism was discovered, and how it orchestrates diverse changes such as erythropoiesis, ventilatory acclimatisation, pulmonary vascular remodelling and altered metabolism. We explore the lessons learnt from genetic disorders of oxygen sensing, and the wider implications in evolution of all animal species, including our own. Finally, we explain how this pathway is relevant to our clinical practice, and how it is being manipulated in new treatments for conditions such as cancer, anaemia and pulmonary hypertension.
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Affiliation(s)
- M E Slingo
- Shackleton Department of Anaesthetics, Southampton University Hospitals NHS Trust, Southampton, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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35
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Riding the Ferrous Wheel of Iron Supplementation in Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2021; 18:946-948. [PMID: 34076563 PMCID: PMC8456737 DOI: 10.1513/annalsats.202103-324ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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