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Provencher S, Archer SL, Ramirez FD, Hibbert B, Paulin R, Boucherat O, Lacasse Y, Bonnet S. Standards and Methodological Rigor in Pulmonary Arterial Hypertension Preclinical and Translational Research. Circ Res 2019; 122:1021-1032. [PMID: 29599278 DOI: 10.1161/circresaha.117.312579] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite advances in our understanding of the pathophysiology and the management of pulmonary arterial hypertension (PAH), significant therapeutic gaps remain for this devastating disease. Yet, few innovative therapies beyond the traditional pathways of endothelial dysfunction have reached clinical trial phases in PAH. Although there are inherent limitations of the currently available models of PAH, the leaky pipeline of innovative therapies relates, in part, to flawed preclinical research methodology, including lack of rigour in trial design, incomplete invasive hemodynamic assessment, and lack of careful translational studies that replicate randomized controlled trials in humans with attention to adverse effects and benefits. Rigorous methodology should include the use of prespecified eligibility criteria, sample sizes that permit valid statistical analysis, randomization, blinded assessment of standardized outcomes, and transparent reporting of results. Better design and implementation of preclinical studies can minimize inherent flaws in the models of PAH, reduce the risk of bias, and enhance external validity and our ability to distinguish truly promising therapies form many false-positive or overstated leads. Ideally, preclinical studies should use advanced imaging, study several preclinical pulmonary hypertension models, or correlate rodent and human findings and consider the fate of the right ventricle, which is the major determinant of prognosis in human PAH. Although these principles are widely endorsed, empirical evidence suggests that such rigor is often lacking in pulmonary hypertension preclinical research. The present article discusses the pitfalls in the design of preclinical pulmonary hypertension trials and discusses opportunities to create preclinical trials with improved predictive value in guiding early-phase drug development in patients with PAH, which will need support not only from researchers, peer reviewers, and editors but also from academic institutions, funding agencies, and animal ethics authorities.
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Affiliation(s)
- Steeve Provencher
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Stephen L Archer
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - F Daniel Ramirez
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Roxane Paulin
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Olivier Boucherat
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Yves Lacasse
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada
| | - Sébastien Bonnet
- From the Pulmonary Hypertension Research Group, Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., S.B.), Institut universitaire de cardiologie et de pneumologie de Québec Research Center (S.P., R.P., O.B., Y.L., S.B.), and Department of Medicine (S.P., R.P., O.B., Y.L., S.B.), Université Laval, Québec, Canada; Department of Medicine, Queen's University, Kingston, Canada (S.L.A.); Division of Cardiology (F.D.R., B.H.), CAPITAL Research Group (F.D.R., B.H.), and Vascular Biology and Experimental Medicine Laboratory (B.H.), University of Ottawa Heart Institute, Ontario, Canada; and Department of Cellular and Molecular Medicine (B.H.) and School of Epidemiology and Public Health (F.D.R.) University of Ottawa, Ontario, Canada.
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Guay CA, Morin-Thibault LV, Bonnet S, Lacasse Y, Lambert C, Lega JC, Provencher S. Pulmonary hypertension-targeted therapies in heart failure: A systematic review and meta-analysis. PLoS One 2018; 13:e0204610. [PMID: 30307953 PMCID: PMC6181322 DOI: 10.1371/journal.pone.0204610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022] Open
Abstract
Background Pulmonary hypertension (PH) due to left heart failure (HF) is the most common form of PH. However, treatment is unclear because there are conflicting results about safety and efficacy of PH-targeted therapies. Objectives To assess the effects of PH-targeted therapy on exercise capacity in HF patients. Methods MEDLINE, EMBASE and the Cochrane Library were searched from January 1990 to July 2017 for randomized controlled trials comparing PH-targeted therapies to conventional therapy in HF. The primary outcome was to assess the effects on exercise capacity. Secondary outcomes included mortality, hospitalisation, NT-proBNP levels, echocardiographic and hemodynamics parameters and discontinuation rate. Results 22 studies were included (n = 5448), including 3, 8 and 11 studies with low, high and unknown risk of bias, respectively. PH-targeted therapies were associated with an improvement of exercise capacity (standardized mean difference 0.29;95%CI:0.08–0.50, p = 0.006). Pre-specified subgroup analyses found that this improvement was predominantly observed in studies evaluating phosphodiesterase-5 inhibitors and prostanoids and in patients with reduced ejection fraction. Moreover, systolic pulmonary artery pressure measured by echocardiography was improved (mean difference: -7.5mmHg; [95%CI]: -14.9,-0.1, p = 0.05), which was also entirely driven by studies evaluating phosphodiesterase-5 inhibitors. However, PH-targeted therapies were associated with an increased treatment discontinuation rates and a potential increase in mortality compared to standard treatment. Conclusions In conclusion, PH-targeted therapies and especially phosphodiesterase-5 inhibitors may improve exercise capacity in patients with HF. However, an increase in adverse outcomes was likely. Moreover, most studies were at high or unknown risk of bias, precluding confident conclusions about the effects of PH-targeted therapies.
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Affiliation(s)
- Charles-Antoine Guay
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Louis-Vincent Morin-Thibault
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Sebastien Bonnet
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Yves Lacasse
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Caroline Lambert
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Jean-Christophe Lega
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Médecine Interne-Pathologie Vasculaire, Lyon, France
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
- * E-mail:
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