1
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Zanotto TM, Gonçalves AEDSS, Saad MJA. Pulmonary hypertension and insulin resistance: a mechanistic overview. Front Endocrinol (Lausanne) 2024; 14:1283233. [PMID: 38239990 PMCID: PMC10794542 DOI: 10.3389/fendo.2023.1283233] [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: 08/25/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a vascular remodeling disease, characterized by increased blood pressure levels in pulmonary circulation, leading to a restriction in the circulation flow and heart failure. Although the emergence of new PAH therapies has increased survival rates, this disease still has a high mortality and patients that receive diagnosis die within a few years. The pathogenesis of PAH involves multiple pathways, with a complex interaction of local and distant cytokines, hormones, growth factors, and transcription factors, leading to an inflammation that changes the vascular anatomy in PAH patients. These abnormalities involve more than just the lungs, but also other organs, and between these affected organs there are different metabolic dysfunctions implied. Recently, several publications demonstrated in PAH patients a disturbance in glucose metabolism, demonstrated by higher levels of glucose, insulin, and lipids in those patients. It is possible that a common molecular mechanism can have a significant role in this connection. In this regard, this narrative review intends to focus on the recent papers that mainly discuss the molecular determinants between insulin resistance (IR) associated PAH, which included obesity subclinical inflammation induced IR, PPAR gamma and Adiponectin, BMPR2, mitochondrial dysfunction and endoplasmic reticulum stress. Therefore, the following review will summarize some of the existing data for IR associated PAH, focusing on the better understanding of PAH molecular mechanisms, for the development of new translational therapies.
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Affiliation(s)
- Tamires M. Zanotto
- Department of Internal Medicine, State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Departament of Medical Clinics, Obesity and Comorbidities Research Centre (O.C.R.C.), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Mario J. A. Saad
- Department of Internal Medicine, State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Departament of Medical Clinics, Obesity and Comorbidities Research Centre (O.C.R.C.), State University of Campinas (UNICAMP), Campinas, SP, Brazil
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2
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Hye T, Dwivedi P, Li W, Lahm T, Nozik-Grayck E, Stenmark KR, Ahsan F. Newer insights into the pathobiological and pharmacological basis of the sex disparity in patients with pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1025-L1037. [PMID: 33719549 DOI: 10.1152/ajplung.00559.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) affects more women than men, although affected females tend to survive longer than affected males. This sex disparity in PAH is postulated to stem from the diverse roles of sex hormones in disease etiology. In animal models, estrogens appear to be implicated not only in pathologic remodeling of pulmonary arteries, but also in protection against right ventricular (RV) hypertrophy. In contrast, the male sex hormone testosterone is associated with reduced survival in male animals, where it is associated with increased RV mass, volume, and fibrosis. However, it also has a vasodilatory effect on pulmonary arteries. Furthermore, patients of both sexes show varying degrees of response to current therapies for PAH. As such, there are many gaps and contradictions regarding PAH development, progression, and therapeutic interventions in male versus female patients. Many of these questions remain unanswered, which may be due in part to lack of effective experimental models that can consistently reproduce PAH pulmonary microenvironments in their sex-specific forms. This review article summarizes the roles of estrogens and related sex hormones, immunological and genetical differences, and the benefits and limitations of existing experimental tools to fill in gaps in our understanding of the sex-based variation in PAH development and progression. Finally, we highlight the potential of a new tissue chip-based model mimicking PAH-afflicted male and female pulmonary arteries to study the sex-based differences in PAH and to develop personalized therapies based on patient sex and responsiveness to existing and new drugs.
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Affiliation(s)
- Tanvirul Hye
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, Texas
| | - Pankaj Dwivedi
- Department of Pharmaceutical and Administrative Sciences, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Wei Li
- Department of Chemical Engineering, Texas Tech University, Lubbock, Texas
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Eva Nozik-Grayck
- Department of Pediatrics and Medicine, Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Kurt R Stenmark
- Department of Pediatrics and Medicine, Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Fakhrul Ahsan
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, Texas.,Department of Pharmaceutical and Biomedical Sciences, California Northstate University, Elk Grove, California
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3
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Teoh JP, Li X, Simoncini T, Zhu D, Fu X. Estrogen-Mediated Gaseous Signaling Molecules in Cardiovascular Disease. Trends Endocrinol Metab 2020; 31:773-784. [PMID: 32682630 DOI: 10.1016/j.tem.2020.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/07/2020] [Accepted: 06/22/2020] [Indexed: 12/14/2022]
Abstract
Gender difference is well recognized as a key risk factor for cardiovascular disease (CVD). Estrogen, the primary female sex hormone, improves cardiovascular functions through receptor (ERα, ERβ, or G protein-coupled estrogen receptor)-initiated genomic or non-genomic mechanisms. Gaseous signaling molecules, including nitric oxide (NO), hydrogen sulfide (H2S), and carbon monoxide (CO), are important regulators of cardiovascular function. Recent studies have demonstrated that estrogen regulates the production of these signaling molecules in cardiovascular cells to exert its cardiovascular protective effects. We discuss current understanding of gaseous signaling molecules in cardiovascular disease (CVD), the underlying mechanisms through which estrogen exerts cardiovascular protective effects by regulating these molecules, and how these findings can be translated to improve the health of postmenopausal women.
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Affiliation(s)
- Jian-Peng Teoh
- Department of Gynecology and Obstetrics, Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Key Laboratory of Cardiovascular Diseases, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511518, P.R. China; Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, 510260, P.R. China
| | - Xiaosa Li
- Department of Gynecology and Obstetrics, Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Key Laboratory of Cardiovascular Diseases, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511518, P.R. China; Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, 510260, P.R. China
| | - Tommaso Simoncini
- Molecular and Cellular Gynecological Endocrinology Laboratory (MCGEL), Department of Reproductive Medicine and Child Development, University of Pisa, Pisa 56100, Italy
| | - Dongxing Zhu
- Department of Gynecology and Obstetrics, Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Key Laboratory of Cardiovascular Diseases, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511518, P.R. China; Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, 510260, P.R. China.
| | - Xiaodong Fu
- Department of Gynecology and Obstetrics, Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Key Laboratory of Cardiovascular Diseases, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511518, P.R. China; Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, 510260, P.R. China.
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4
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Omidkhoda N, Vakilian F, Mohammadpour AH, Sathyapalan T, Sahebkar A. Aldosterone and Mineralocorticoid Receptor Antagonists on Pulmonary Hypertension and Right Ventricular Failure: A Review. Curr Pharm Des 2020; 26:3862-3870. [DOI: 10.2174/1381612826666200523171137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/06/2020] [Indexed: 12/23/2022]
Abstract
There is an increasing number of therapeutic agents being developed for the treatment of pulmonary
artery hypertension (PAH) which is a condition characterized by raised pulmonary artery pressure and right heart
failure. Despite our better understanding of the pathophysiology of PAH, the treatment outcomes are still suboptimal.
There is growing evidence suggesting the role of increases in the levels of aldosterone, which is a mineralocorticoid
hormone, in the pathophysiology of PAH; however, the extent to which hyperaldosteronism is associated
with PAH in patients is unclear. There are also a few studies assessing the effects of mineralocorticoid receptor
antagonists (MRA) in PAH. MRAs are a recognized treatment for heart failure and hypertension. In this review,
we focus on the relationship between aldosterone level in patients with PAH and right ventricular failure
and the effect of MRAs on the PAH severity.
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Affiliation(s)
- Navid Omidkhoda
- Pharmaceutical Research Center, Institute of Pharmaceutical Technology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farveh Vakilian
- Atherosclerotic Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir H. Mohammadpour
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Thozhukat Sathyapalan
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull HU3 2JZ, United Kingdom
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5
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Rafikov R, Nair V, Sinari S, Babu H, Sullivan JC, Yuan JXJ, Desai AA, Rafikova O. Gender Difference in Damage-Mediated Signaling Contributes to Pulmonary Arterial Hypertension. Antioxid Redox Signal 2019; 31:917-932. [PMID: 30652485 PMCID: PMC6765065 DOI: 10.1089/ars.2018.7664] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims: Pulmonary arterial hypertension (PAH) is a progressive lethal disease with a known gender dimorphism. Female patients are more susceptible to PAH, whereas male patients have a lower survival rate. Initial pulmonary vascular damage plays an important role in PAH pathogenesis. Therefore, this study aimed at investigating the role of gender in activation of apoptosis/necrosis-mediated signaling pathways in PAH. Results: The media collected from pulmonary artery endothelial cells (PAECs) that died by necrosis or apoptosis were used to treat naive PAECs. Necrotic cell death stimulated phosphorylation of toll-like receptor 4, accumulation of interleukin 1 beta, and expression of E-selectin in a redox-dependent manner; apoptosis did not induce any of these effects. In the animal model of severe PAH, the necrotic marker, high mobility group box 1 (HMGB1), was visualized in the pulmonary vascular wall of male but not female rats. This vascular necrosis was associated with male-specific redox changes in plasma, activation of the same inflammatory signaling pathway seen in response to necrosis in vitro, and an increased endothelial-leukocyte adhesion in small pulmonary arteries. In PAH patients, gender-specific changes in redox homeostasis correlated with the prognostic marker, B-type natriuretic peptide. Males had also shown elevated circulating levels of HMGB1 and pro-inflammatory changes. Innovation: This study discovered the role of gender in the initiation of damage-associated signaling in PAH and highlights the importance of the gender-specific approach in PAH therapy. Conclusion: In PAH, the necrotic cell death is augmented in male patients compared with female patients. Factors released from necrotic cells could alter redox homeostasis and stimulate inflammatory signaling pathways.
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Affiliation(s)
- Ruslan Rafikov
- Division of Endocrinology, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Vineet Nair
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Shripad Sinari
- Center for Biomedical Informatics and Biostatistics, University of Arizona, Tucson, Arizona
| | | | | | - Jason X-J Yuan
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, Arizona
| | - Ankit A Desai
- Division of Cardiology, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Olga Rafikova
- Division of Endocrinology, Department of Medicine, University of Arizona, Tucson, Arizona
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6
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Patel MS, Bowen DK, Tassone NM, Gould AD, Kochan KS, Firmiss PR, Kukulka NA, Devine MY, Li B, Gong EM, Dettman RW. The Homeodomain Transcription Factor NKX3.1 Modulates Bladder Outlet Obstruction Induced Fibrosis in Mice. Front Pediatr 2019; 7:446. [PMID: 31781523 PMCID: PMC6861332 DOI: 10.3389/fped.2019.00446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/15/2019] [Indexed: 12/29/2022] Open
Abstract
Fibrosis is an irreversible remodeling process characterized by the deposition of collagen in the extracellular matrix of various organs through a variety of pathologies in children, leading to the stiffening of healthy tissues and organ dysfunction. Despite the prevalence of fibrotic disease in children, large gaps exist in our understanding of the mechanisms that lead to fibrosis, and there are currently no therapies to treat or reverse it. We previously observed that castration significantly reduces fibrosis in the bladders of male mice that have been partially obstructed. Here, we investigated if the expression of androgen response genes were altered in mouse bladders after partial bladder outlet obstruction (PO). Using a QPCR microarray and QRTPCR we found that PO was sufficient to increase expression of the androgen response gene Nkx3.1. Consistent with this was an increase in the expression of NKX3.1 protein. Immunofluorescent antibody localization demonstrated nuclear NKX3.1 in most bladder cells after PO. We tested if genetic deletion of Nkx3.1 alters remodeling of the bladder wall after PO. After PO, Nkx3.1 KO/KO bladders underwent remodeling, demonstrating smaller bladder area, thickness, and bladder: body weight ratios than obstructed, wild type controls. Remarkably, Nkx3.1 KO/KO specifically affected histological parameters of fibrosis, including reduced collagen to muscle ratio. Loss of Nkx3.1 altered collagen and smooth muscle cytoskeletal gene expression following PO which supported our histologic findings. Together these findings indicated that after PO, Nkx3.1 expression is induced in the bladder and that it mediates important pathways that lead to tissue fibrosis. As Nkx3.1 is an androgen response gene, our data suggest a possible mechanism by which fibrosis is mediated in male mice and opens the possibility of a molecular pathway mediated by NKX3.1 that could explain sexual dimorphism in bladder fibrosis.
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Affiliation(s)
- Mehul S Patel
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Diana K Bowen
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Nicholas M Tassone
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Andrew D Gould
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Kirsten S Kochan
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Paula R Firmiss
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Natalie A Kukulka
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Megan Y Devine
- Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Belinda Li
- Department of Urology, Loyola University Medical Center, Maywood, IL, United States
| | - Edward M Gong
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Gong Laboratory, Division of Pediatric Urology, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Robert W Dettman
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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7
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Lee HW, Park SH. Elevated microRNA-135a is associated with pulmonary arterial hypertension in experimental mouse model. Oncotarget 2018; 8:35609-35618. [PMID: 28415675 PMCID: PMC5482602 DOI: 10.18632/oncotarget.16011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 03/02/2017] [Indexed: 12/12/2022] Open
Abstract
Multiple causes are associated with the complex mechanism of pathogenesis of pulmonary arterial hypertension (PAH), but the molecular pathway in the pathogenesis of PAH is still insufficiently understood. In this study, we investigated epigenetic changes that cause PAH induced by exposure to combined Th2 antigen (Ovalbumin, OVA) and urban particulate matter (PM) in mice. To address that, we focused on the epigenetic mechanism, linked to microRNA (miR)-135a. We found that miR-135a levels were significantly increased, and levels of bone morphogenetic protein receptor type II (BMPR2) which is the target of miR-135a, were significantly decreased in this experimental PAH mouse model. Therefore to evaluate the role of miR-135a, we injected AntagomiR-135a into this mouse model. AntagomiR-135a injected mice showed decreased right ventricular systolic pressures (RVSPs), right ventricular hypertrophy (RVH), and the percentage of severely thickened pulmonary arteries compared to control scrambled miRNA injected mice. Both mRNA and protein expression of BMPR2 were recovered in the AntagomiR-135a injected mice compared to control mice. Our study understands if miR-135a could serve as a biomarker helping to manage PAH. The blocking of miR-135a could lead to new therapeutic modalities to alleviate exacerbation of PAH caused by exposure to Th2 antigen and urban air pollution.
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Affiliation(s)
- Hyun-Wook Lee
- Department of Environmental Medicine, New York University School of Medicine, Tuxedo, New York, USA
| | - Sung-Hyun Park
- Department of Environmental Medicine, New York University School of Medicine, Tuxedo, New York, USA
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8
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Shenoy CC, Khan Z, Zheng Y, Jones TL, Khazaie K, Daftary GS. Progressive Fibrosis: A Progesterone- and KLF11-Mediated Sexually Dimorphic Female Response. Endocrinology 2017; 158:3605-3619. [PMID: 28938437 DOI: 10.1210/en.2017-00171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/08/2017] [Indexed: 01/06/2023]
Abstract
Progressive scarring is ubiquitous postoperatively and in an array of chronic systemic diseases. Recent studies indicate that such scarring has a high female propensity; females are also almost exclusively affected by endometriosis, a common sex steroid-dependent fibrotic disease. Endometriosis-related fibrosis is regulated epigenetically through transcription factor Krüppel-like factor 11 (KLF11). In response to surgical induction of endometriosis, Klf11-/- female mice develop significant fibrosis in contrast to wild-type mice. We therefore hypothesized that female fibrotic predilection was mediated by differential sex steroid regulation of KLF11/collagen 1a1 signaling and investigated the fibrotic response in wild-type and Klf11-/- male and female animals using a sterile peritonitis model. Fibrosis selectively developed in Klf11-/- females. Fibrosis in these animals was almost completely abrogated by ovariectomy. Ovariectomized animals were selectively supplemented with estradiol, medroxyprogesterone acetate (MPA), or dihydrotestosterone; fibrosis was only observed in mice exposed to MPA. Fibrosis therefore selectively developed in Klf11-/- female mice in response to physiological or pharmacological progesterone. The fibrotic response in these animals was also mitigated in response to antiprogestin therapy. Profibrotic gene expression was activated in a primary human peritoneal cell line in response to KLF11 short hairpin RNA and MPA but not estradiol. KLF11/collagen 1a1 signaling previously shown to be linked to fibrosis was thus selectively dysregulated in MPA-treated cells. Our in vivo and in vitro findings in an animal model and human cells, respectively, suggest that progressive fibrotic scarring is a sexually dimorphic response irrespective of etiology; moreover, it is responsive to novel, individualized therapeutic intervention.
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Affiliation(s)
- Chandra C Shenoy
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905
| | - Zaraq Khan
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905
| | - Ye Zheng
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905
| | - Tiffanny L Jones
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905
| | | | - Gaurang S Daftary
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905
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9
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Sex-specific cardiopulmonary exercise testing parameters as predictors in patients with idiopathic pulmonary arterial hypertension. Hypertens Res 2017; 40:868-875. [PMID: 28566737 DOI: 10.1038/hr.2017.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 01/07/2017] [Accepted: 02/23/2017] [Indexed: 01/11/2023]
Abstract
Cardiopulmonary exercise testing (CPET) has been used for prognosis in idiopathic pulmonary arterial hypertension (IPAH). We explored whether sex differences had an impact on prognostic assessments of CPET in IPAH. Data were retrieved from 21 male and 36 female incident IPAH patients who underwent both right heart catheterization and CPET from 2010 to 2016 at Shanghai Pulmonary Hospital. Cox proportional hazards analysis was used to assess the prognostic value of CPET. The mean duration of follow-up was 22±15 months. Nine men and 15 women had an event. The differences in clinical parameters in the whole population were not the same as the inter-subgroup differences. Event-free women had significantly higher cardiac output, lower pulmonary vascular resistance and percentage of predicted FVC compared with event men (all P<0.05). Event-free men had significantly higher end-tidal partial pressure of CO2 (PETCO2) at anaerobic threshold (AT), peak workload, PETCO2, maximum oxygen consumption (VO2)/minute ventilation (VE), and oxygen uptake efficiency slope and lower end-tidal partial pressure of O2 (PETO2) at AT, peak PETO2, and lowest VE/VCO2 compared with event men. Event-free women had dramatically higher peak VO2, VCO2, VE and O2 pulse than event women (all P<0.05). Peak PETCO2 was the independent predictor of event-free survival in all patients and males, whereas peak O2 pulse was the independent predictor of event-free survival in females. Men with peak PETCO2⩾20.50 mm Hg, women with peak O2 pulse ⩾6.25 ml per beat and all patients with peak PETCO2⩾27.03 mm Hg had significantly better event-free survival. Sex-specific CPET parameters are predictors of poor outcomes. Decreased peak PETCO2 in men and peak O2 pulse in women were associated with lower event-free survival in IPAH.
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10
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Yuan P, Chen TX, Pudasaini B, Zhang J, Guo J, Zhang SJ, Wang L, Zhao QH, Gong SG, Jiang R, Wu WH, He J, Liu JM, Hu QH. Sex-specific cardiopulmonary exercise testing indices related to hemodynamics in idiopathic pulmonary arterial hypertension. Ther Adv Respir Dis 2017; 11:135-145. [PMID: 28043202 PMCID: PMC5933651 DOI: 10.1177/1753465816684424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Many studies have highlighted sex preponderance in idiopathic pulmonary
arterial hypertension (IPAH). It is well established that there are
differences in exercise capacities in the two sexes but how much of that
difference reflects on disease severity or correlates to markers of severity
in the two sexes is still not clear. Right heart catheterization (RHC) and
cardiopulmonary exercise testing (CPET) have been widely used for assessing
functional capacity, prognosis and treatment response in IPAH. We aimed to
investigate the ‘sex-specific’ CPET parameters in relation to hemodynamics
in IPAH. Methods: Data were retrieved from 30 males and 53 females [mean ± standard deviation
(SD) age: 39.6 ± 17.2 and 37.5 ± 12.0] stable IPAH patients who underwent
both RHC and CPET at Shanghai Pulmonary Hospital from 2010 to 2016.
Univariate and forward/backward multiple stepwise regression analysis was
performed to assess the prognostic value of CPET and hemodynamic
parameters. Results: There were no significant differences in clinical variables between men and
women. Peak workload, peak oxygen uptake, anaerobic threshold (AT), peak
minute ventilation, carbon dioxide output, O2 pulse and oxygen
uptake efficiency slope were significantly higher in men compared with women
(p < 0.05). Several CPET indexes correlated with
hemodynamics. Pulmonary vascular resistance (PVR) and cardiac output (CO)
were distinctly different between the sexes. Peak end-tidal partial pressure
of CO2 (PETCO2) was an independent
predictor of PVR elevation in all patients and in men. Peak maximum oxygen
consumption (VO2) was independently predictive of CO decline in
all patients and in men. Only peak O2 pulse was an independent
predictor of increased PVR and decreased CO in women. Conclusions: Even after adjusting for age, body mass index and World Health Organization
functional class, different CPET parameters correlated with PVR elevation
and CO decline in men and women differently, which could potentially better
predict severity in men and women with IPAH.
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Affiliation(s)
- Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Tian-Xiang Chen
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jie Zhang
- The Organization and Personnel Department, Qilu Children's Hospital of Shandong University, Shandong University, Shandong, China
| | - Jian Guo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Si-Jin Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai 200433, China
| | - Qing-Hua Hu
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai 200433, China
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11
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Joshi SR, Lakhkar A, Dhagia V, Zias AL, Soldatos V, Oshima K, Jiang H, Gotlinger K, Capdevila JH, Schwartzman ML, McMurtry IF, Gupte SA. Cyp2c44 gene disruption exacerbated pulmonary hypertension and heart failure in female but not male mice. Pulm Circ 2016; 6:360-8. [PMID: 27683613 DOI: 10.1086/688060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Epoxyeicosatrienoicacids (EETs), synthesized from arachidonic acid by epoxygenases of the CYP2C and CYP2J gene subfamilies, contribute to hypoxic pulmonary vasoconstriction (HPV) in mice. Despite their roles in HPV, it is controversial whether EETs mediate or ameliorate pulmonary hypertension (PH). A recent study showed that deficiency of Cyp2j did not protect male and female mice from hypoxia-induced PH. Since CYP2C44 is a functionally important epoxygenase, we hypothesized that knockout of the Cyp2c44 gene would protect both sexes of mice from hypoxia-induced PH. We tested this hypothesis in wild-type (WT) and Cyp2c44 knockout (Cyp2c44 (-/-)) mice exposed to normoxia (room air) and hypoxia (10% O2) for 5 weeks. Exposure of WT and Cyp2c44 (-/-) mice to hypoxia resulted in pulmonary vascular remodeling, increased pulmonary artery resistance, and decreased cardiac function in both sexes. However, in female Cyp2c44 (-/-) mice, compared with WT mice, (1) pulmonary artery resistance and right ventricular hypertrophy were greater, (2) cardiac index was lower, (3) left ventricular and arterial stiffness were higher, and (4) plasma aldosterone levels were higher, but (5) there was no difference in levels of EET in lungs and heart. Paradoxically and unexpectedly, we found that Cyp2c44 disruption exacerbated hypoxia-induced PH in female but not male mice. We attribute exacerbated PH in female Cyp2c44 (-/-) mice to elevated aldosterone and as-yet-unknown systemic factors. Therefore, we suggest a role for the human CYP2C genes in protecting women from severe PH and that this could be one of the underlying causes for a better 5-year survival rate in women than in men.
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Affiliation(s)
- Sachindra Raj Joshi
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anand Lakhkar
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vidhi Dhagia
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ariadne L Zias
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vasiliki Soldatos
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Kaori Oshima
- Department of Pharmacology, University of South Alabama, Mobile, Alabama, USA
| | - Houli Jiang
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Katherine Gotlinger
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jorge H Capdevila
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michal L Schwartzman
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ivan F McMurtry
- Department of Pharmacology, University of South Alabama, Mobile, Alabama, USA
| | - Sachin A Gupte
- Department of Pharmacology, School of Medicine, New York Medical College, Valhalla, New York, USA
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12
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Swift AJ, Capener D, Hammerton C, Thomas SM, Elliot C, Condliffe R, Wild JM, Kiely DG. Right ventricular sex differences in patients with idiopathic pulmonary arterial hypertension characterised by magnetic resonance imaging: pair-matched case controlled study. PLoS One 2015; 10:e0127415. [PMID: 25996939 PMCID: PMC4440634 DOI: 10.1371/journal.pone.0127415] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/14/2015] [Indexed: 11/25/2022] Open
Abstract
Purpose Sex differences exist in both the prevalence and survival of patients with idiopathic pulmonary arterial hypertension (IPAH). Men are less frequently affected by the condition but have worse outcome as compared to females. We sought to characterise the sex related differences in right ventricular remodelling in age matched male and female patients with IPAH using cardiac magnetic resonance imaging (MRI). Methods A case controlled pair-matched study was conducted with patients matched by age and sex. Steady state free precession (SSFP) MRI of the heart was performed at 1.5T. Cardiac volume, function and mass measurements were corrected for age, sex and BSA according to reference data. Results 40 age and sex matched patients with IPAH were identified. The mean age was 57 (SD 17) in both male and female cohorts. Men had proportionally lower right ventricular (RV) ejection fraction, RV stroke volume and LV stroke volume than females, p=0.028, p=0.007 and p=0.013, respectively. However, there was no significant difference in RV mass or haemodynamic indices of mPAP and PVR between males and females. Conclusion Male patients with IPAH have proportionally worse RV function despite similar afterload. We hypothesise that adaptive remodelling of the RV in response to increased afterload in IPAH is more effective in females.
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Affiliation(s)
- Andrew J. Swift
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
- * E-mail:
| | - Dave Capener
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
| | - Charlotte Hammerton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
| | - Steven M. Thomas
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jim M. Wild
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - David G. Kiely
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, United Kingdom
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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13
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Rafikova O, Rafikov R, Meadows ML, Kangath A, Jonigk D, Black SM. The sexual dimorphism associated with pulmonary hypertension corresponds to a fibrotic phenotype. Pulm Circ 2015; 5:184-97. [PMID: 25992281 DOI: 10.1086/679724] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/18/2014] [Indexed: 01/23/2023] Open
Abstract
Although female predominance in the development of all types of pulmonary hypertension (PH) is well established, many clinical studies have confirmed that females have better prognosis and higher survival rate than males. There is no clear explanation of why sex influences the pathogenesis and progression of PH. Using a rat angioproliferative model of PH, which closely resembles the primary pathological changes observed in humans, we evaluated the role of sex in the development and progression of PH. Female rats had a more pronounced increase in medial thickness in the small pulmonary arteries. However, the infiltration of small pulmonary arteries by inflammatory cells was found only in male rats, and this corresponded to increased myeloperoxidase activity and abundant adventitial and medial fibrosis that were not present in female rats. Although the level of right ventricle (RV) peak systolic pressure was similar in both groups, the survival rate in male rats was significantly lower. Moreover, male rats presented with a more pronounced increase in RV thickness that correlated with diffuse RV fibrosis and significantly impaired right cardiac function. The reduction in fibrosis in female rats correlated with increased expression of caveolin-1 and reduced endothelial nitric oxide synthase-derived superoxide. We conclude that, in the pathogenesis of PH, female sex is associated with greater remodeling of the pulmonary arteries but greater survival. Conversely, in males, the development of pulmonary and cardiac fibrosis leads to early and severe RV failure, and this may be an important reason for the lower survival rate among males.
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Affiliation(s)
- Olga Rafikova
- Pulmonary Vascular Disease Program, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA ; These authors contributed equally to this study
| | - Ruslan Rafikov
- Pulmonary Vascular Disease Program, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA ; These authors contributed equally to this study
| | - Mary Louise Meadows
- Pulmonary Vascular Disease Program, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
| | - Archana Kangath
- Pulmonary Vascular Disease Program, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hanover, Germany
| | - Stephen M Black
- Pulmonary Vascular Disease Program, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
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14
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Abstract
Oral contraception (OC) remains a popular noninvasive, readily reversible approach for pregnancy prevention and, largely off label, for control of acne, hirsutism, dysmenorrhea, irregular menstruation, menorrhagia, and other menstrual-related symptoms. Many OC formulations exist, with generics offering lower cost and comparable efficacy. Certain medical conditions, including hypertension, migraine, breast cancer, and risk of venous thromboembolism (VTE), present contraindications. Blood pressure measurement is the only physical examination or testing needed before prescription. Although no OC is clearly superior to others, OCs containing the second-generation progestin levonorgestrel have been associated with lower VTE risk than those containing other progestins.
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Affiliation(s)
- Ginger Evans
- VA Puget Sound Health Care System, 1660 South Columbian Way, S-123-PCC, Seattle, WA 98108, USA.
| | - Eliza L Sutton
- Women's Health Care Center, University of Washington, 4245 Roosevelt Way Northeast, Box 354765, Seattle, WA 98105, USA
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15
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Perros F, Humbert M, Cohen-Kaminsky S. [Pulmonary arterial hypertension: a flavor of autoimmunity]. Med Sci (Paris) 2013; 29:607-16. [PMID: 23859515 DOI: 10.1051/medsci/2013296013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
It is admitted that autoimmunity results from a combination of risks such as genetic background, environmental triggers, and stochastic events. Pulmonary arterial hypertension (PAH) shares with the so-called prototypic autoimmune diseases, genetic risk factors, female predominance and sex hormone influence, association with other chronic inflammatory and autoimmune diseases, defects in regulatory T cells function, and presence of autoantibodies. Case reports have been published indicating the beneficial effect of some immunosuppressive and anti-inflammatory therapies in PAH, supporting the potential role of immune mechanisms in the pathophysiology of the disease. In this review, we discuss the current knowledge on autoimmune mechanisms operating in PAH, especially mounting a local autoimmune response inside the pulmonary tissue, namely pulmonary lymphoid neogenesis. A better understanding of the role of autoimmunity in pulmonary vascular remodelling may help develop targeted immunomodulatory strategies in PAH.
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Affiliation(s)
- Frédéric Perros
- Université Paris-Sud, faculté de médecine, hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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16
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Armstrong AC, Bandeira ÂMP, Correia LCL, Melo HCO, Silveira CAM, Albuquerque E, Moraes JC, Silva AML, Lima JAC, Sobral DC. Pulmonary artery pressure, gender, menopause, and pregnancy in schistosomiasis-associated pulmonary hypertension. Arq Bras Cardiol 2013; 101:154-9. [PMID: 23821406 PMCID: PMC3998155 DOI: 10.5935/abc.20130130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 03/06/2013] [Indexed: 01/23/2023] Open
Abstract
Background Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major
concern worldwide. However, the role of gender specific contributing factors in
SPAH is unknown. Objective We investigated how systolic pulmonary artery pressure (SPAP) values and the
presence of severe SPAP relate to gender, menopausal status, and pregnancy history
in SPAH patients. Methods Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66
were enrolled in the study. Information about age, menopausal status, pregnancy,
echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP)
was collected from medical records. The relation between values of SPAP and mPAP
and their agreement for severe disease were assessed. Regression models assessed
the association of gender, menopausal status, and pregnancy history with SPAP
values and the presence of severe SPAP. Results Moderate correlation and good agreement for severe disease were found between mPAP
and SPAP. Mean SPAP values were similar for men and women. A trend toward higher
values of SPAP was found for non-menopausal women compared to men. Higher SPAP
values were found for menopausal compared to non-menopausal women; the values were
non-significant after adjustment for age. Pregnancy history had no association
with SPAP. Menopause and positive pregnancy had no association with severe SPAP.
Conclusion In SPAH patients, neither gender, nor menopausal status, nor pregnancy history
showed independent correlation with SPAP values assessed by echocardiography.
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Affiliation(s)
- Anderson C. Armstrong
- Escola de Medicina Johns Hopkins - Divisão de Cardiologia, Baltimore,
MD
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
- Mailing Address: Anderson C. Armstrong, 600 North Wolfe Street / Blalock
524. Baltimore, MD 21287-0409, USA. E-mail:
| | | | | | - Humberto C. O. Melo
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
| | | | - Eugênio Albuquerque
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
| | - Jeová C. Moraes
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
| | - Antônio M. L. Silva
- Universidade Federal do Vale do São Francisco - Colegiado de
Medicina, Petrolina, PE - Brazil
| | - João A. C. Lima
- Escola de Medicina Johns Hopkins - Divisão de Cardiologia, Baltimore,
MD
| | - Dário C. Sobral
- Universidade de Pernambuco – Faculdade de Ciências Médicas, Recife,
PE - Brazil
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17
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A pilot study of the effect of spironolactone therapy on exercise capacity and endothelial dysfunction in pulmonary arterial hypertension: study protocol for a randomized controlled trial. Trials 2013; 14:91. [PMID: 23547564 PMCID: PMC3653687 DOI: 10.1186/1745-6215-14-91] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/14/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pulmonary arterial hypertension is a rare disorder associated with poor survival. Endothelial dysfunction plays a central role in the pathogenesis and progression of pulmonary arterial hypertension. Inflammation appears to drive this dysfunctional endothelial phenotype, propagating cycles of injury and repair in genetically susceptible patients with idiopathic and disease-associated pulmonary arterial hypertension. Therapy targeting pulmonary vascular inflammation to interrupt cycles of injury and repair and thereby delay or prevent right ventricular failure and death has not been tested. Spironolactone, a mineralocorticoid and androgen receptor antagonist, has been shown to improve endothelial function and reduce inflammation. Current management of patients with pulmonary arterial hypertension and symptoms of right heart failure includes use of mineralocorticoid receptor antagonists for their diuretic and natriuretic effects. We hypothesize that initiating spironolactone therapy at an earlier stage of disease in patients with pulmonary arterial hypertension could provide additional benefits through anti-inflammatory effects and improvements in pulmonary vascular function. METHODS/DESIGN Seventy patients with pulmonary arterial hypertension without clinical evidence of right ventricular failure will be enrolled in a randomized, double-blinded, placebo-controlled trial to investigate the effect of early treatment with spironolactone on exercise capacity, clinical worsening and vascular inflammation in vivo. Our primary endpoint is change in placebo-corrected 6-minute walk distance at 24 weeks and the incidence of clinical worsening in the spironolactone group compared to placebo. At a two-sided alpha level of 0.05, we will have at least 84% power to detect an effect size (group mean difference divided by standard deviation) of 0.9 for the difference in the change of 6-minute walk distance from baseline between the two groups. Secondary endpoints include the effect of spironolactone on the change in placebo-corrected maximal oxygen consumption; plasma markers of vascular inflammation and peripheral blood mononuclear cell gene expression profiles; sympathetic nervous system activation, renin-angiotensin-aldosterone system activation and sex hormone metabolism; and right ventricular structure and function using echocardiography and novel high-resolution magnetic resonance imaging-based techniques. Safety and tolerability of spironolactone will be assessed with periodic monitoring for hyperkalemia and renal insufficiency as well as the incidence of drug discontinuation for untoward effects. TRIAL REGISTRATION ClinicalTrials.gov: NCT01712620.
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18
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Wang VN, Ahmed M, Ciofani A, Sasson Z, Granton JT, Mak S. The effect of endogenous estrogen on Doppler-estimated right ventricular systolic pressure during exercise. Can J Physiol Pharmacol 2012; 90:1364-71. [PMID: 22966864 DOI: 10.1139/y2012-100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We evaluated the effect of endogenous estrogen levels on exercise-related changes in right ventricular systolic pressure (RVSP) of healthy, eumenorrheic, sedentary women. Volunteers were studied at two separates phases of the menstrual cycle (LO and HI estrogen phases), exercised on a semi-supine ergometer with escalating workload and monitored continuously by 12-lead ECG and automated blood pressure cuff. At each exercise stage, Doppler echocardiography measurements were obtained and analyzed to determine RVSP. Fourteen subjects (age 24 ± 5) were studied. Exercise duration was significantly higher on the HI estrogen day, but no significant differences in hemodynamic response to exercise were found between the two study days. There were also no significant differences with respect to heart rate (HR) acceleration during early exercise, as well as resting and peak RVSP, HR, blood pressure, and rate pressure product. Doppler-estimated RVSP demonstrated a linear relationship to HR at a ratio of 1 mm Hg (1 mm Hg = 133.3224 Pa) for every 5 bpm (beats per minute) increase in HR. There were no differences in the slope of this relationship between HI and LO estrogen phases of the menstrual cycle. Our findings did not demonstrate any effect of endogenous estrogen levels on the modulation of the pulmonary vascular response to exercise in healthy women.
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Affiliation(s)
- Vicki N Wang
- Department of Medicine, Division of Cardiology and the John H. Daniels Cardiac Research Centre, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada
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19
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White K, Johansen AK, Nilsen M, Ciuclan L, Wallace E, Paton L, Campbell A, Morecroft I, Loughlin L, McClure JD, Thomas M, Mair KM, MacLean MR. Activity of the estrogen-metabolizing enzyme cytochrome P450 1B1 influences the development of pulmonary arterial hypertension. Circulation 2012; 126:1087-98. [PMID: 22859684 DOI: 10.1161/circulationaha.111.062927] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a hyperproliferative vascular disorder observed predominantly in women. Estrogen is a potent mitogen in human pulmonary artery smooth muscle cells and contributes to PAH in vivo; however, the mechanisms attributed to this causation remain obscure. Curiously, heightened expression of the estrogen-metabolizing enzyme cytochrome P450 1B1 (CYP1B1) is reported in idiopathic PAH and murine models of PAH. METHODS AND RESULTS Here, we investigated the putative pathogenic role of CYP1B1 in PAH. Quantitative reverse transcription-polymerase chain reaction, immunoblotting, and in situ analysis revealed that pulmonary CYP1B1 is increased in hypoxic PAH, hypoxic+SU5416 PAH, and human PAH and is highly expressed within the pulmonary vascular wall. PAH was assessed in mice via measurement of right ventricular hypertrophy, pulmonary vascular remodeling, and right ventricular systolic pressure. Hypoxic PAH was attenuated in CYP1B1(-/-) mice, and the potent CYP1B1 inhibitor 2,3',4,5'-tetramethoxystilbene (TMS; 3 mg · kg(-1) · d(-1) IP) significantly attenuated hypoxic PAH and hypoxic+SU5416 PAH in vivo. TMS also abolished estrogen-induced proliferation in human pulmonary artery smooth muscle cells and PAH-pulmonary artery smooth muscle cells. The estrogen metabolite 16α-hydroxyestrone provoked human pulmonary artery smooth muscle cell proliferation, and this mitogenic effect was greatly pronounced in PAH-pulmonary artery smooth muscle cells. ELISA analysis revealed that 16α-hydroxyestrone concentration was elevated in PAH, consistent with CYP1B1 overexpression and activity. Finally, administration of the CYP1B1 metabolite 16α-hydroxyestrone (1.5 mg · kg(-1) · d(-1) IP) caused the development of PAH in mice. CONCLUSIONS Increased CYP1B1-mediated estrogen metabolism promotes the development of PAH, likely via the formation of mitogens, including 16α-hydroxyestrone. Collectively, this study reveals a possible novel therapeutic target in clinical PAH.
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Affiliation(s)
- Kevin White
- Professor of Pulmonary Pharmacology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.
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20
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Umar S, Rabinovitch M, Eghbali M. Estrogen paradox in pulmonary hypertension: current controversies and future perspectives. Am J Respir Crit Care Med 2012; 186:125-31. [PMID: 22561960 DOI: 10.1164/rccm.201201-0058pp] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although the incidence of pulmonary hypertension is higher in female patients, numerous experimental studies have demonstrated better outcome in female animals, exacerbation of the disease after ovariectomy, and a strong protective effect of estrogen: a phenomenon known as the "estrogen paradox" of pulmonary hypertension. On the other hand, some clinical studies have indirectly linked estrogen to increased risk of portopulmonary hypertension, whereas others implicate increased estrogen metabolism and high levels of certain estrogen metabolites in promoting pulmonary vascular remodeling in familial pulmonary arterial hypertension. In this review we investigate the estrogen paradox through highlighting the differential receptor-mediated effects of estrogen. Although estrogen and estrogen receptor-based therapies have shown promise in rescuing preexisting pulmonary hypertension in animals, their role is yet to be defined in humans.
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Affiliation(s)
- Soban Umar
- Division of Molecular Medicine, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, USA
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21
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Abstract
Sex differences in the biology of different organ systems and the influence of sex hormones in modulating health and disease are increasingly relevant in clinical and research areas. Although work has focused on sex differences and sex hormones in cardiovascular, musculoskeletal, and neuronal systems, there is now increasing clinical evidence for sex differences in incidence, morbidity, and mortality of lung diseases including allergic diseases (such as asthma), chronic obstructive pulmonary disease, pulmonary fibrosis, lung cancer, as well as pulmonary hypertension. Whether such differences are inherent and/or whether sex steroids play a role in modulating these differences is currently under investigation. The purpose of this review is to define sex differences in lung structure/function under normal and specific disease states, with exploration of whether and how sex hormone signaling mechanisms may explain these clinical observations. Focusing on adult age groups, the review addresses the following: 1) inherent sex differences in lung anatomy and physiology; 2) the importance of certain time points in life such as puberty, pregnancy, menopause, and aging; 3) expression and signaling of sex steroid receptors under normal vs. disease states; 4) potential interplay between different sex steroids; 5) the question of whether sex steroids are beneficial or detrimental to the lung; and 6) the potential use of sex steroid signaling as biomarkers and therapeutic avenues in lung diseases. The importance of focusing on sex differences and sex steroids in the lung lies in the increasing incidence of lung diseases in women and the need to address lung diseases across the life span.
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Affiliation(s)
- Elizabeth A Townsend
- Department of Physiology and Biomedical Engineering, College of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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22
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Sioulas VD, Gracia CR. Ovarian stimulation and embryo banking for fertility preservation in a woman with severe mixed connective tissue disease: Is it safe? J Assist Reprod Genet 2011; 29:271-5. [PMID: 22205344 DOI: 10.1007/s10815-011-9697-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 12/13/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To report the first case of using assisted reproductive technologies (ART) for fertility preservation in a patient with mixed connective tissue disease (MCTD), secondary pulmonary hypertension (PH) and antiphospholipid syndrome (APS). DESIGN Case-report and review of the literature. SETTING Academic infertility practice and tertiary care center. PATIENT(S) A 25-year-old woman with MCTD, complicated with PH and APS, who was scheduled for gonadotoxic therapy INTERVENTION(S) Controlled ovarian hyperstimulation, egg retrieval, embryo banking. MAIN OUTCOME MEASURE(S) Successful ART cycle leading to embryo banking without worsening her underlying disease. RESULT(S) Following successful embryo cryopreservation, the patient experienced respiratory failure and other severe complications, resulting in a prolonged hospital stay. CONCLUSION(S) Controlled ovarian hyperstimulation for embryo banking in women with MCTD, PH and APS may pose a risk for potentially catastrophic complications. A multidisciplinary approach to these patients is necessary to optimize the outcomes of such procedures. More data are needed regarding the safety of fertility preservation technologies in patients with complex medical diseases.
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Affiliation(s)
- Vasileios D Sioulas
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
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23
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Umar S, Iorga A, Matori H, Nadadur RD, Li J, Maltese F, van der Laarse A, Eghbali M. Estrogen rescues preexisting severe pulmonary hypertension in rats. Am J Respir Crit Care Med 2011; 184:715-23. [PMID: 21700911 DOI: 10.1164/rccm.201101-0078oc] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Pulmonary hypertension (PH) is characterized by progressive increase in pulmonary artery pressure leading to right ventricular (RV) hypertrophy, RV failure, and death. Current treatments only temporarily reduce severity of the disease, and an ideal therapy is still lacking. OBJECTIVES Estrogen pretreatment has been shown to attenuate development of PH. Because PH is not often diagnosed early, we examined if estrogen can rescue preexisting advanced PH. METHODS PH was induced in male rats with monocrotaline (60 mg/kg). At Day 21, rats were either treated with 17-β estradiol or estrogen (E2, 42.5 μg/kg/d), estrogen receptor-β agonist (diarylpropionitrile, 850 μg/kg/d), or estrogen receptor α-agonist (4,4',4"-[4-Propyl-(1H)-pyrazole-1,3,5-triyl] trisphenol, 850 μg/kg/d) for 10 days or left untreated to develop RV failure. Serial echocardiography, cardiac catheterization, immunohistochemistry, Western blot, and real-time polymerase chain reaction were performed. MEASUREMENTS AND MAIN RESULTS Estrogen therapy prevented progression of PH to RV failure and restored lung and RV structure and function. This restoration was maintained even after removal of estrogen at Day 30, resulting in 100% survival at Day 42. Estradiol treatment restored the loss of blood vessels in the lungs and RV. In the presence of angiogenesis inhibitor TNP-470 (30 mg/kg) or estrogen receptor-β antagonist (PHTPP, 850 μg/kg/d), estrogen failed to rescue PH. Estrogen receptor-β selective agonist was as effective as estrogen in rescuing PH. CONCLUSIONS Estrogen rescues preexisting severe PH in rats by restoring lung and RV structure and function that are maintained even after removal of estrogen. Estrogen-induced rescue of PH is associated with stimulation of cardiopulmonary neoangiogenesis, suppression of inflammation, fibrosis, and RV hypertrophy. Furthermore, estrogen rescue is likely mediated through estrogen receptor-β.
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Affiliation(s)
- Soban Umar
- University of California Los Angeles School of Medicine, Department of Anesthesiology, BH-160CHS, 650 Charles Young Drive, Los Angeles, CA 90095-7115, USA
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Zhang R, Dai LZ, Xie WP, Yu ZX, Wu BX, Pan L, Yuan P, Jiang X, He J, Humbert M, Jing ZC. Survival of Chinese patients with pulmonary arterial hypertension in the modern treatment era. Chest 2011; 140:301-309. [PMID: 21330386 DOI: 10.1378/chest.10-2327] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In a previous study of Chinese patients with idiopathic pulmonary arterial hypertension (IPAH) in the nontargeted therapy era (defined as the time before 2006 when new pulmonary arterial hypertension-specific drugs were not available in China), we reported 1- and 3-year survival estimates of only 68% and 39%, respectively. However, it is not yet known whether the survival of patients with pulmonary arterial hypertension is improved in the modern treatment era (defined in China as after 2006). METHODS A retrospective cohort study was undertaken in 276 consecutive patients with newly diagnosed incident IPAH and connective tissue disease-related pulmonary arterial hypertension (CTDPAH) who were referred between 2007 and 2009. Baseline characteristics and survival rates in the two groups were compared. RESULTS The 1- and 3-year survival estimates were 92.1% and 75.1%, respectively, in patients with IPAH, and 85.4% and 53.6%, respectively, in patients with CTDPAH. Patients with CTDPAH had a significantly lower mean pulmonary artery pressure, more pericardial effusion, and more severe impairment of the diffusion capacity of the lung for carbon monoxide than patients with IPAH. A diagnosis of CTDPAH, World Health Organization functional class III or IV, single-breath diffusion capacity of the lung for carbon monoxide < 80% predicted, and the presence of pericardial effusion were independent predictors of mortality. The 1- and 3-year survival rates of male patients were 93.5% and 77.5%, respectively, in those with IPAH, and 71.1% and 47.4%, respectively, in those with CTDPAH. CONCLUSIONS The survival rates of patients with pulmonary arterial hypertension have improved in China in the modern treatment era, despite the high costs of treatment and financial constraints. However, the survival rates of patients with CTDPAH are inferior to those of patients with IPAH. Our study also indicates poorer survival rates in male patients with CTDPAH.
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Affiliation(s)
- Rui Zhang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li-Zhi Dai
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei-Ping Xie
- Department of Respiratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zai-Xin Yu
- Department of Cardiology, Xiangya Hospital of Central-South University, Changsha, China
| | - Bing-Xiang Wu
- Department of Cardiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Pan
- Department of Respiratory Medicine, Beijing Shijitan Hospital, Beijing, China
| | - Ping Yuan
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Marc Humbert
- INSERM U999 Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris, Université Paris-Sud 11, Clamart, France
| | - Zhi-Cheng Jing
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
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Barbosa PB, Ferreira EMV, Arakaki JSO, Takara LS, Moura J, Nascimento RB, Nery LE, Neder JA. Kinetics of skeletal muscle O2 delivery and utilization at the onset of heavy-intensity exercise in pulmonary arterial hypertension. Eur J Appl Physiol 2011; 111:1851-61. [DOI: 10.1007/s00421-010-1799-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 12/20/2010] [Indexed: 11/30/2022]
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Pugh ME, Hemnes AR. Metabolic and hormonal derangements in pulmonary hypertension: from mouse to man. INTERNATIONAL JOURNAL OF CLINICAL PRACTICE. SUPPLEMENT 2010; 64:5-13. [PMID: 20939841 PMCID: PMC2965027 DOI: 10.1111/j.1742-1241.2010.02523.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a complex disease with significant morbidity and mortality. Recent animal and human studies have highlighted abnormalities in regulation and metabolism of insulin, sex hormones, adipokines and lipids that may play a role in disease development. Mouse studies suggest features of the metabolic syndrome (MS) including insulin resistance, deficiencies in peroxisome proliferator-activated receptor γ and apolipoprotein E, and low adiponectin are linked to development of PAH. In humans, insulin resistance, the MS and low levels of high-density lipoprotein have been associated with PAH. In addition, abnormal metabolism of oestrogens has been demonstrated in human and animal models of PAH, suggesting an important relationship of sex hormones and pulmonary vascular disease. Improved understanding of how metabolic and hormonal derangements relate to development and progression of pulmonary hypertension may lead to better disease therapies and understanding of potential risk factors. This review will focus on the animal and human data regarding metabolic and sex hormone derangements in PAH.
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Affiliation(s)
- M E Pugh
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
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