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Mao Z, Wang C, Liu J, Li X, Duan H, Ye Y, Liu H, Lv L, Xue G, He Z, Wuren T, Wang H. Superoxide dismutase 1-modified dental pulp stem cells alleviate high-altitude pulmonary edema by inhibiting oxidative stress through the Nrf2/HO-1 pathway. Gene Ther 2024; 31:422-433. [PMID: 38834681 DOI: 10.1038/s41434-024-00457-x] [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: 02/15/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
High-altitude pulmonary edema (HAPE) is a deadly form of altitude sickness, and there is no effective treatment for HAPE. Dental pulp stem cells (DPSCs) are a type of mesenchymal stem cell isolated from dental pulp tissues and possess various functions, such as anti-inflammatory and anti-oxidative stress. DPSCs have been used to treat a variety of diseases, but there are no studies on treating HAPE. In this study, Sprague-Dawley rats were exposed to acute low-pressure hypoxia to establish the HAPE model, and SOD1-modified DPSCs (DPSCsHiSOD1) were administered through the tail vein. Pulmonary arterial pressure, lung water content (LWC), total lung protein content of bronchoalveolar lavage fluid (BALF) and lung homogenates, oxidative stress, and inflammatory indicators were detected to evaluate the effects of DPSCsHiSOD1 on HAPE. Rat type II alveolar epithelial cells (RLE-6TN) were used to investigate the effects and mechanism of DPSCsHiSOD1 on hypoxia injury. We found that DPSCs could treat HAPE, and the effect was better than that of dexamethasone treatment. SOD1 modification could enhance the function of DPSCs in improving the structure of lung tissue, decreasing pulmonary arterial pressure and LWC, and reducing the total lung protein content of BALF and lung homogenates, through anti-oxidative stress and anti-inflammatory effects. Furthermore, we found that DPSCsHiSOD1 could protect RLE-6TN from hypoxic injury by reducing the accumulation of reactive oxygen species (ROS) and activating the Nrf2/HO-1 pathway. Our findings confirm that SOD1 modification could enhance the anti-oxidative stress ability of DPSCs through the Nrf2/HO-1 signalling pathway. DPSCs, especially DPSCsHiSOD1, could be a potential treatment for HAPE. Schematic diagram of the antioxidant stress mechanism of DPSCs in the treatment of high-altitude pulmonary edema. DPSCs can alleviate oxidative stress by releasing superoxide dismutase 1, thereby reducing ROS production and activating the Nrf2/HO-1 signalling pathway to ameliorate lung cell injury in HAPE.
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Affiliation(s)
- Zhuang Mao
- Beijing Institute of Radiation Medicine, Beijing, 100850, China
| | - Changyao Wang
- Beijing Institute of Radiation Medicine, Beijing, 100850, China
- School of Life Sciences, Hebei University, Baoding, 071002, China
| | - Juanli Liu
- Key Laboratory for Application of High-Altitude Medicine, Qinghai University, Xi'ning, 810008, China
- Research Center for High Altitude Medicine, Qinghai University, Xi'ning, 810008, China
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xi'ning, 810007, China
| | - Xue Li
- Beijing Institute of Radiation Medicine, Beijing, 100850, China
- College of Life Science, Anhui Medical University, Hefei, 230032, China
| | - Han Duan
- School of Life Sciences, Hebei University, Baoding, 071002, China
| | - Yi Ye
- Key Laboratory for Application of High-Altitude Medicine, Qinghai University, Xi'ning, 810008, China
- Research Center for High Altitude Medicine, Qinghai University, Xi'ning, 810008, China
| | - Huifang Liu
- Key Laboratory for Application of High-Altitude Medicine, Qinghai University, Xi'ning, 810008, China
- Research Center for High Altitude Medicine, Qinghai University, Xi'ning, 810008, China
| | - Lin Lv
- Beijing Institute of Radiation Medicine, Beijing, 100850, China
| | - Guanzhen Xue
- Key Laboratory for Application of High-Altitude Medicine, Qinghai University, Xi'ning, 810008, China
- Research Center for High Altitude Medicine, Qinghai University, Xi'ning, 810008, China
| | - Zhichao He
- Beijing Institute of Radiation Medicine, Beijing, 100850, China
- College of Life Science, Anhui Medical University, Hefei, 230032, China
| | - Tana Wuren
- Key Laboratory for Application of High-Altitude Medicine, Qinghai University, Xi'ning, 810008, China.
- Research Center for High Altitude Medicine, Qinghai University, Xi'ning, 810008, China.
| | - Hua Wang
- Beijing Institute of Radiation Medicine, Beijing, 100850, China.
- School of Life Sciences, Hebei University, Baoding, 071002, China.
- College of Life Science, Anhui Medical University, Hefei, 230032, China.
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Khan S, Randhawa S, Patail H, Spira Y, Frishman WH, Aronow WS, Lanier GM. Pharmacological Update and Emerging Treatments of Pulmonary Hypertension. Cardiol Rev 2024:00045415-990000000-00192. [PMID: 38294225 DOI: 10.1097/crd.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Pulmonary hypertension (PH) is defined as elevated pressures in the pulmonary artery and is associated with significant morbidity and mortality. The World Health Organization classifies PH into 5 distinct groups based on underlying etiology, pathology, and modality of treatment. Therapeutic approach may be challenging due to the extensive spectrum of causes and underlying mechanisms mediating PH. The 5 groups include pulmonary arterial hypertension (group 1), PH secondary to left heart disease (group 2), PH secondary to chronic lung disease (group 3), chronic thromboembolic pulmonary hypertension (group 4), and PH due to miscellaneous causes (group 5). Although significant progress has been made in the treatment of group 1 PH, there is a continued need to develop new therapies for all types of PH. Additionally, most treatments currently available improve functional capacity and symptoms but without a significant benefit in mortality. In this review, we aim to describe the various etiologies of PH and their established pharmacotherapies, as well as expand on emerging therapeutic options for each group.
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Affiliation(s)
- Shazli Khan
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sukhbir Randhawa
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY
| | - Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Hartford, CT
| | - Yaakov Spira
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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3
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Farmakis IT, Baroutidou A, Patsiou V, Arvanitaki A, Doundoulakis I, Hobohm L, Zafeiropoulos S, Konstantinides SV, D'Alto M, Badagliacca R, Giannakoulas G. Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients. ERJ Open Res 2024; 10:00706-2023. [PMID: 38259812 PMCID: PMC10801731 DOI: 10.1183/23120541.00706-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.
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Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michele D'Alto
- Department of Cardiology, University “L. Vanvitelli”-Monaldi Hospital, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Klose H, Harbaum L, Richter MJ, Lichtblau M, Marra AM, Kabitz HJ, Harutyunova S, Milger-Kneidinger K, Lange TJ. [Targeted therapy for pulmonary arterial hypertension in patients without comorbidities]. Pneumologie 2023; 77:890-900. [PMID: 37963478 DOI: 10.1055/a-2145-4711] [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
The 2022 guidelines on pulmonary hypertension from the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) provide therapeutic strategies that account for the variability in the clinical presentation of newly diagnosed patients. We summarize treatment recommendations for pulmonary arterial hypertension (PAH) in patients without significant comorbidities, particularly for idiopathic, hereditary, drug/toxin-induced, or connective tissue disease-associated PAH. In this group of patients, multidimensional assessments for short-term mortality risk guide initial treatment decisions and treatment decisions during follow-up. Upfront dual combination therapy (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) is recommended for low- and intermediate-risk patients, and triple therapy including a parenteral prostacyclin should be considered in high- or intermediate-high-risk patients. If a low or intermediate-low-risk profile cannot be achieved during therapy, sequential add-on therapy escalation with parenteral prostacyclin or a prostacyclin receptor agonist should be considered, and switching from a phosphodiesterase type-5 inhibitor to a guanylate cyclase stimulator may also be considered.
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Affiliation(s)
- Hans Klose
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Lars Harbaum
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, zzt. Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Mona Lichtblau
- Klinik für Pneumologie, Zentrum für Pulmonale Hypertonie, Universitätsspital Zürich, Zürich, Schweiz
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University of Naples, Napoli, Italy
| | - Hans-Joachim Kabitz
- Klinik für Pneumologie und Schlafmedizin, Kantonsspital Aarau (KSA), Aarau, Schweiz
| | - Satenik Harutyunova
- Zentrum für pulmonale Hypertonie, Thoraxklinik an der Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Katrin Milger-Kneidinger
- Medizinische Klinik und Poliklinik V, Ludwig-Maximilians-Universität (LMU) Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Bad Reichenhall, Deutschland
- Fakultät für Medizin, Lehrstuhl für Innere Medizin II, Universität Regensburg, Regensburg, Deutschland
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5
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Zhong HL, Li PZ, Li D, Guan CX, Zhou Y. The role of vasoactive intestinal peptide in pulmonary diseases. Life Sci 2023; 332:122121. [PMID: 37742737 DOI: 10.1016/j.lfs.2023.122121] [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: 05/14/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 09/26/2023]
Abstract
Vasoactive intestinal peptide (VIP) is an abundant neurotransmitter in the lungs and other organs. Its discovery dates back to 1970. And VIP gains attention again due to the potential application in COVID-19 after a research wave in the 1980s and 1990s. The diverse biological impacts of VIP extend beyond its usage in COVID-19 treatment, encompassing its involvement in various pulmonary and systemic disorders. This review centers on the function of VIP in various lung diseases, such as pulmonary arterial hypertension, chronic obstructive pulmonary disease, asthma, cystic fibrosis, acute lung injury/acute respiratory distress syndrome, pulmonary fibrosis, and lung tumors. This review also outlines two main limitations of VIP as a potential medication and gathers information on extended-release formulations and VIP analogues.
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Affiliation(s)
- Hong-Lin Zhong
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha, Hunan 410078, China
| | - Pei-Ze Li
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha, Hunan 410078, China
| | - Di Li
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha, Hunan 410078, China
| | - Cha-Xiang Guan
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha, Hunan 410078, China.
| | - Yong Zhou
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha, Hunan 410078, China.
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6
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Papa S, Scoccia G, Serino G, Adamo FI, Jabbour JP, Caputo A, Boromei M, Filomena D, Laviola D, Maggio E, Manzi G, Mihai A, Recchioni T, Sabusco A, Valeri L, Vinciullo S, Vizza CD, Badagliacca R. Impact of Parenteral Prostanoids in Pulmonary Arterial Hypertension: The Relevance of Timing. J Clin Med 2023; 12:6840. [PMID: 37959305 PMCID: PMC10648828 DOI: 10.3390/jcm12216840] [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: 06/07/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Parenteral prostanoids are being recommended in pulmonary arterial hypertension (PAH) treatment, but the prognostic relevance of delayed treatment initiation is still debated. This study assessed the impact of the timing of prostacyclin treatment initiation on reducing PVR and achieving a low-risk profile in PAH patients. The study enrolled 151 patients who started on parenteral prostanoids with different treatment strategies. All patients underwent right heart catheterization, clinical evaluation, and risk assessments at baseline and after 1-year follow-up. Patients with an upfront strategy including parenteral prostanoid plus one oral drug had -5.3 ± 6.2 WU (-50 ± 19%) reduction in PVR, patients with an upfront strategy including parenteral prostanoid plus double oral drug had -12.8 ± 5.9 WU (-68 ± 17%) reduction in PVR, while patients with an add-on strategy including parenteral prostanoid after oral drugs had -3.9 ± 3.5 WU (-23 ± 19%) reduction in PVR. An upfront strategy including parenteral prostanoids was independently associated with an increased likelihood of achieving the greater reduction of PVR compared with an add-on strategy. Additionally, the greater the severity of PH at the time of diagnosis, in terms of PVR and RV reverse remodeling, the higher the probability of treatment failure. An upfront strategy including a parenteral prostanoid is associated with the highest likelihood of achieving a low-risk profile and a greater reduction of PVR compared with parenteral prostanoid as an add-on to oral treatment.
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Affiliation(s)
- Silvia Papa
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Gianmarco Scoccia
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giorgia Serino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Francesca Ileana Adamo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Jean Pierre Jabbour
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Annalisa Caputo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Michela Boromei
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Filomena
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Laviola
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Enrico Maggio
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giovanna Manzi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Mihai
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Tommaso Recchioni
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Sabusco
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy;
| | - Livia Valeri
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Sara Vinciullo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Carmine Dario Vizza
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Roberto Badagliacca
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
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7
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Boucly A, Gerges C, Savale L, Jaïs X, Jevnikar M, Montani D, Sitbon O, Humbert M. Pulmonary arterial hypertension. Presse Med 2023; 52:104168. [PMID: 37516248 DOI: 10.1016/j.lpm.2023.104168] [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] [Received: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laurent Savale
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
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8
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Ahmed MS, Ghallab M, Ostrow T, Nashawi M, Alagha Z, Levine A, Aronow WS, Lanier GM. Pharmacotherapy of refractory pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:1861-1874. [PMID: 37698041 DOI: 10.1080/14656566.2023.2257134] [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: 04/27/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.
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Affiliation(s)
- Mahmoud Samy Ahmed
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Muhammad Ghallab
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Talia Ostrow
- Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mouhamed Nashawi
- Department of Medicine, Baylor Scott & White Health, Dallas, TX, USA
| | - Zakaria Alagha
- Department of Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
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9
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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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10
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Balistrieri A, Makino A, Yuan JXJ. Pathophysiology and pathogenic mechanisms of pulmonary hypertension: role of membrane receptors, ion channels, and Ca 2+ signaling. Physiol Rev 2023; 103:1827-1897. [PMID: 36422993 PMCID: PMC10110735 DOI: 10.1152/physrev.00030.2021] [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: 08/02/2021] [Revised: 11/11/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022] Open
Abstract
The pulmonary circulation is a low-resistance, low-pressure, and high-compliance system that allows the lungs to receive the entire cardiac output. Pulmonary arterial pressure is a function of cardiac output and pulmonary vascular resistance, and pulmonary vascular resistance is inversely proportional to the fourth power of the intraluminal radius of the pulmonary artery. Therefore, a very small decrease of the pulmonary vascular lumen diameter results in a significant increase in pulmonary vascular resistance and pulmonary arterial pressure. Pulmonary arterial hypertension is a fatal and progressive disease with poor prognosis. Regardless of the initial pathogenic triggers, sustained pulmonary vasoconstriction, concentric vascular remodeling, occlusive intimal lesions, in situ thrombosis, and vascular wall stiffening are the major and direct causes for elevated pulmonary vascular resistance in patients with pulmonary arterial hypertension and other forms of precapillary pulmonary hypertension. In this review, we aim to discuss the basic principles and physiological mechanisms involved in the regulation of lung vascular hemodynamics and pulmonary vascular function, the changes in the pulmonary vasculature that contribute to the increased vascular resistance and arterial pressure, and the pathogenic mechanisms involved in the development and progression of pulmonary hypertension. We focus on reviewing the pathogenic roles of membrane receptors, ion channels, and intracellular Ca2+ signaling in pulmonary vascular smooth muscle cells in the development and progression of pulmonary hypertension.
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Affiliation(s)
- Angela Balistrieri
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California
- Harvard University, Cambridge, Massachusetts
| | - Ayako Makino
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jason X-J Yuan
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California
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11
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Garcia MVF, Coz-Yataco A, Al-Jaghbeer MJ. Pulmonary arterial hypertension trials put to the test: Using the fragility index to assess trials robustness. Heart Lung 2023; 61:147-152. [PMID: 37271106 DOI: 10.1016/j.hrtlng.2023.05.019] [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: 03/20/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) are considered the gold standard for evidence-based medicine. The Fragility Index (FI) is a tool to assess the robustness of RCT results. FI was validated for dichotomous outcomes and recent work expanded its use to continuous outcomes. Studying the robustness of RCTs in Pulmonary Arterial Hypertension (PAH) treatments is crucial due to the severity and mortality risks associated with this rare condition. OBJECTIVES Analyze FI and Fragility quotient (FQ) of significant primary outcomes in PAH RCTs and study FI correlation with sample size and journal impact factor. METHODS FI and FQ calculation followed by Spearman correlation to assess the correlation between FI and sample size, and FI and impact factor. RESULTS The median sample size of the 21 trials was 202 patients (IQR 106-267), with 6 trials reporting primary outcomes as dichotomous and 15 reporting continuous primary outcomes. The median FI was 10 (IQR 3-20), and the median FQ was 0.044 (0.026-0.097). A moderate correlation was found between FI and sample size, with r = 0.56; P = 0.008 and FI and journal impact factor (r=0.50; P=0.019). The FI for continuous outcomes was similar to that for dichotomous outcomes. CONCLUSIONS This study represents the first analysis of the FI and FQ of PAH treatment RCTs, and expands the use of FI to continuous outcomes in this context. The moderate correlation between FI and sample size suggests that increasing sample size alone is partially correlated to a higher FI. The similarity between FI for continuous and dichotomous outcomes supports the broader use of FI in PAH RCTs.
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Affiliation(s)
| | - Angel Coz-Yataco
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Mohammed J Al-Jaghbeer
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
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12
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Perros F, Jutant ÉM, Savale L, Dorfmüller P, Humbert M, Montani D. [Physiopathology and treatment of pulmonary arterial hypertension]. Med Sci (Paris) 2023; 39:359-369. [PMID: 37094269 DOI: 10.1051/medsci/2023053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease affecting mainly the pre-capillary pulmonary vascular bed. However, some forms of the disease have venous/capillary involvement. It is an obstructive remodelling of the pulmonary arterioles coupled with vascular pruning, increasing right ventricular afterload and leading to right heart failure. PAH has a complex pathogeny that is detailed in this review. Current specific treatments target endothelial dysfunction, and primarily aim at vasodilatation. Promising innovative treatments targeting the pulmonary artery remodelling are under development.
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Affiliation(s)
- Frédéric Perros
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Étienne-Marie Jutant
- Université de Poitiers, CHU de Poitiers, service de pneumologie, Inserm CIC 1402 Axe IS-ALIVE, Poitiers, France
| | - Laurent Savale
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Allemagne
| | - Marc Humbert
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
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13
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Camara RP, Coelho FDN, Cruz-Martins N, Marques-Alves P, Castro G, Baptista R, Ferreira F. Incidence of Bloodstream Infection in Patients with Pulmonary Hypertension under Intravenous Epoprostenol or Iloprost—A Multicentre, Retrospective Study. Int J Mol Sci 2023; 24:ijms24076434. [PMID: 37047407 PMCID: PMC10094981 DOI: 10.3390/ijms24076434] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Intravenous synthetic prostacyclin analogs (iPCAs), such as epoprostenol, treprostinil and iloprost have been widely used for the treatment of pulmonary arterial hypertension (PAH). Despite having good outcomes, continuous infusion of iPCAs has been associated with some adverse effects. Bloodstream infection (BSI) is one of the most severe complications, although poorly recognized, especially under iloprost administration, which few studies have addressed. This study aimed to compare the BSI incidence rates between intravenous iloprost and epoprostenol administration. Patients with pulmonary hypertension (PH) functional class III or IV receiving intravenous iloprost or epoprostenol through Hickman catheter, between 2004 and 2019, were retrospectively selected from two PH treatment centers. From a total of 36 patients (13 for iloprost and 23 for epoprostenol), 75% (n = 27) fulfilled the PAH criteria, mainly belonging to the idiopathic group. Overall BSI rate was 1.5/1000 days of treatment (3.38 and 0.09/1000 days for iloprost and epoprostenol, respectively). Patients receiving iloprost were at a higher risk of developing BSI than those receiving epoprostenol (HR: 12.5; 95% CI: 1.569–99.092). A higher mortality rate from BSI was also identified in the iloprost group (p = 0.04). Twenty-seven patients developed BSI, with 92% of them requiring hospitalization. A total of 29 agents were found, 10 Gram-positive (mainly Staphylococcus aureus; n = 5) and 19 Gram-negative (mainly Pseudomonas aeruginosa; n = 6) bacteria. Iloprost administration was linked to a significantly higher incidence of BSI, worse prognosis, and more BSI-related deaths than epoprostenol. BSI due to Gram-negative, commensal, low-virulence bacteria was also higher in the iloprost group. In short, physicians should be aware when prescribing iPCA to guarantee their patients’ safety and best medical care.
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Affiliation(s)
- Raquel Paulinetti Camara
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Pulmonology Department, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro-Montijo, 2830-003 Barreiro, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Francisco das Neves Coelho
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Polyvalent Intensive Care Unit, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, 1349-019 Lisbon, Portugal
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, 4099-002 Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, 4099-002 Porto, Portugal
- Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Rua Central de Gandra, 4585-116 Gandra, Portugal
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Patrícia Marques-Alves
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Graça Castro
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Rui Baptista
- Cardiology Department, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- ICBR—Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3004-561 Coimbra, Portugal
| | - Filipa Ferreira
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
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14
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [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: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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15
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Degering J, Egenlauf B, Harutyunova S, Benjamin N, Salkić A, Xanthouli P, Eichstaedt CA, Seeger R, Sitbon O, Grünig E. Tolerability, safety and survival in patients with severe pulmonary arterial hypertension treated with intravenous epoprostenol (Veletri ®): a prospective, 6-months, open label, observational, non-interventional study. Respir Res 2023; 24:18. [PMID: 36653855 PMCID: PMC9847036 DOI: 10.1186/s12931-022-02296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Epoprostenol AS (Veletri®), a thermostable epoprostenol formulation, provides better drug stability and improved clinical use compared to previous epoprostenol formulations. This study aims to expand clinical experience in the use of Veletri®, especially regarding tolerability, safety and survival. METHODS Pulmonary arterial hypertension (PAH) patients at high risk despite pretreatment with at least double oral combination therapy and with clinical indication for epoprostenol (Veletri®) treatment were consecutively included in this prospective, open label, observational, non-interventional study. Clinical data were assessed at baseline, after 3 and 6 months. Adverse events (AEs) and serious adverse events (SAEs) were documented. Survival from initiation of Veletri® was assessed at last patient out. RESULTS Fifteen patients (60 ± 13.7 years, WHO functional class III (n = 10) or IV (n = 5), severely impaired right ventricular function, mean pulmonary arterial pressure 54.8 ± 8.9 mmHg, mean pulmonary vascular resistance 4.4 ± 0.7 (median 3.8) Wood Units) were enrolled and treated with a mean dosage of 7.9 ± 3.9 (median 7.5) ng/kg/min. Eleven patients completed the study (treatment withdrawal n = 1, death n = 3). After a mean follow-up of 19.1 ± 13.5 (median 18.0) months, seven patients died and three were listed for lung transplantation. Seven AEs (nausea n = 3, diarrhea n = 1, flushing n = 2, headaches n = 1) and three SAEs (catheter infection n = 2, catheter occlusion n = 1) were related to Veletri®. The 1- and 2-year survival rates were 73.3% and 52.4%, respectively. CONCLUSIONS The study showed that safety and tolerability of epoprostenol AS (Veletri®) was comparable to previous prostacyclin formulations and was feasible for most patients. The maximum tolerable dosage was lower than dosages reported in the literature. In future applications/trials the up-titration process should be pushing for higher dosages of epoprostenol in the occurrence of side effects, as the achievement of a high and effective dosage is crucial for the clinical benefit of the patients. Survival was as expected in these prevalent severely impaired patients. Trial registration The study was registered in the EUPAS registry (EUPAS32492).
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Affiliation(s)
- Julia Degering
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany
| | - Benjamin Egenlauf
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Satenik Harutyunova
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Amina Salkić
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Panagiota Xanthouli
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Division of Rheumatology, Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christina A. Eichstaedt
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany ,grid.7700.00000 0001 2190 4373Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Rebekka Seeger
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Olivier Sitbon
- grid.460789.40000 0004 4910 6535Department of Respiratory Diseases, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Ekkehard Grünig
- grid.5253.10000 0001 0328 4908Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstraße 1, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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16
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Sex- and Gender-Related Aspects in Pulmonary Hypertension. Heart Fail Clin 2023; 19:11-24. [DOI: 10.1016/j.hfc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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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: 476] [Impact Index Per Article: 476.0] [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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18
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Bruno RR, Wolff G, Kelm M, Jung C. Pharmacological treatment of cardiogenic shock - A state of the art review. Pharmacol Ther 2022; 240:108230. [PMID: 35697151 DOI: 10.1016/j.pharmthera.2022.108230] [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: 05/13/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.
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Affiliation(s)
- Raphael Romano Bruno
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Georg Wolff
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Duesseldorf, Germany
| | - Christian Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany.
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19
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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: 1121] [Impact Index Per Article: 560.5] [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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20
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Pitre T, Su J, Cui S, Scanlan R, Chiang C, Husnudinov R, Khalid MF, Khan N, Leung G, Mikhail D, Saadat P, Shahid S, Mah J, Mielniczuk L, Zeraatkar D, Mehta S. Medications for the treatment of pulmonary arterial hypertension: a systematic review and network meta-analysis. Eur Respir Rev 2022; 31:31/165/220036. [PMID: 35948391 DOI: 10.1183/16000617.0036-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/30/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND There is no consensus on the most effective treatments of pulmonary arterial hypertension (PAH). Our objective was to compare effects of medications for PAH. METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrials.gov from inception to December 2021. We performed a frequentist random-effects network meta-analysis on all included trials. We rated the certainty of the evidence using the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS We included 53 randomised controlled trials with 10 670 patients. Combination therapy with endothelin receptor antagonist (ERA) plus phosphodiesterase-5 inhibitors (PDE5i) reduced clinical worsening (120.7 fewer events per 1000, 95% CI 136.8-93.4 fewer; high certainty) and was superior to either ERA or PDE5i alone, both of which reduced clinical worsening, as did riociguat monotherapy (all high certainty). PDE5i (24.9 fewer deaths per 1000, 95% CI 35.2 fewer to 2.1 more); intravenous/subcutaneous prostanoids (18.3 fewer deaths per 1000, 95% CI 28.6 fewer deaths to 0) and riociguat (29.1 fewer deaths per 1000, 95% CI 38.6 fewer to 8.7 more) probably reduce mortality as compared to placebo (all moderate certainty). Combination therapy with ERA+PDE5i (49.9 m, 95% CI 25.9-73.8 m) and riociguat (49.5 m, 95% CI 17.3-81.7 m) probably increase 6-min walk distance as compared to placebo (moderate certainty). CONCLUSION Current PAH treatments improve clinically important outcomes, although the degree and certainty of benefit vary between treatments.
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Affiliation(s)
- Tyler Pitre
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Johnny Su
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonya Cui
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ryan Scanlan
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher Chiang
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Renata Husnudinov
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Nadia Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Gareth Leung
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David Mikhail
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Pakeezah Saadat
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Shaneela Shahid
- Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jasmine Mah
- Dept of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Dena Zeraatkar
- Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Harvard Medical School, Harvard University, Boston, MA, USA.,D. Zeraatkar and S. Mehta contributed equally to this article as senior authors and supervised the work
| | - Sanjay Mehta
- Southwest Ontario PH Clinic, Division of Respirology, Dept of Medicine, Lawson Health Research Institute, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada.,PHA Canada, Vancouver, BC, Canada.,D. Zeraatkar and S. Mehta contributed equally to this article as senior authors and supervised the work
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21
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Schoenberg NC, Ruopp NF, Parikh, Farber, HW. Epoprostenol‐Associated Ascites in Pulmonary Arterial Hypertension. Pulm Circ 2022; 12:e12092. [PMID: 35795488 PMCID: PMC9248792 DOI: 10.1002/pul2.12092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/01/2022] [Accepted: 05/03/2022] [Indexed: 11/16/2022] Open
Abstract
The development of ascites in pulmonary arterial hypertension (PAH) in the absence of pre‐existing hepatic dysfunction is usually associated with decompensated right heart failure or cardiac cirrhosis. Ascites in PAH has rarely been associated with intravenous epoprostenol, a synthetic form of the prostaglandin PGI2.
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Affiliation(s)
| | | | - Parikh
- Hartford Healthcare Medical Group Hartford CT
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22
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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23
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Nekoukar Z, Moghimi M, Salehifar E. A narrative review on adverse effects of dasatinib with a focus on pharmacotherapy of dasatinib-induced pulmonary toxicities. Blood Res 2021; 56:229-242. [PMID: 34776414 PMCID: PMC8721448 DOI: 10.5045/br.2021.2021117] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/15/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic myeloid leukemia (CML), a myeloproliferative disorder caused by the over activity of BCR-ABL1 (breakpoint cluster region-Abelson), has been successfully treated by Tyrosine kinase inhibitors (TKIs). While imatinib is known as the first-line treatment of CML, in some cases other TKIs including dasatinib, nilotinib, bosutinib, and ponatinib may be preferred. Dasatinib, a second-generation TKI, inhibits multiple family kinases including BCR-ABL, SRC family kinases, receptor kinases, and TEC family kinases. It is effective against most imatinib-resistant cases except T315I mutation. Despite the superiority of dasatinib in its hematologic and cytogenetic responses in CML compared to imatinib, its potentially harmful pulmonary complications including pleural effusion (PE) and pulmonary arterial hypertension (PAH) may limit its use. Appropriate management of these serious adverse reactions is critical in both improving the quality of life and the outcome of the patient. In this narrative review, we will scrutinize the pulmonary complications of dasatinib and focus on the management of these toxicities.
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Affiliation(s)
- Zahra Nekoukar
- Department of Clinical Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Minoo Moghimi
- Department of Clinical Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Salehifar
- Pharmaceutical Sciences Research Center, Hemoglobinopathy Institute, Department of Clinical Pharmacy, Mazandaran University of Medial Scienses, Sari, Iran
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24
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Ewert R, Habedank D, Halank M, Stubbe B, Opitz CF. Strategies for optimizing intravenous prostacyclin-analog therapy in patients with pulmonary arterial hypertension. Expert Rev Respir Med 2021; 16:57-66. [PMID: 34846985 DOI: 10.1080/17476348.2022.2011220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Intravenous prostacyclin-analogs (PCA, e.g. epoprostenol, treprostinil, iloprost) have become an essential part in the therapy of patients with pulmonary hypertension (PH), mainly pulmonary arterial hypertension (PAH). They show considerable differences in pharmacology. A combination therapy including intravenous drugs is regarded as the 'gold standard' in most of PAH patients. AREAS COVERED This review discusses and summarizes the studies and concepts on which this therapy is based. To date, intravenous prostacyclin-analogs are mainly administered when standard therapy fails to improve patients to low-risk status. However, preliminary data from uncontrolled studies suggest that an 'upfront triple' therapy including intravenous or subcutaneous prostacyclin-analogs could be preferable in selected patients. EXPERT OPINION Various IV PCA have been evaluated in the treatment of patients with PAH. Today, combination therapy is the 'gold standard' for the majority of patients. Intravenous PCA is recommended from functional class III onwards. Timing of its initiation is still a point of discussion. An escalation of therapy to IV or SC PCA is always necessary if a low-risk status cannot be achieved with other targeted therapies. Preliminary data suggest that selected patients could benefit from an 'upfront triple' therapy. Controlled studies on which such recommendation could be based are lacking.
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Affiliation(s)
- Ralf Ewert
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
| | - Dirk Habedank
- Internal Medicine, Cardiology, DRK Kliniken Berlin, Berlin, Germany
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Beate Stubbe
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
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25
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Abstract
Pulmonary arterial hypertension is characterized by obliteration and obstruction of the pulmonary arterioles that in turn results in high right ventricular afterload and right heart failure. The pathobiology of pulmonary arterial hypertension is complex, with contributions from multiple pathophysiologic processes that are regulated by a variety of molecular mechanisms. This nature likely explains the limited efficacy of our current therapies, which only target a small portion of the pathobiological mechanisms that underlie advanced disease. Here we review the pathobiology of pulmonary arterial hypertension, focusing on the systemic, cellular, and molecular mechanisms that underlie the disease.
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Affiliation(s)
- Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Room 128A Hanes House, 330 Trent Drive, Durham, NC 27710, USA.
| | - Yen-Rei A Yu
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, 12605 E. 16th Avenue, Aurora, CO 80045, USA
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26
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Abstract
It is important for both the patient and physician communities to have timely access to information recognizing rapid progress in the diagnosis and treatment of familiar but relatively uncommon cardiovascular diseases. Patients with 3 cardiovascular diseases (ie, hypertrophic cardiomyopathy, pulmonary arterial hypertension, and transthyretin (TTR) cardiac amyloidosis (ATTR)]), once considered rare without effective management options and associated with malignant prognosis, have now benefited substantially from the development of a variety of innovative therapeutic strategies. In addition, in each case, enhanced diagnostic testing has expanded the patient population and allowed for more widespread administration of contemporary treatments. In hypertrophic cardiomyopathy, introduction of implantable defibrillators to prevent sudden death as well as high-benefit:low-risk septal reduction therapies to reverse heart failure have substantially reduced morbidity and disease-related mortality (to 0.5% per year). For pulmonary arterial hypertension, a disease once characterized by a particularly grim prognosis, prospective randomized drug trials with aggressive single (or combined) pharmacotherapy have measurably improved survival and quality of life for many patients. In cardiac amyloidosis, development of disease-specific drugs can for the first time reduce morbidity and mortality, prominently with breakthrough ATTR-protein-stabilizing tafamidis. In conclusion, in less common and visible cardiovascular diseases, it is crucial to recognize substantial progress and achievement, given that penetration of such information into clinical practice and the patient community can be inconsistent. Diseases such as hypertrophic cardiomyopathy, pulmonary arterial hypertension, and ATTR cardiac amyloidosis, once linked to a uniformly adverse prognosis, are now associated with the opportunity for patients to experience satisfactory quality of life and extended longevity.
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Affiliation(s)
- Barry J. Maron
- Division of CardiologyHCM InstituteTufts Medical CenterBostonMA
| | - Martin S. Maron
- Division of CardiologyHCM InstituteTufts Medical CenterBostonMA
| | - Mathew S. Maurer
- Cardiac Amyloidosis CenterColumbia University Irving Medical CenterNew York–Presbyterian HospitalNew YorkNY
| | - Ethan J. Rowin
- Division of CardiologyHCM InstituteTufts Medical CenterBostonMA
| | - Bradley A. Maron
- Division of Cardiovascular MedicineBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
| | - Nazzareno Galiè
- Alma Mater Studiorum University of BolognaBolognaItaly
- S. Orsola University HospitalBolognaItaly
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27
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Maximal Exercise Testing Using the Incremental Shuttle Walking Test Can Be Used to Risk-Stratify Patients with Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2021; 18:34-43. [PMID: 32926635 PMCID: PMC7780966 DOI: 10.1513/annalsats.202005-423oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rationale: Exercise capacity predicts mortality in pulmonary arterial hypertension (PAH), but limited data exist on the routine use of maximal exercise testing. Objectives: This study evaluates a simple-to-perform maximal test (the incremental shuttle walking test) and its use in risk stratification in PAH. Methods: Consecutive patients with pulmonary hypertension were identified from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) registry (2001–2018). Thresholds for levels of risk were identified at baseline and tested at follow-up, and their incorporation into current risk stratification approaches was assessed. Results: Of 4,524 treatment-naive patients with pulmonary hypertension who underwent maximal exercise testing, 1,847 patients had PAH. A stepwise reduction in 1-year mortality was seen between levels 1 (≤30 m; 32% mortality) and 7 (340–420 m; 1% mortality) with no mortality for levels 8–12 (≥430 m) in idiopathic and connective tissue disease–related PAH. Thresholds derived at baseline of ≤180 m (>10%; high risk), 190–330 m (5–10%; intermediate risk), and ≥340 m (<5%; low risk of 1-yr mortality) were applied at follow-up and also accurately identified levels of risk. Thresholds were incorporated into the REVEAL (Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management) 2.0 risk score calculator and French low-risk approach to risk stratification, and distinct categories of risk remained. Conclusions: We have demonstrated that maximal exercise testing in PAH stratifies mortality risk at baseline and follow-up. This study highlights the potential value of the incremental shuttle walking test as an alternative to the 6-minute walking test, combining some of the advantages of maximal exercise testing and maintaining the simplicity of a simple-to-perform field test.
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Zhang W, Sun Q, Chen B, Basta M, Xu C, Li Y. Insomnia symptoms are associated with metabolic syndrome in patients with severe psychiatric disorders. Sleep Med 2021; 83:168-174. [PMID: 34022493 DOI: 10.1016/j.sleep.2021.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/17/2021] [Accepted: 03/26/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To examine the relationship between insomnia symptoms and metabolic syndrome in patients with severe psychiatric disorders. METHODS We conducted a cross-sectional study including 272 inpatients (mean age: 34.06 ± 11.52 years, 67.3% males) with severe psychiatric disorders consecutively admitted in Shantou University Mental Health Center Inpatient Department. All patients underwent a psychiatric evaluation. Insomnia symptoms were assessed by the Pittsburgh Sleep Quality Index (PSQI) and defined present if PSQI>7. The diagnosis of metabolic syndrome was defined using the new International Diabetes Federation definition based on clinical and laboratory evaluation. RESULTS Among the 272 patients, 94 (34.6%) presented insomnia symptoms. Overall, patients with insomnia symptoms had significantly higher percentage of metabolic syndrome (23.4% vs. 12.4%, p = 0.019) and hypertriglyceridemia (30.9% vs. 19.1%, p = 0.029), and marginally significantly higher levels of fasting insulin (58.75 ± 37.22 pmol/L vs. 51.72 ± 34.09 pmol/L, p = 0.050), homeostasis model assessment of insulin resistance (1.83 ± 1.31 vs. 1.62 ± 1.25, p = 0.055) and percentage of insulin resistance (55.3% vs. 44.4%, p = 0.086) compared to those without insomnia symptoms. Multiple logistic regressions showed that patients with insomnia symptoms had significantly higher odds for metabolic syndrome [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.25-7.14], central obesity (OR = 3.02, 95% CI = 1.18-7.76), hypertriglyceridemia (OR = 2.46, 95% CI = 1.28-4.76) and marginally significantly higher odds for insulin resistance (OR = 1.68, 95% CI = 0.93-3.02) after controlling for potential confounders. CONCLUSIONS Within severely mentally ill patients, insomnia symptoms are associated with metabolic syndrome and insulin resistance. It appears that insomnia symptoms are independent clinical indicators of underlying metabolic syndrome in patients with severe psychiatric disorders.
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Affiliation(s)
- Wenjuan Zhang
- Department of Sleep Medicine, Shantou University Mental Health Center, Shantou, Guangdong, China; Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China
| | - Qimeng Sun
- Department of Sleep Medicine, Shantou University Mental Health Center, Shantou, Guangdong, China; Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China
| | - Baixin Chen
- Department of Sleep Medicine, Shantou University Mental Health Center, Shantou, Guangdong, China; Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China
| | - Maria Basta
- Department of Psychiatry, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Chongtao Xu
- Department of Sleep Medicine, Shantou University Mental Health Center, Shantou, Guangdong, China; Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China
| | - Yun Li
- Department of Sleep Medicine, Shantou University Mental Health Center, Shantou, Guangdong, China; Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China.
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Vlachou M, Fayed H, Dawson A, Reddecliffe S, Stevenson A, Thomson RJ, Schreiber BE, Coghlan JG. Intravenous prostanoids in systemic sclerosis-associated pulmonary arterial hypertension: a single centre experience. Rheumatology (Oxford) 2021; 61:1106-1114. [PMID: 34142120 DOI: 10.1093/rheumatology/keab478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/25/2021] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES The current study evaluates survival rates among Systemic Sclerosis-associated Pulmonary Arterial Hypertension (SSc-PAH) patients on intravenous (IV) prostanoids, and short-term impact of IV prostanoids on clinical and haemodynamic parameters. METHODS Baseline demographics, invasive and non-invasive data, ESC (European Society of Cardiology) score and REVEAL score of 81 SSc-PAH patients (median age 61 years, interquartile range 54-67 years, 84% females) were prospectively recorded, from November 2006 till November 2020, before initiation of IV prostanoids, and at first formal reassessment. Survival data were retrieved from National Health Service Spine and hospital databases. RESULTS Significant improvements in clinical and haemodynamic parameters in response to IV prostanoid therapy were documented. Functional class (FC) (16.6% improved by 1FC, p = 0.041), mean pulmonary arterial pressure (-6.5mmHg, p = 0.036), pulmonary vascular resistance (PVR) (-2.6 WU, p = 0.012), cardiac index (CI) (+0.7l/min/m2, p = 0.003) and mixed venous oxygen saturation (SvO2) (+3%, p = 0.036), improved. Estimated survival for CTD-PAH patients on IV prostanoids was 64%, 31%, and 18%, at 1-year, 3-years, and 5-years, respectively. Independent baseline predictors of mortality were older age (HR:1.043, 95% CI: 1.011-1.075, p = 0.007), higher N-terminal pro-brain natriuretic peptide levels (HR:2.191, 95% CI: 1.131-4.243, p = 0.020), and lower SvO2 levels (HR:0.962, 95% CI:0.926-0.998, p = 0.039). High ESC risk or high and very high REVEAL score was associated with significantly worse survival compared to patients with lower risk scores, both at baseline and when reassessed after a median of 6.5 months. CONCLUSIONS Survival among SSc-PAH patients on IV prostanoids remains poor, risk scoring at baseline and after 6.5-months therapy improves prognostication.
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Affiliation(s)
- Maria Vlachou
- National Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | - Hossam Fayed
- National Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | - Adele Dawson
- National Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | - Sally Reddecliffe
- National Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | | | - Ross J Thomson
- Department of Cardiology, Royal Free Hospital, London, UK.,William Harvey Research Institute, Queen Mary, University of London, UK
| | | | - J Gerry Coghlan
- National Pulmonary Hypertension Unit, Royal Free Hospital, London, UK.,Department of Cardiology, Royal Free Hospital, London, UK
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Cristo Ropero MJ, Cruz-Utrilla A, Escribano-Subias MP. Epoprostenol for the treatment of pulmonary arterial hypertension. Expert Rev Clin Pharmacol 2021; 14:1005-1013. [PMID: 34030557 DOI: 10.1080/17512433.2021.1929925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Pulmonary arterial hypertension (PAH) is a rare, progressive, and severe disease. Since the first demonstration of survival benefit of intravenous epoprostenol in monotherapy in 1996, prostanoids remain the cornerstone for PAH patients at high risk. This review is essential to understand the current situation of this drug among all the therapeutic possibilities concerning this entity.Areas covered: The aim of this article is to review the pharmacological properties of epoprostenol and to update its clinical evidence in different specific clinical scenarios. A deep literature search was carried out on the MEDLINE database for published literature before March 2021.Expert opinion: Epoprostenol is still the best treatment option for high-risk PAH patients. Nevertheless, there are many unsolved questions: drug dosing, its use in combination therapy with other pulmonary vasodilators, and the utility in PAH associated with connective tissue disease, congenital heart disease, or pulmonary veno-occlusive disease are only a few examples. Its safety and efficacy are supported by clinical trials, observational work, and experience, both as monotherapy and in combination therapy. Epoprostenol should be considered a destination treatment in high-risk patients and not only as a bridge to pulmonary transplantation. However, it remains underused in clinical practice.
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Affiliation(s)
- María José Cristo Ropero
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 De Octubre, Madrid, Spain
| | - Alejandro Cruz-Utrilla
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 De Octubre, Madrid, Spain
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Stubbe B, Opitz CF, Halank M, Habedank D, Ewert R. Intravenous prostacyclin-analogue therapy in pulmonary arterial hypertension - A review of the past, present and future. Respir Med 2021; 179:106336. [PMID: 33647836 DOI: 10.1016/j.rmed.2021.106336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
Therapy with intravenous prostacyclin analogues in patients with pulmonary arterial hypertension (PAH) has been established for decades and is an integral component of the current guidelines for the treatment of pulmonary hypertension. Initially, these drugs were infused by external pump systems via tunnelled right atrial catheters with the need for cooling and frequent exchange of drug reservoirs. Associated complications included, among others, catheter-related infections. More recently, fully implantable pump systems have been developed with drug reservoirs that are filled transcutaneously, allowing intervals between refills of several weeks. This technique results in a low rate of infections. Epoprostenol, iloprost and treprostinil have all been used intravenously in PAH, but titration, dosing and dose escalation in long-term therapy are not standardized. Intravenous prostacyclin analogues are still under-used, despite available data suggesting that early and broad application of these therapies as part of risk-oriented, guideline-directed combination therapy for patients with PAH may lead to a survival benefit. This review provides a detailed overview of the drugs, infusion systems and dosing strategies used for intravenous therapy in patients with PAH.
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Affiliation(s)
- Beate Stubbe
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany.
| | - Christian F Opitz
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden, Germany
| | - Dirk Habedank
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
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Palliative Care in Pulmonary Arterial Hypertension. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Genecand L, Wacker J, Beghetti M, Lador F. Selexipag for the treatment of pulmonary arterial hypertension. Expert Rev Respir Med 2020; 15:583-595. [PMID: 33382345 DOI: 10.1080/17476348.2021.1866990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION : Pulmonary arterial hypertension (PAH) is a rare pulmonary vasculopathy. This review focuses on selexipag, a prostacyclin receptor agonist validated for the treatment of PAH. AREAS COVERED We review the structure, mechanisms of action, pharmacokinetics, and pharmacodynamics of selexipag. Clinical efficacy and tolerability are discussed using the main clinical trial published for selexipag (GRIPHON) and its post-hoc analysis. EXPERT OPINION Selexipag should be added as a triple oral combination therapy in case of insufficient response to oral combination therapy with endothelin receptor antagonist and phosphodiesterase 5 inhibitor. However, selexipag should not replace parenteral prostacyclin in high-risk patients.
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Affiliation(s)
- Léon Genecand
- Internal Medicine Department,Riviera Chablais Hospital, Rennaz, Switzerland.,Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland
| | - Julie Wacker
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Paediatric Cardiology Unit, University Hospitals of Geneva, Switzerland; Centre Universitaire Romand De Cardiologie Et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Switzerland
| | - Maurice Beghetti
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Paediatric Cardiology Unit, University Hospitals of Geneva, Switzerland; Centre Universitaire Romand De Cardiologie Et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine Specialties, Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
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Abstract
Purpose of Review This review focuses on the therapeutic management and individualized approach to Group 1 pulmonary arterial hypertension (PAH), utilizing Food and Drug Administration-approved PAH-specific therapies and various interventional and surgical options for PAH. Recent Findings The paradigm for the optimal management of PAH has shifted in recent years. Upfront combination therapy with an endothelin receptor antagonist and a phosphodiesterase 5 inhibitor is now widely accepted as standard of care. In addition, there is increasing emphasis on starting prostanoids early in order to delay time to clinical worsening. However, less is known regarding which prostanoid agent to initiate and the optimum time to do so. In order to facilitate shared decision-making, there is an increasing need for decision tools based on guidelines and collective clinical experiences to navigate between pharmacologic and interventional treatments, as well as explore innovative, therapeutic pathways for PAH. Summary The management of PAH has become increasingly complex. With a growing number of PAH-specific therapies, intimate knowledge of the therapeutics and the potential barriers to adherence are integral to providing optimal care for this high-risk patient population. While current PAH-specific therapies largely mediate their effects through pulmonary vasodilation, ongoing research efforts are focused on ways to disrupt the mechanisms leading to pulmonary vascular remodeling. By targeting aberrations identified in the metabolism and proliferative state of pulmonary vascular cells, novel PAH treatment pathways may be just on the horizon.
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Bisserier M, Pradhan N, Hadri L. Current and emerging therapeutic approaches to pulmonary hypertension. Rev Cardiovasc Med 2020; 21:163-179. [PMID: 32706206 PMCID: PMC7389678 DOI: 10.31083/j.rcm.2020.02.597] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/25/2020] [Indexed: 12/15/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and fatal lung disease of multifactorial etiology. Most of the available drugs and FDA-approved therapies for treating pulmonary hypertension attempt to overcome the imbalance between vasoactive and vasodilator mediators, and restore the endothelial cell function. Traditional medications for treating PAH include the prostacyclin analogs and receptor agonists, phosphodiesterase 5 inhibitors, endothelin-receptor antagonists, and cGMP activators. While the current FDA-approved drugs showed improvements in quality of life and hemodynamic parameters, they have shown only very limited beneficial effects on survival and disease progression. None of them offers a cure against PAH, and the median survival rate remains less than three years from diagnosis. Extensive research efforts have led to the emergence of innovative therapeutic approaches in the area of PAH. In this review, we provide an overview of the current FDA-approved therapies in PAH and discuss the associated clinical trials and reported-side effects. As recent studies have led to the emergence of innovative therapeutic approaches in the area of PAH, we also focus on the latest promising therapies in preclinical studies such as stem cell-based therapies, gene transfer, and epigenetic therapies.
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Affiliation(s)
- Malik Bisserier
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Natasha Pradhan
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Lahouaria Hadri
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Treiber A, Delahaye S, Seeland S, Gnerre C. The endothelin receptor antagonist macitentan for the treatment of pulmonary arterial hypertension: A cross-species comparison of its cytochrome P450 induction pattern. Pharmacol Res Perspect 2020; 8:e00619. [PMID: 32613761 PMCID: PMC7330163 DOI: 10.1002/prp2.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/18/2022] Open
Abstract
The dual endothelin receptor antagonist macitentan was approved in 2013 for the treatment of pulmonary arterial hypertension. Macitentan is an inducer of cytochrome P450 expression in vivo in animal species but not in man. In rat and dog, changes in P450 expression manifest as autoinduction upon repeat dosing. The induction pattern, however, significantly differed between both species, and between male and female rats. While macitentan exposure steadily declined with dose in the dog, P450 induction was saturable in the rat reaching levels of 40%-60% and 60%-80% at steady-state in male and female animals, respectively. The nature and number of P450 enzymes involved in macitentan clearance were identified as a major reason for the observed species differences. In the dog, macitentan was metabolized by a single P450 enzyme, that is, Cyp3a12, whereas several members of the Cyp2c and Cyp3a families were involved in the rat. Macitentan selectively upregulated Cyp3a expression in rat, whereas the expression of the Cyp2c enzymes involved in macitentan metabolism remained mostly unchanged, eventually leading to a higher contribution of Cyp3a upon induction. Macitentan also induced CYP3A4 expression in human hepatocytes via initial activation of the human pregnane X receptor. No such induction was evident in humans at the therapeutic macitentan dose of 10 mg as shown in a clinical drug-drug interaction study with the CYP3A4 substrate sildenafil.
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Affiliation(s)
- Alexander Treiber
- Department of Non‐Clinical Drug Metabolism and PharmacokineticsIdorsia Pharmaceuticals LtdAllschwilSwitzerland
| | - Stephane Delahaye
- Department of Non‐Clinical Drug Metabolism and PharmacokineticsIdorsia Pharmaceuticals LtdAllschwilSwitzerland
| | - Swen Seeland
- Department of Non‐Clinical Drug Metabolism and PharmacokineticsIdorsia Pharmaceuticals LtdAllschwilSwitzerland
| | - Carmela Gnerre
- Department of Non‐Clinical Drug Metabolism and PharmacokineticsIdorsia Pharmaceuticals LtdAllschwilSwitzerland
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Schlueter M, Beaudet A, Davies E, Gurung B, Karabis A. Evidence synthesis in pulmonary arterial hypertension: a systematic review and critical appraisal. BMC Pulm Med 2020; 20:202. [PMID: 32723397 PMCID: PMC7388228 DOI: 10.1186/s12890-020-01241-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The clinical landscape of pulmonary arterial hypertension (PAH) has evolved in terms of disease definition and classification, trial designs, available therapies and treatment strategies as well as clinical guidelines. This study critically appraises published evidence synthesis studies, i.e. meta-analyses (MA) and network-meta-analyses (NMA), to better understand their quality, validity and discuss the impact of the findings from these studies on current decision-making in PAH. METHODS A systematic literature review to identify MA/NMA studies considering approved and available therapies for treatment of PAH was conducted. Embase, Medline and the Cochrane's Database of Systematic Reviews were searched from database inception to April 22, 2020, supplemented by searches in health technology assessment websites. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) checklist covering six domains (relevance, credibility, analysis, reporting quality and transparency, interpretation and conflict of interest) was selected for appraisal of the included MA/NMA studies. RESULTS Fifty-two full publications (36 MAs, 15 NMAs, and 1 MA/NMA) in PAH met the inclusion criteria. The majority of studies were of low quality, with none of the studies being scored as 'strong' across all checklist domains. Key limitations included the lack of a clearly defined, relevant decision problem, shortcomings in assessing and addressing between-study heterogeneity, and an incomplete or misleading interpretation of results. CONCLUSIONS This is the first critical appraisal of published MA/NMA studies in PAH, suggesting low quality and validity of published evidence synthesis studies in this therapeutic area. Besides the need for direct treatment comparisons assessed in long-term randomized controlled trials, future efforts in evidence synthesis in PAH should improve analysis quality and scrutiny in order to meaningfully address challenges arising from an evolving therapeutic landscape.
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Affiliation(s)
| | - Amélie Beaudet
- Actelion Pharmaceuticals Ltd, Gewerbestrasse 16, CH-4123, Allschwil, Switzerland
| | - Evan Davies
- Actelion Pharmaceuticals Ltd, Gewerbestrasse 16, CH-4123, Allschwil, Switzerland
| | - Binu Gurung
- IQVIA, 210 Pentonville Road, London, N1 9JY, UK
| | - Andreas Karabis
- IQVIA, Herikerbergweg 314, 1101 CT, Amsterdam, Netherlands
- Department of Statistical Science, University College London, London, WC1E 6BT, UK
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Zolty R. Pulmonary arterial hypertension specific therapy: The old and the new. Pharmacol Ther 2020; 214:107576. [PMID: 32417272 DOI: 10.1016/j.pharmthera.2020.107576] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a vascular disorder associated with high morbidity and mortality rate and is characterized by pulmonary vascular remodeling and increased pulmonary vascular resistance, ultimately resulting in right ventricular failure and death. Over the past few decades, significant advances in the understanding of the epidemiology, pathogenesis, and pathophysiology of pulmonary arterial hypertension have occured. This has led to the development of disease specific treatment including prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators. These therapies significantly improve exercise capacity, quality of life, pulmonary hemodynamics, but none of the current treatments are actually curative and long-term prognosis remains poor. Thus, there is a clear need to develop new therapies. Several potential pharmacologic agents for the treatment of pulmonary arterial hypertension are under clinical development and some promising results with these treatments have been reported. These agents include tyrosine protein kinase inhibitors, rho-kinase inhibitors, synthetically produced vasoactive intestinal peptide, antagonists of the 5-HT2 receptors, and others. This article will review several of these promising new therapies and will discuss the current evidence regarding their potential benefit in pulmonary arterial hypertension.
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Affiliation(s)
- Ronald Zolty
- Cardiovascular Divisions, 982265 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE 68198, United States of America.
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Arvind B, Relan J, Kothari SS. "Treat and repair" strategy for shunt lesions: a critical review. Pulm Circ 2020; 10:2045894020917885. [PMID: 32313642 DOI: 10.1177/2045894020917885] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/18/2020] [Indexed: 11/15/2022] Open
Abstract
The issue of operability in patients with shunt lesions and raised pulmonary vascular resistance is contentious. Several reports suggest that patients traditionally considered inoperable may be operated after treatment with targeted drug therapy for pulmonary arterial hypertension. We reviewed all the published literature of "treat and repair" approach to gain more insights into the utility of this approach. A critical appraisal of the published literature suggests that this approach is less established for patients with post tricuspid shunts, and for patients with pre-tricuspid shunts with modestly elevated indexed pulmonary vascular resistance (possibly greater than 11 WU.m2). Targeted drug therapy may be able to extend the therapeutic window in carefully selected patients, but its use as a routine in this setting seems unwarranted.
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Affiliation(s)
- Balaji Arvind
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Jay Relan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam S Kothari
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Christiansen D, Porter S, Hurlburt L, Weiss A, Granton J, Wentlandt K. Pulmonary Arterial Hypertension: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions. J Pain Symptom Manage 2020; 59:932-943. [PMID: 31805363 DOI: 10.1016/j.jpainsymman.2019.11.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 01/13/2023]
Abstract
Pulmonary arterial hypertension (PAH) is often a progressive and ultimately fatal disease. It is characterized by an elevated mean pulmonary arterial pressure because of disease of the small pulmonary arterioles. PAH leads to a constellation of symptoms, including dyspnea, fatigue, syncope, chest discomfort, and peripheral edema. Disease-targeted therapies for PAH produce symptomatic and functional improvement, but long-term survival remains uncommon without lung transplantation. Palliative care is appropriate to support patients with advanced PAH who typically have a high symptom burden. However, palliative care has historically focused on supporting patients with malignant disease, rather than progressive chronic disease such as PAH. Our aim is to provide palliative care clinicians with a background in the classification, pathophysiology, and modern treatment of PAH. This review describes disease-targeted therapies and their effects on symptoms, physical functioning, and health-related quality of life. We also review the unique physiology of PAH and its implication for palliative interventions. Pharmacological interactions with, and precautions related to commonly used palliative care medications, are discussed.
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Affiliation(s)
- David Christiansen
- Department of Internal Medicine, Section of Respiratory Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra Porter
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Lindsay Hurlburt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology, Department of Medicine, University Health Network, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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Jandhyala R. Influence of Pharmaceutical Company Engagement Activities on the Decision to Prescribe: A Pilot Survey of UK Rare Disease Medicine Prescribers. Pharmaceut Med 2020; 34:127-134. [PMID: 32048216 DOI: 10.1007/s40290-019-00323-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Traditionally, the pharmaceutical industry has used 'promotional personal engagement' activities, which involve interactions between sales forces and prescribers, in order to generate 'sales'-or prescriptions-of their new medicinal product(s). There appears to be now a favouring of 'non-personal engagement' (external information sources or activities existing outside the direct control of the company) and 'non-promotional personal engagement' activities (focused around creating peer-to-peer relationships between prescribers and pharmaceutical physicians). OBJECTIVES The purpose of this study was to examine the influence of non-personal engagement and non-promotional personal engagement activities on the prescribing habits of British healthcare professionals, using the traditional promotional personal engagement activities as a comparator. METHODS A questionnaire was distributed to 122 prescribers (physicians, nurses and pharmacists) working with two selected products for pulmonary arterial hypertension. The participants were asked to rate the influence that the listed activities had on their decision to prescribe each of the two products using a scale of 0-10, where 0 = 'no influence' and 10 = 'most important influence'. RESULTS Of the 122 targeted healthcare professionals who received the questionnaire, 34 (27.9%) responded within the 2-week time limit (24 physicians, 5 nurse prescribers and 5 pharmacists). The findings of the survey had a confidence level of 90% and a margin of error of 12%, given that 34 of 122 people responded. All proposed activities were scored by the respondents as having some influence on their prescribing. Personal engagement activities are effective for influencing prescribing, but non-promotional personal engagement activities may be more influential than promotional personal engagement activities. Furthermore, non-personal engagement activities may be more effective in influencing prescriptions of a product than either non-promotional or promotional personal engagement activities. CONCLUSIONS All personal engagement activities affect HCP prescribing behaviours; however, they appear to be more influential when performed on a non-promotional basis by representatives of the company's medical department.
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Affiliation(s)
- Ravi Jandhyala
- University of Leicester Business School, Leicester, UK.
- Medialis Limited, 13 Horse Fair, Banbury, Oxfordshire, OX16 0AH, UK.
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Picken C, Laing P, Shen L, Clapp LH, Brocchini S. Synthetic routes to treprostinil N-acyl methylsulfonamide. Tetrahedron Lett 2020. [DOI: 10.1016/j.tetlet.2019.151428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Meyer AS, Johansson PI, Kjaergaard J, Frydland M, Meyer MA, Henriksen HH, Thomsen JH, Wiberg SC, Hassager C, Ostrowski SR. "Endothelial Dysfunction in Resuscitated Cardiac Arrest (ENDO-RCA): Safety and efficacy of low-dose Iloprost, a prostacyclin analogue, in addition to standard therapy, as compared to standard therapy alone, in post-cardiac-arrest-syndrome patients.". Am Heart J 2020; 219:9-20. [PMID: 31710844 DOI: 10.1016/j.ahj.2019.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/06/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE An increasingly recognized prognostic factor for out-of-hospital-cardiac-arrest (OHCA) patients is the ischemia-reperfusion injury after restored blood circulation. Endothelial injury is common in patients resuscitated from cardiac arrest and is associated with poor outcome. This study was designed to investigate if iloprost infusion, a prostacyclin analogue, reduces endothelial damage in OHCA patients. METHODS 50 patients were randomized in a placebo controlled double-blinded trial and allocated 1:2 to 48-hours iloprost infusion, (1 ng/kg/min) or placebo (saline infusion). Endothelial biomarkers (soluble thrombomodulin (sTM), sE-selectin, syndecan-1, soluble vascular endothelial growth factor (sVEGF), vascular endothelial cadherine (VEcad), nucleosomes) and sympathoadrenal activation (epinephrine/norepinephrine) from baseline to 48 and 96-hours were evaluated. RESULTS Iloprost infusion did not influence endothelial biomarkers by the 48-hour endpoint. A rebound effect was observed with higher biomarker plasma values in the iloprost group (sTM p=0.02; Syndecan p=0.004; nucleosomes p<0.001; VEcad p<0.03) after 96-hours. There was a significant difference in 180-day mortality in favor of placebo. There was no difference regarding total adverse events between groups (p=0.73). Two patients were withdrawn in the iloprost group due to hypotension. CONCLUSIONS The administration of low-dose iloprost (1ng/kg/min) to OHCA patients did not significantly influence endothelial biomarkers as measured by the 48- hour endpoint. A rebound effect was however observed in the 96-hour statistical model, with increasing endothelial biomarker levels after cessation of the iloprost-infusion.
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Petrovič M, Locatelli I. Comparative effectiveness of pulmonary arterial hypertension drugs in treatment-naive patients: a network meta-analysis. J Comp Eff Res 2019; 9:7-22. [PMID: 31845591 DOI: 10.2217/cer-2019-0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: No network meta-analysis has been conducted to study efficacy of drug therapies specific for treatment of pulmonary arterial hypertension in treatment-naive patients only. Methods: Randomized controlled trials on pulmonary arterial hypertension-specific drug therapies were searched and a Bayesian network meta-analysis was performed. The 6-min walking distance (6MWD) and all-cause mortality were efficacy outcomes, whereas discontinuation due to adverse events was a safety-related outcome. Results: Analysis included 3.713 patients from 21 trials. Combination of ambrisentan and tadalafil showed the greatest impact on 6MWD, followed by epoprostenol and intravenous treprostinil (high dose). The latter two demonstrated marked effect size on mortality, although not statistically significant. Conclusion: According to 6MWD, ambrisentan/tadalafil combination was considered as most effective among all comparisons. Prospero ID: CRD42019110832.
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Affiliation(s)
- Maja Petrovič
- Krka, d. d., Novo mesto, Šmarješka c. 6, 8501 Novo mesto, Slovenia.,University of Ljubljana, Faculty of Pharmacy, Department of Social Pharmacy, Aškerčeva c. 7, 1000 Ljubljana, Slovenia
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Department of Social Pharmacy, Aškerčeva c. 7, 1000 Ljubljana, Slovenia
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Argula RG, Ward C, Feghali-Bostwick C. Therapeutic Challenges And Advances In The Management Of Systemic Sclerosis-Related Pulmonary Arterial Hypertension (SSc-PAH). Ther Clin Risk Manag 2019; 15:1427-1442. [PMID: 31853179 PMCID: PMC6916691 DOI: 10.2147/tcrm.s219024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disorder with multi-organ involvement. SSc-associated pulmonary arterial hypertension (SSc-PAH) is one of the leading causes of morbidity and mortality in the SSc population. With advances in our understanding of pulmonary arterial hypertension (PAH) diagnosis and treatment, outcomes for all PAH patients have significantly improved. While SSc-PAH patients have also benefited from these advances, significant challenges remain. Diagnosis of PAH is a challenging endeavor in SSc patients who often have many co-existing pulmonary and cardiac comorbidities. Given the significantly elevated prevalence and lifetime risk of PAH in the SSc population, screening for SSc-PAH is a critically useful strategy. Treatment with pulmonary arterial (PA) vasodilators has resulted in a dramatic improvement in the survival and quality of life of PAH patients. While therapy with PA vasodilators is beneficial in SSc-PAH patients, therapy effects appear to be attenuated when compared to responses in patients with idiopathic PAH (IPAH). This review attempts to chronicle and summarize the advances in our understanding of the optimal screening strategies to identify PAH in patients with SSc. The article also reviews the advances in the therapeutic and risk stratification strategies for SSc-PAH patients.
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Affiliation(s)
- Rahul G Argula
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Celine Ward
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
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Ntiloudi D, Qanud K, Tomaio JN, Giannakoulas G, Al-Abed Y, Zanos S. Pulmonary arterial hypertension: the case for a bioelectronic treatment. Bioelectron Med 2019; 5:20. [PMID: 32232109 PMCID: PMC7098229 DOI: 10.1186/s42234-019-0036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease of unknown etiology that progresses to right ventricular failure. It has a complex pathophysiology, which involves an imbalance between vasoconstrictive and vasodilative processes in the pulmonary circulation, pulmonary vasoconstriction, vascular and right ventricular remodeling, systemic inflammation, and autonomic imbalance, with a reduced parasympathetic and increased sympathetic tone. Current pharmacological treatments for PAH include several classes of drugs that target signaling pathways in vascular biology and cardiovascular physiology, but they can have severe unwanted effects and they do not typically stop the progression of the disease. Pulmonary artery denervation has been tested clinically as a method to suppress sympathetic overactivation, however it is a nonspecific and irreversible intervention. Bioelectronic medicine, in particular vagus nerve stimulation (VNS), has been used in cardiovascular disorders like arrhythmias, heart failure and arterial hypertension and could, in principle, be tested as a treatment in PAH. VNS can produce pulmonary vasodilation and renormalize right ventricular function, via activation of pulmonary and cardiac vagal fibers. It can suppress systemic inflammation, via activation of fibers that innervate the spleen. Finally, VNS can gradually restore the balance between parasympathetic and sympathetic tone by regulating autonomic reflexes. Preclinical studies support the feasibility of using VNS in PAH. However, there are challenges with such an approach, arising from the need to affect a relatively small number of relevant vagal fibers, and the potential for unwanted cardiac and noncardiac effects of VNS in this sensitive patient population.
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Affiliation(s)
- Despοina Ntiloudi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA.,2Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Khaled Qanud
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Jacquelyn-Nicole Tomaio
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | | | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Stavros Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
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Nakamura K, Akagi S, Ejiri K, Yoshida M, Miyoshi T, Toh N, Nakagawa K, Takaya Y, Matsubara H, Ito H. Current Treatment Strategies and Nanoparticle-Mediated Drug Delivery Systems for Pulmonary Arterial Hypertension. Int J Mol Sci 2019; 20:ijms20235885. [PMID: 31771203 PMCID: PMC6928621 DOI: 10.3390/ijms20235885] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/10/2019] [Accepted: 11/21/2019] [Indexed: 12/20/2022] Open
Abstract
There are three critical pathways for the pathogenesis and progression of pulmonary arterial hypertension (PAH): the prostacyclin (prostaglandin I2) (PGI2), nitric oxide (NO), and endothelin pathways. The current approved drugs targeting these three pathways, including prostacyclin (PGI2), phosphodiesterase type-5 (PDE5) inhibitors, and endothelin receptor antagonists (ERAs), have been shown to be effective, however, PAH remains a severe clinical condition and the long-term survival of patients with PAH is still suboptimal. The full therapeutic abilities of available drugs are reduced by medication, patient non-compliance, and side effects. Nanoparticles are expected to address these problems by providing a novel drug delivery approach for the treatment of PAH. Drug-loaded nanoparticles for local delivery can optimize the efficacy and minimize the adverse effects of drugs. Prostacyclin (PGI2) analogue, PDE5 inhibitors, ERA, pitavastatin, imatinib, rapamycin, fasudil, and oligonucleotides-loaded nanoparticles have been reported to be effective in animal PAH models and in vitro studies. However, the efficacy and safety of nanoparticle mediated-drug delivery systems for PAH treatment in humans are unknown and further clinical studies are required to clarify these points.
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Affiliation(s)
- Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
- Correspondence: ; Tel.: +81-86-235-7351; Fax: +81-86-235-7353
| | - Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Masashi Yoshida
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
| | - Hiromi Matsubara
- Division of Cardiology, National Hospital Organization Okayama Medical Center, Okayama 701-1192, Japan;
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (S.A.); (K.E.); (M.Y.); (T.M.); (N.T.); (Y.T.); (H.I.)
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Thyroid Dysfunction in Patients with Pulmonary Artery Hypertension (PAH): The Effect of Therapies Affecting the Prostanoid Pathway. Lung 2019; 197:761-768. [PMID: 31696306 DOI: 10.1007/s00408-019-00283-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Epoprostenol, a synthetic prostaglandin I2 (PGI2) analog, has been the mainstay of treatment for severe pulmonary arterial hypertension (PAH) for the last two decades. Treprostinil, another synthetic prostaglandin analog, and selexipag, an oral selective Inositol Phosphate (IP) prostacyclin receptor agonist, have also been approved for treatment of PAH. Prostacyclin and its analogs cause a variety of side effects in patients with PAH; however, thyroid dysfunction is rarely reported. METHODS After treating an index case of thyroid dysfunction occurring after initiation of epoprostenol, we reviewed our databases of PAH patients treated with epoprostenol, treprostinil or selexipag to identify the occurrence of this association. RESULTS We identified six cases of thyroid dysfunction in our cohort: five after initiation of an intravenous prostacyclin (epoprostenol) and one after initiation of an oral prostacyclin receptor agonist (selexipag). Four of the patients presented with hyperthyroidism and two with a large autoimmune goiter. Graves' disease was seen in three patients, Hashimoto's disease in two patients and thyrotoxicosis in one patient. CONCLUSION Therapy with medications targeting the prostacyclin pathway is a potential risk factor for the development of symptomatic thyroid disease.
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Feenstra J, Hopkins P, Trotter M, O'Brien K. Effectiveness of epoprostenol in the management of pulmonary arterial hypertension: findings of an Australian retrospective chart review. Intern Med J 2019; 50:1377-1384. [PMID: 31661174 DOI: 10.1111/imj.14668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressively fatal disease. Parenteral prostanoids, including intravenous (IV) epoprostenol, are the most effective therapies for PAH. As epoprostenol requires continuous infusion, therapy is challenging and use is managed by specialist units. AIMS To describe the clinical outcomes for the use of IV epoprostenol in an Australian pulmonary vascular disease unit and identify opportunities to improve its use. METHOD We conducted a retrospective chart review of all adult patients who received IV epoprostenol for PAH at Prince Charles Hospital. Data were collected at baseline, initiation of epoprostenol and quarterly to the end of the audit period or the discontinuation of epoprostenol. Descriptive statistics were performed and comparisons made to epoprostenol initiation. Kaplan-Meier curves were used to estimate survival outcomes. RESULTS Thirty-nine patients received epoprostenol therapy. Most (87.2%) were female, had connective tissue disease (46.2%) or idiopathic PAH (35.9%) and had a World Health Organization functional Class of III or IV at initiation. The mean duration of epoprostenol therapy was 2.9 years. Intravenous epoprostenol was associated with favourable outcomes; 1, 3 and 5-year survival rates since initiation of 90.0, 75.8 and 68.2%; robust improvements in functional class; and improvements in 6-min walking distance of 160.4 m at 3 years; 94.9% patients experienced at least one drug-related adverse event and line complications were common. CONCLUSION Epoprostenol therapy was associated with impressive survival rates and durable improvements in functional outcomes. Epoprostenol therapy is challenging; however, it is manageable by the majority of patients with most experiencing positive, sustainable outcomes.
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Affiliation(s)
- John Feenstra
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Peter Hopkins
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Michael Trotter
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Kathy O'Brien
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
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