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Wang Y, Gou Y, Yuan R, Zou Q, Zhang X, Zheng T, Fei K, Shi R, Zhang M, Li Y, Gong Z, Luo C, Xiong Y, Shan D, Wei C, Shen L, Tang G, Li M, Zhu L, Li X, Jiang Y. A chromosome-level genome of Chenghua pig provides new insights into the domestication and local adaptation of pigs. Int J Biol Macromol 2024; 270:131796. [PMID: 38677688 DOI: 10.1016/j.ijbiomac.2024.131796] [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: 07/26/2023] [Revised: 03/24/2024] [Accepted: 04/04/2024] [Indexed: 04/29/2024]
Abstract
As a country with abundant genetic resources of pigs, the domestication history of pigs in China and the adaptive evolution of Chinese pig breeds at different latitudes have rarely been elucidated at the genome-wide level. To fill this gap, we first assembled a high-quality chromosome-level genome of the Chenghua pig and used it as a benchmark to analyse the genomes of 272 samples from three genera of three continents. The divergence of the three species belonging to three genera, Phacochoerus africanus, Potamochoerus porcus, and Sus scrofa, was assessed. The introgression of pig breeds redefined that the migration routes were basically from southern China to central and southwestern China, then spread to eastern China, arrived in northern China, and finally reached Europe. The domestication of pigs in China occurred ∼12,000 years ago, earlier than the available Chinese archaeological domestication evidence. In addition, FBN1 and NR6A1 were identified in our study as candidate genes related to extreme skin thickness differences in Eurasian pig breeds and adaptive evolution at different latitudes in Chinese pig breeds, respectively. Our study provides a new resource for the pig genomic pool and refines our understanding of pig genetic diversity, domestication, migration, and adaptive evolution at different latitudes.
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Affiliation(s)
- Yifei Wang
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Yuwei Gou
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Rong Yuan
- Chengdu Livestock and Poultry Genetic Resources Protection Center, Chengdu, Sichuan 610081, China
| | - Qin Zou
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Xukun Zhang
- Academy for Engineering and Technology, Fudan University, Shanghai 200433, China
| | - Ting Zheng
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Kaixin Fei
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Rui Shi
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Mei Zhang
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Yujing Li
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Zhengyin Gong
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Chenggang Luo
- Chengdu Livestock and Poultry Genetic Resources Protection Center, Chengdu, Sichuan 610081, China
| | - Ying Xiong
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
| | - Dai Shan
- BGI Genomics, BGI-Shenzhen, Shenzhen 518083, China
| | - Chenyang Wei
- BGI Genomics, BGI-Shenzhen, Shenzhen 518083, China
| | - Linyuan Shen
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Guoqing Tang
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Mingzhou Li
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Li Zhu
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Xuewei Li
- College of Animal Science and Technology, Sichuan Agricultural University, Chengdu, Sichuan 611130, China
| | - Yanzhi Jiang
- Department of Zoology, College of Life Science, Sichuan Agricultural University, Ya'an, Sichuan 625014, China.
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Pitcher A, Spata E, Emberson J, Davies K, Halls H, Holland L, Wilson K, Reith C, Child AH, Clayton T, Dodd M, Flather M, Jin XY, Sandor G, Groenink M, Mulder B, De Backer J, Evangelista A, Forteza A, Teixido-Turà G, Boileau C, Jondeau G, Milleron O, Lacro RV, Sleeper LA, Chiu HH, Wu MH, Neubauer S, Watkins H, Dietz H, Baigent C. Angiotensin receptor blockers and β blockers in Marfan syndrome: an individual patient data meta-analysis of randomised trials. Lancet 2022; 400:822-831. [PMID: 36049495 PMCID: PMC7613630 DOI: 10.1016/s0140-6736(22)01534-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) and β blockers are widely used in the treatment of Marfan syndrome to try to reduce the rate of progressive aortic root enlargement characteristic of this condition, but their separate and joint effects are uncertain. We aimed to determine these effects in a collaborative individual patient data meta-analysis of randomised trials of these treatments. METHODS In this meta-analysis, we identified relevant trials of patients with Marfan syndrome by systematically searching MEDLINE, Embase, and CENTRAL from database inception to Nov 2, 2021. Trials were eligible if they involved a randomised comparison of an ARB versus control or an ARB versus β blocker. We used individual patient data from patients with no prior aortic surgery to estimate the effects of: ARB versus control (placebo or open control); ARB versus β blocker; and indirectly, β blocker versus control. The primary endpoint was the annual rate of change of body surface area-adjusted aortic root dimension Z score, measured at the sinuses of Valsalva. FINDINGS We identified ten potentially eligible trials including 1836 patients from our search, from which seven trials and 1442 patients were eligible for inclusion in our main analyses. Four trials involving 676 eligible participants compared ARB with control. During a median follow-up of 3 years, allocation to ARB approximately halved the annual rate of change in the aortic root Z score (mean annual increase 0·07 [SE 0·02] ARB vs 0·13 [SE 0·02] control; absolute difference -0·07 [95% CI -0·12 to -0·01]; p=0·012). Prespecified secondary subgroup analyses showed that the effects of ARB were particularly large in those with pathogenic variants in fibrillin-1, compared with those without such variants (heterogeneity p=0·0050), and there was no evidence to suggest that the effect of ARB varied with β-blocker use (heterogeneity p=0·54). Three trials involving 766 eligible participants compared ARBs with β blockers. During a median follow-up of 3 years, the annual change in the aortic root Z score was similar in the two groups (annual increase -0·08 [SE 0·03] in ARB groups vs -0·11 [SE 0·02] in β-blocker groups; absolute difference 0·03 [95% CI -0·05 to 0·10]; p=0·48). Thus, indirectly, the difference in the annual change in the aortic root Z score between β blockers and control was -0·09 (95% CI -0·18 to 0·00; p=0·042). INTERPRETATION In people with Marfan syndrome and no previous aortic surgery, ARBs reduced the rate of increase of the aortic root Z score by about one half, including among those taking a β blocker. The effects of β blockers were similar to those of ARBs. Assuming additivity, combination therapy with both ARBs and β blockers from the time of diagnosis would provide even greater reductions in the rate of aortic enlargement than either treatment alone, which, if maintained over a number of years, would be expected to lead to a delay in the need for aortic surgery. FUNDING Marfan Foundation, the Oxford British Heart Foundation Centre for Research Excellence, and the UK Medical Research Council.
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Affiliation(s)
- Alex Pitcher
- The Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Enti Spata
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kelly Davies
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Heather Halls
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lisa Holland
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kate Wilson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anne H Child
- Royal Brompton and Harefield Hospitals Unit, Guy's and St Thomas' NHS Trust and Department of Surgery and Oncology, Imperial College London, London, UK
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Dodd
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marcus Flather
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Xu Yu Jin
- The Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - George Sandor
- Children's Heart Centre, British Columbia's Children's Hospital, Vancouver, BC, Canada; Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maarten Groenink
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Amsterdam, The Netherlands
| | - Barbara Mulder
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Amsterdam, The Netherlands
| | - Julie De Backer
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, Ghent, Belgium; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Ghent, Belgium
| | - Arturo Evangelista
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Barcelona, Spain
| | | | - Gisela Teixido-Turà
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Barcelona, Spain
| | - Catherine Boileau
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm U1148, LVTS, F-75018 Paris, France; Service de Cardiologie, AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; CRMR Syndrome de Marfan et apparentés. AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Paris, France
| | - Guillaume Jondeau
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm U1148, LVTS, F-75018 Paris, France; Service de Cardiologie, AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; CRMR Syndrome de Marfan et apparentés. AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Paris, France
| | - Olivier Milleron
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm U1148, LVTS, F-75018 Paris, France; Service de Cardiologie, AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; CRMR Syndrome de Marfan et apparentés. AP-HP Hôpital Bichat-Claude Bernard, F-75018, Paris, France; European Reference Network for Rare Multisystemic Vascular Disease (VASCERN), HTAD Rare Disease Working Group, Paris, France
| | - Ronald V Lacro
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Hsin-Hui Chiu
- Department of Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics and Adult Congenital Heart Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Hugh Watkins
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Hal Dietz
- Howard Hughes Medical Institute and Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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3
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Mao M, Labelle-Dumais C, Tufa SF, Keene DR, Gould DB. Elevated TGFβ signaling contributes to ocular anterior segment dysgenesis in Col4a1 mutant mice. Matrix Biol 2022; 110:151-173. [PMID: 35525525 PMCID: PMC10410753 DOI: 10.1016/j.matbio.2022.05.001] [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: 12/21/2021] [Revised: 04/08/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
Ocular anterior segment dysgenesis (ASD) refers to a collection of developmental disorders affecting the anterior structures of the eye. Although a number of genes have been implicated in the etiology of ASD, the underlying pathogenetic mechanisms remain unclear. Mutations in genes encoding collagen type IV alpha 1 (COL4A1) and alpha 2 (COL4A2) cause Gould syndrome, a multi-system disorder that often includes ocular manifestations such as ASD and glaucoma. COL4A1 and COL4A2 are abundant basement membrane proteins that provide structural support to tissues and modulate signaling through interactions with other extracellular matrix proteins, growth factors, and cell surface receptors. In this study, we used a combination of histological, molecular, genetic and pharmacological approaches to demonstrate that altered TGFβ signaling contributes to ASD in mouse models of Gould syndrome. We show that TGFβ signaling was elevated in anterior segments from Col4a1 mutant mice and that genetically reducing TGFβ signaling partially prevented ASD. Notably, we identified distinct roles for TGFβ1 and TGFβ2 in ocular defects observed in Col4a1 mutant mice. Importantly, we show that pharmacologically promoting type IV collagen secretion or reducing TGFβ signaling ameliorated ocular pathology in Col4a1 mutant mice. Overall, our findings demonstrate that altered TGFβ signaling contributes to COL4A1-related ocular dysgenesis and implicate this pathway as a potential therapeutic target for the treatment of Gould syndrome.
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Affiliation(s)
- Mao Mao
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Cassandre Labelle-Dumais
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Sara F Tufa
- Shriners Children's, Micro-Imaging Center, Portland, Oregon 97239, United States
| | - Douglas R Keene
- Shriners Children's, Micro-Imaging Center, Portland, Oregon 97239, United States
| | - Douglas B Gould
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, United States; Department of Anatomy, University of California, San Francisco, San Francisco, CA 94143, United States; Institute for Human Genetics, University of California, San Francisco, San Francisco, CA 94143, United States; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, United States; Bakar Aging Research Institute, University of California, San Francisco, San Francisco, CA 94143, United States.
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4
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Pena RC, Bowman MAH, Ahmad M, Pham J, Kline-Rogers E, Case MJ, Lee J, Eagle K. An Assessment of the Current Medical Management of Thoracic Aortic Disease: A Patient-Centered Scoping Literature Review. Semin Vasc Surg 2022; 35:16-34. [DOI: 10.1053/j.semvascsurg.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 11/11/2022]
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5
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Deleeuw V, De Clercq A, De Backer J, Sips P. An Overview of Investigational and Experimental Drug Treatment Strategies for Marfan Syndrome. J Exp Pharmacol 2021; 13:755-779. [PMID: 34408505 PMCID: PMC8366784 DOI: 10.2147/jep.s265271] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
Marfan syndrome (MFS) is a heritable connective tissue disorder caused by pathogenic variants in the gene coding for the extracellular matrix protein fibrillin-1. While the disease affects multiple organ systems, the most life-threatening manifestations are aortic aneurysms leading to dissection and rupture. Other cardiovascular complications, including mitral valve prolapse, primary cardiomyopathy, and arrhythmia, also occur more frequently in patients with MFS. The standard medical care relies on cardiovascular imaging at regular intervals, along with pharmacological treatment with β-adrenergic receptor blockers aimed at reducing the aortic growth rate. When aortic dilatation reaches a threshold associated with increased risk of dissection, prophylactic surgical aortic replacement is performed. Although current clinical management has significantly improved the life expectancy of patients with MFS, no cure is available and fatal complications still occur, underscoring the need for new treatment options. In recent years, preclinical studies have identified a number of potentially promising therapeutic targets. Nevertheless, the translation of these results into clinical practice has remained challenging. In this review, we present an overview of the currently available knowledge regarding the underlying pathophysiological processes associated with MFS cardiovascular pathology. We then summarize the treatment options that have been developed based on this knowledge and are currently in different stages of preclinical or clinical development, provide a critical review of the limitations of current studies and highlight potential opportunities for future research.
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Affiliation(s)
- Violette Deleeuw
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, Ghent, 9000, Belgium
| | - Adelbert De Clercq
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, Ghent, 9000, Belgium
| | - Julie De Backer
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, Ghent, 9000, Belgium.,Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, 9000, Belgium
| | - Patrick Sips
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, Ghent, 9000, Belgium
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6
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van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome: follow-up of the multicentre randomized controlled COMPARE trial. Eur Heart J 2021; 41:4181-4187. [PMID: 32548624 PMCID: PMC7711887 DOI: 10.1093/eurheartj/ehaa377] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/07/2020] [Accepted: 04/24/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS The COMPARE trial showed a small but significant beneficial effect of 3-year losartan treatment on aortic root dilatation rate in adults with Marfan syndrome (MFS). However, no significant effect was found on clinical endpoints, possibly due to a short follow-up period. The aim of the current study was therefore to investigate the long-term clinical outcomes after losartan treatment. METHODS AND RESULTS In the original COMPARE study (inclusion 2008-2009), adult patients with MFS (n = 233) were randomly allocated to either the angiotensin-II receptor blocker losartan® on top of regular treatment (β-blockers in 71% of the patients) or no additional medication. After the COMPARE trial period of 3 years, study subjects chose to continue their losartan medication or not. In a median follow-up period of 8 years, 75 patients continued losartan medication, whereas 78 patients, originally allocated to the control group, never used losartan after inclusion. No differences existed between baseline characteristics of the two groups except for age at inclusion [losartan 34 (interquartile range, IQR 26-43) years, control 41 (IQR 30-52) years; P = 0.031], and β-blocker use (losartan 81%, control 64%; P = 0.022). A pathological FBN1 mutation was present in 76% of patients and 58% of the patients were male. Clinical endpoints, defined as all-cause mortality, aortic dissection/rupture, elective aortic root replacement, reoperation, and vascular graft implantation beyond the aortic root, were compared between the two groups. A per-patient composite endpoint was also analysed. Five deaths, 14 aortic dissections, 23 aortic root replacements, 3 reoperations, and 3 vascular graft implantations beyond the aortic root occurred during follow-up. Except for aortic root replacement, all endpoints occurred in patients with an operated aortic root. Patients who used losartan during the entire follow-up period showed a reduced number of events compared to the control group (death: 0 vs. 5, P = 0.014; aortic dissection: 3 vs. 11, P = 0.013; elective aortic root replacement: 10 vs. 13, P = 0.264; reoperation: 1 vs. 2, P = 0.463; vascular graft implantations beyond the aortic root 0 vs. 3, P = 0.071; and composite endpoint: 14 vs. 26, P = 0.019). These results remained similar when corrected for age and β-blocker use in a multivariate analysis. CONCLUSION These results suggest a clinical benefit of combined losartan and β-blocker treatment in patients with MFS.
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Affiliation(s)
- Mitzi M van Andel
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hamid Jalalzadeh
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Janneke Timmermans
- Department of Cardiology, St. Radboud University Medical Center, Geert grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - Arthur J Scholte
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Vivian de Waard
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Maarten Groenink
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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7
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Iung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJ, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K, Ernst S, Ladouceur M, Aboyans V, Alexander D, Christodorescu R, Corrado D, D’Alto M, de Groot N, Delgado V, Di Salvo G, Dos Subira L, Eicken A, Fitzsimons D, Frogoudaki AA, Gatzoulis M, Heymans S, Hörer J, Houyel L, Jondeau G, Katus HA, Landmesser U, Lewis BS, Lyon A, Mueller CE, Mylotte D, Petersen SE, Petronio AS, Roffi M, Rosenhek R, Shlyakhto E, Simpson IA, Sousa-Uva M, Torp-Pedersen CT, Touyz RM, Van De Bruaene A. Guía ESC 2020 para el tratamiento de las cardiopatías congénitas del adulto. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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8
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563-645. [PMID: 32860028 DOI: 10.1093/eurheartj/ehaa554] [Citation(s) in RCA: 798] [Impact Index Per Article: 266.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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9
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van Dorst DCH, de Wagenaar NP, van der Pluijm I, Roos-Hesselink JW, Essers J, Danser AHJ. Transforming Growth Factor-β and the Renin-Angiotensin System in Syndromic Thoracic Aortic Aneurysms: Implications for Treatment. Cardiovasc Drugs Ther 2020; 35:1233-1252. [PMID: 33283255 PMCID: PMC8578102 DOI: 10.1007/s10557-020-07116-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 12/12/2022]
Abstract
Thoracic aortic aneurysms (TAAs) are permanent pathological dilatations of the thoracic aorta, which can lead to life-threatening complications, such as aortic dissection and rupture. TAAs frequently occur in a syndromic form in individuals with an underlying genetic predisposition, such as Marfan syndrome (MFS) and Loeys-Dietz syndrome (LDS). Increasing evidence supports an important role for transforming growth factor-β (TGF-β) and the renin-angiotensin system (RAS) in TAA pathology. Eventually, most patients with syndromic TAAs require surgical intervention, as the ability of present medical treatment to attenuate aneurysm growth is limited. Therefore, more effective medical treatment options are urgently needed. Numerous clinical trials investigated the therapeutic potential of angiotensin receptor blockers (ARBs) and β-blockers in patients suffering from syndromic TAAs. This review highlights the contribution of TGF-β signaling, RAS, and impaired mechanosensing abilities of aortic VSMCs in TAA formation. Furthermore, it critically discusses the most recent clinical evidence regarding the possible therapeutic benefit of ARBs and β-blockers in syndromic TAA patients and provides future research perspectives and therapeutic implications.
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Affiliation(s)
- Daan C H van Dorst
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nathalie P de Wagenaar
- Department of Molecular Genetics, Erasmus University Medical Center, Room Ee702b, Erasmus MC, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.,Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ingrid van der Pluijm
- Department of Molecular Genetics, Erasmus University Medical Center, Room Ee702b, Erasmus MC, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.,Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen Essers
- Department of Molecular Genetics, Erasmus University Medical Center, Room Ee702b, Erasmus MC, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands. .,Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. .,Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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10
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Abstract
Marfan Syndrome (MFS) is an autosomal dominant, genetically inherited connective tissue disorder which primarily affects the cardiovascular system, but can also have systemic manifestations. First described in 1896, MFS has a prevalence of around 1/5000 in the general population. It is becoming increasingly common to see patients with MFS in a clinical setting due to the improved care of patients with adult congenital heart disease and general improvement in survival. Mortality, however, remains high largely due to the risk of aortic dissection as a result of the aortic root dilatation frequently seen in these patients. Contemporary management has therefore been focused on imaging-based surveillance to prevent these catastrophic events and intervene surgically in a timely manner. However, it is increasingly recognized that some patients do suffer aortic dissection below the expected threshold for surgical intervention. With this in mind, there has been interest in the role of biomarkers as an adjunct to imaging in the care of these patients. This article will provide an overview of the literature on potential biomarkers studied so far in MFS, as well as potential future directions.
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11
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Muiño-Mosquera L, De Backer J. Angiotensin-II receptor blockade in Marfan syndrome. Lancet 2019; 394:2206-2207. [PMID: 31836197 DOI: 10.1016/s0140-6736(19)32536-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Laura Muiño-Mosquera
- Department of Paediatrics, Division of Paediatric Cardiology, Ghent University Hospital, Ghent 9000, Belgium; Centre for Medical Genetics, Ghent University Hospital, Ghent 9000, Belgium.
| | - Julie De Backer
- Centre for Medical Genetics, Ghent University Hospital, Ghent 9000, Belgium; Department of Cardiology, Ghent University Hospital, Ghent 9000, Belgium
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12
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Mullen M, Jin XY, Child A, Stuart AG, Dodd M, Aragon-Martin JA, Gaze D, Kiotsekoglou A, Yuan L, Hu J, Foley C, Van Dyck L, Knight R, Clayton T, Swan L, Thomson JDR, Erdem G, Crossman D, Flather M. Irbesartan in Marfan syndrome (AIMS): a double-blind, placebo-controlled randomised trial. Lancet 2019; 394:2263-2270. [PMID: 31836196 PMCID: PMC6934233 DOI: 10.1016/s0140-6736(19)32518-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Irbesartan, a long acting selective angiotensin-1 receptor inhibitor, in Marfan syndrome might reduce aortic dilatation, which is associated with dissection and rupture. We aimed to determine the effects of irbesartan on the rate of aortic dilatation in children and adults with Marfan syndrome. METHODS We did a placebo-controlled, double-blind randomised trial at 22 centres in the UK. Individuals aged 6-40 years with clinically confirmed Marfan syndrome were eligible for inclusion. Study participants were all given 75 mg open label irbesartan once daily, then randomly assigned to 150 mg of irbesartan (increased to 300 mg as tolerated) or matching placebo. Aortic diameter was measured by echocardiography at baseline and then annually. All images were analysed by a core laboratory blinded to treatment allocation. The primary endpoint was the rate of aortic root dilatation. This trial is registered with ISRCTN, number ISRCTN90011794. FINDINGS Between March 14, 2012, and May 1, 2015, 192 participants were recruited and randomly assigned to irbesartan (n=104) or placebo (n=88), and all were followed for up to 5 years. Median age at recruitment was 18 years (IQR 12-28), 99 (52%) were female, mean blood pressure was 110/65 mm Hg (SDs 16 and 12), and 108 (56%) were taking β blockers. Mean baseline aortic root diameter was 34·4 mm in the irbesartan group (SD 5·8) and placebo group (5·5). The mean rate of aortic root dilatation was 0·53 mm per year (95% CI 0·39 to 0·67) in the irbesartan group compared with 0·74 mm per year (0·60 to 0·89) in the placebo group, with a difference in means of -0·22 mm per year (-0·41 to -0·02, p=0·030). The rate of change in aortic Z score was also reduced by irbesartan (difference in means -0·10 per year, 95% CI -0·19 to -0·01, p=0·035). Irbesartan was well tolerated with no observed differences in rates of serious adverse events. INTERPRETATION Irbesartan is associated with a reduction in the rate of aortic dilatation in children and young adults with Marfan syndrome and could reduce the incidence of aortic complications. FUNDING British Heart Foundation, the UK Marfan Trust, the UK Marfan Association.
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Affiliation(s)
- Michael Mullen
- Barts Heart Centre, Barts Health NHS Trust, London, UK; Department of Cardiovascular Medicine and Devices, Queen Mary University, London, UK
| | - Xu Yu Jin
- Core Echo Lab, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anne Child
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | | | - Matthew Dodd
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David Gaze
- Department of Life Sciences, University of Westminster, London UK
| | - Anatoli Kiotsekoglou
- Core Echo Lab, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Li Yuan
- Core Echo Lab, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Ultrasound Department, Wuhan Children's Hospital, Tongji Medical School, Huazhong University of Science and Technology, Hubei, China
| | - Jiangting Hu
- Core Echo Lab, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Laura Van Dyck
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Rosemary Knight
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Lorna Swan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Toronto Congenital Cardiac Centre for Adults, Toronto, Canada
| | | | - Guliz Erdem
- Department of Cardiology, Acibadem International Hospital Istanbul, Turkey; School of Medicine, Acibadem University, Istanbul, Turkey
| | - David Crossman
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norfolk, Norwich, UK; Cardiology Department, Norfolk and Norwich University Hospital, Norwich, UK.
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13
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Abstract
Current management of aortic aneurysms relies exclusively on prophylactic operative repair of larger aneurysms. Great potential exists for successful medical therapy that halts or reduces aneurysm progression and hence alleviates or postpones the need for surgical repair. Preclinical studies in the context of abdominal aortic aneurysm identified hundreds of candidate strategies for stabilization, and data from preoperative clinical intervention studies show that interventions in the pathways of the activated inflammatory and proteolytic cascades in enlarging abdominal aortic aneurysm are feasible. Similarly, the concept of pharmaceutical aorta stabilization in Marfan syndrome is supported by a wealth of promising studies in the murine models of Marfan syndrome-related aortapathy. Although some clinical studies report successful medical stabilization of growing aortic aneurysms and aortic root stabilization in Marfan syndrome, these claims are not consistently confirmed in larger and controlled studies. Consequently, no medical therapy can be recommended for the stabilization of aortic aneurysms. The discrepancy between preclinical successes and clinical trial failures implies shortcomings in the available models of aneurysm disease and perhaps incomplete understanding of the pathological processes involved in later stages of aortic aneurysm progression. Preclinical models more reflective of human pathophysiology, identification of biomarkers to predict severity of disease progression, and improved design of clinical trials may more rapidly advance the opportunities in this important field.
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Affiliation(s)
- Jan H. Lindeman
- Dept. Vascular Surgery, Leiden University Medical Center, The Netherlands
| | - Jon S. Matsumura
- Division of Vascular Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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14
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Favalli V, Serio A, Giuliani LP, Arbustini E. 'Precision and personalized medicine,' a dream that comes true? J Cardiovasc Med (Hagerstown) 2018; 18 Suppl 1:e1-e6. [PMID: 27661611 DOI: 10.2459/jcm.0000000000000423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Valentina Favalli
- Centre for Inherited Cardiovascular Diseases, IRCCS Foundation, Policlinico San Matteo, University Hospital, Pavia, Italy
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15
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Affiliation(s)
- U Muscha Steckelings
- From the IMM - Department of Cardiovascular and Renal Research, University of Southern Denmark, Odense (U.M.S.)
| | - Michael Bader
- From the IMM - Department of Cardiovascular and Renal Research, University of Southern Denmark, Odense (U.M.S.).,Max Delbrück Center for Molecular Medicine, Berlin, Germany (M.B.).,Charite - University Medicine, Berlin, Germany (M.B.).,German Center for Cardiovascular Research, Berlin Partner Site, Germany (M.B.).,Berlin Institute of Health, Germany (M.B.).,Institute for Biology, University of Lübeck, Germany (M.B.)
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16
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Yu C, Jeremy RW. Angiotensin, transforming growth factor β and aortic dilatation in Marfan syndrome: Of mice and humans. IJC HEART & VASCULATURE 2018; 18:71-80. [PMID: 29876507 PMCID: PMC5988480 DOI: 10.1016/j.ijcha.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 02/21/2018] [Accepted: 02/28/2018] [Indexed: 01/09/2023]
Abstract
Marfan syndrome is consequent upon mutations in FBN1, which encodes the extracellular matrix microfibrillar protein fibrillin-1. The phenotype is characterised by development of thoracic aortic aneurysm. Current understanding of the pathogenesis of aneurysms in Marfan syndrome focuses upon abnormal vascular smooth muscle cell signalling through the transforming growth factor beta (TGFβ) pathway. Angiotensin II (Ang II) can directly induce aortic dilatation and also influence TGFβ synthesis and signalling. It has been hypothesised that antagonism of Ang II signalling may protect against aortic dilatation in Marfan syndrome. Experimental studies have been supportive of this hypothesis, however results from multiple clinical trials are conflicting. This paper examines current knowledge about the interactions of Ang II and TGFβ signalling in the vasculature, and critically interprets the experimental and clinical findings against these signalling interactions.
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Affiliation(s)
- Christopher Yu
- Sydney Medical School, University of Sydney, Sydney 2006, Australia
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17
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Muiño-Mosquera L, De Nobele S, Devos D, Campens L, De Paepe A, De Backer J. Efficacy of losartan as add-on therapy to prevent aortic growth and ventricular dysfunction in patients with Marfan syndrome: a randomized, double-blind clinical trial. Acta Cardiol 2017; 72:616-624. [PMID: 28657492 DOI: 10.1080/00015385.2017.1314134] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Marfan syndrome (MFS) is a multisystemic hereditary connective tissue disease. Aortic root aneurysms and dissections are the most common and life-threatening cardiovascular disorders affecting these patients. Other cardiac manifestations include mitral valve prolapse, ventricular dysfunction and arrhythmias. Medical treatment of cardiovascular features is ultimately aimed at slowing down aortic root growth rate and preventing dissection. Losartan has been proposed as a new therapeutic tool for this purpose. To which extent losartan affects cardiac function has not been studied previously. METHODS We designed a prospective, double-blind, randomized placebo-controlled trial to evaluate the effect of losartan added to beta-blocker therapy on aortic growth and ventricular function in patients with MFS. Secondary outcomes were aortic dissection, prophylactic aortic surgery and death. RESULTS Twenty-two patients were enrolled in the trial. There was a mild and similar increase in the aortic root during the 3 years of follow-up in both groups (median 1 mm, IQR [-1-1.5] and 1 mm, IQR [-0.25-1] in the losartan and placebo group, respectively, p = 1). Diastolic and systolic ventricular function was normal at baseline in both groups and remained stable during the study. One patient in the placebo group presented a subclavian artery dissection during follow-up. CONCLUSION Losartan on top of beta-blocker therapy has no additional effect on aortic growth or on cardiac function in patients with MFS. Our results are underpowered but are in line with the result from other groups. In order to have a better insight on whether a group of patients could benefit more from losartan therapy, the outcome of an on-going meta-analysis should be awaited.
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Affiliation(s)
- Laura Muiño-Mosquera
- Department of Medical Genetics, University Hospital Ghent, Ghent, Belgium
- Division of Paediatric Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Sylvia De Nobele
- Department of Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Daniel Devos
- Department of Radiology, University Hospital Ghent, Ghent, Belgium
| | - Laurence Campens
- Department of Medical Genetics, University Hospital Ghent, Ghent, Belgium
- Department of Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Anne De Paepe
- Department of Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Julie De Backer
- Department of Medical Genetics, University Hospital Ghent, Ghent, Belgium
- Department of Cardiology, University Hospital Ghent, Ghent, Belgium
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18
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Falvella FS, Marelli S, Cheli S, Montanelli S, Viecca F, Salvi L, Ferrara A, Clementi E, Trifirò G, Pini A. Pharmacogenetic approach to losartan in Marfan patients: a starting point to improve dosing regimen? Drug Metab Pers Ther 2017; 31:157-63. [PMID: 27474842 DOI: 10.1515/dmpt-2016-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/01/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Losartan is under evaluation for managing Marfan patients with aortic root dilatation. Cytochrome P450 (CYP) enzymes convert losartan to E3174 active metabolite. The aim of this study is to describe the distribution of CYP2C9*2, CYP2C9*3, CYP3A4*22 and CYP3A5*3 defective alleles, according to losartan tolerance in paediatric Marfan patients. METHODS We genotyped 53 paediatric Marfan patients treated with losartan. The rate of aortic root dilatation was evaluated using the delta z-score variation. Differences in tolerated losartan daily doses with respect to CYP metabolic classes were assessed through the Kruskal-Wallis test. RESULTS The losartan daily dose spans from 0.16 to 2.50 mg/kg (median 1.10 mg/kg). As we expect from the pharmacokinetics pathway, we observe highest tolerated dose in CYP2C9 poor metabolisers (median 1.50 mg/kg, interquartile range 1.08-1.67 mg/kg); however, this difference is not statistically significant. CONCLUSIONS The optimal dose of angiotensin receptor blocker is not known, and no data are available about losartan pharmacogenetic profile in Marfan syndrome; we have proposed a strategy to tackle this issue based on evaluating the major genetic polymorphisms involved in the losartan conversion into active carboxylic acid metabolite. Further studies are needed to support the use of genetic polymorphisms as predictors of the right dose of losartan.
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19
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Abstract
BACKGROUND Marfan syndrome is a hereditary disorder affecting the connective tissue and is caused by a mutation of the fibrillin-1 (FBN1) gene. It affects multiple systems of the body, most notably the cardiovascular, ocular, skeletal, dural and pulmonary systems. Aortic root dilatation is the most frequent cardiovascular manifestation and its complications, including aortic regurgitation, dissection and rupture are the main cause of morbidity and mortality. OBJECTIVES To assess the long-term efficacy and safety of beta-blocker therapy as compared to placebo, no treatment or surveillance only in people with Marfan syndrome. SEARCH METHODS We searched the following databases on 28 June 2017; CENTRAL, MEDLINE, Embase, Science Citation Index Expanded and the Conference Proceeding Citation Index - Science in the Web of Science Core Collection. We also searched the Online Metabolic and Molecular Bases of Inherited Disease (OMMBID), ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 30 June 2017. We did not impose any restriction on language of publication. SELECTION CRITERIA All randomised controlled trials (RCTs) of at least one year in duration assessing the effects of beta-blocker monotherapy compared with placebo, no treatment or surveillance only, in people of all ages with a confirmed diagnosis of Marfan syndrome were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for inclusion, extracted data and assessed trial quality. Trial authors were contacted to obtain missing data. Dichotomous outcomes will be reported as relative risk and continuous outcomes as mean differences with 95% confidence intervals. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One open-label, randomised, single-centre trial including 70 participants with Marfan syndrome (aged 12 to 50 years old) met the inclusion criteria. Participants were randomly assigned to propranolol (N = 32) or no treatment (N = 38) for an average duration of 9.3 years in the control group and 10.7 years in the treatment group. The initial dose of propranolol was 10 mg four times daily and the optimal dose was reached when the heart rate remained below 100 beats per minute during exercise or the systolic time interval increased by 30%. The mean (± standard error (SE)) optimal dose of propranolol was 212 ± 68 mg given in four divided doses daily.Beta-blocker therapy did not reduce the incidence of all-cause mortality (RR 0.24, 95% CI 0.01 to 4.75; participants = 70; low-quality evidence). Mortality attributed to Marfan syndrome was not reported. Non-fatal serious adverse events were also not reported. However, study authors report on pre-defined, non-fatal clinical endpoints, which include aortic dissection, aortic regurgitation, cardiovascular surgery and congestive heart failure. Their analysis showed no difference between the treatment and control groups in these outcomes (RR 0.79, 95% CI 0.37 to 1.69; participants = 70; low-quality evidence).Beta-blocker therapy did not reduce the incidence of aortic dissection (RR 0.59, 95% CI 0.12 to 3.03), aortic regurgitation (RR 1.19, 95% CI 0.18 to 7.96), congestive heart failure (RR 1.19, 95% CI 0.18 to 7.96) or cardiovascular surgery, (RR 0.59, 95% CI 0.12 to 3.03); participants = 70; low-quality evidence.The study reports a reduced rate of aortic dilatation measured by M-mode echocardiography in the treatment group (aortic ratio mean slope: 0.084 (control) vs 0.023 (treatment), P < 0.001). The change in systolic and diastolic blood pressure, total adverse events and withdrawal due to adverse events were not reported in the treatment or control group at study end point.We judged this study to be at high risk of selection (allocation concealment) bias, performance bias, detection bias, attrition bias and selective reporting bias. The overall quality of evidence was low. We do not know whether a statistically significant reduced rate of aortic dilatation translates into clinical benefit in terms of aortic dissection or mortality. AUTHORS' CONCLUSIONS Based on only one, low-quality RCT comparing long-term propranolol to no treatment in people with Marfan syndrome, we could draw no definitive conclusions for clinical practice. High-quality, randomised trials are needed to evaluate the long-term efficacy of beta-blocker treatment in people with Marfan syndrome. Future trials should report on all clinically relevant end points and adverse events to evaluate benefit versus harm of therapy.
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Affiliation(s)
- Hyun‐Kyoung Koo
- University of British Columbia217‐2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | | | - Vijaya M Musini
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
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Sartor L, Forteza A. Strategies to prevent aortic complications in Marfan syndrome. J Thorac Dis 2017; 9:S434-S438. [PMID: 28616337 DOI: 10.21037/jtd.2017.04.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lucio Sartor
- Division of Cardiovascular Surgery, Hospital Universitario Quirónsalud Madrid, Madrid, Spain
| | - Alberto Forteza
- Division of Cardiovascular Surgery, Hospital Universitario Quirónsalud Madrid, Madrid, Spain.,Marfan Unit, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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21
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Kuijpers JM, Mulder BJM. Aortopathies in adult congenital heart disease and genetic aortopathy syndromes: management strategies and indications for surgery. Heart 2017; 103:952-966. [DOI: 10.1136/heartjnl-2015-308626] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Abstract
Aortic aneurysms are a major health problem because they account for 1-2% of all deaths in the Western population. Although abdominal aortic aneurysms (AAAs) are more prevalent than thoracic aortic aneurysms (TAAs), TAAs have been more exhaustively studied over the past 2 decades because they have a higher heritability and affect younger individuals. Gene identification in both syndromic and nonsyndromic TAA is proceeding at a rapid pace and has already pinpointed >20 genes associated with familial TAA risk. Whereas these genes explain <30% of all cases of familial TAA, their functional characterization has substantially improved our knowledge of the underlying pathological mechanisms. As such, perturbed extracellular matrix homeostasis, transforming growth factor-β signalling, and vascular smooth muscle cell contractility have been proposed as important processes in TAA pathogenesis. These new insights enable novel treatment options that are currently being investigated in large clinical trials. Moreover, together with the advent of next-generation sequencing approaches, these genetic findings are promoting a shift in the management of patients with TAA by enabling gene-tailored interventions. In this Review, we comprehensively describe the molecular landscape of familial TAA, and we discuss whether familial TAA, from a biological point of view, can serve as a paradigm for the genetically more complex forms of the condition, such as sporadic TAA or AAA.
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Meffert P, Tscheuschler A, Beyersdorf F, Heilmann C, Kocher N, Uffelmann X, Discher P, Rylski B, Siepe M, Kari FA. Characterization of serum matrix metalloproteinase 2/9 levels in patients with ascending aortic aneurysms. Interact Cardiovasc Thorac Surg 2016; 24:20-26. [DOI: 10.1093/icvts/ivw309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/29/2016] [Accepted: 07/11/2016] [Indexed: 01/05/2023] Open
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24
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A Case Based Approach to Clinical Genetics of Thoracic Aortic Aneurysm/Dissection. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9579654. [PMID: 27314043 PMCID: PMC4897665 DOI: 10.1155/2016/9579654] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/30/2016] [Accepted: 04/19/2016] [Indexed: 12/04/2022]
Abstract
Thoracic aortic aneurysm/dissection (TAAD) is a potential lethal condition with a rising incidence. This condition may occur sporadically; nevertheless, it displays familial clustering in >20% of the cases. Family history confers a six- to twentyfold increased risk of TAAD and has to be considered in the identification and evaluation of patients needing an adequate clinical follow-up. Familial TAAD recognizes a number of potential etiologies with a significant genetic heterogeneity, in either syndromic or nonsyndromic forms of the manifestation. The clinical impact and the management of patients with TAAD differ according to the syndromic and nonsyndromic forms of the manifestation. The clinical management of TAAD patients varies, depending on the different forms. Starting from the description of patient history, in this paper, we summarized the state of the art concerning assessment of clinical/genetic profile and therapeutic management of TAAD patients.
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25
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Verstraeten A, Alaerts M, Van Laer L, Loeys B. Marfan Syndrome and Related Disorders: 25 Years of Gene Discovery. Hum Mutat 2016; 37:524-31. [DOI: 10.1002/humu.22977] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/09/2016] [Accepted: 02/18/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Aline Verstraeten
- Center of Medical Genetics, Faculty of Medicine and Health Sciences; University of Antwerp and Antwerp University Hospital; Antwerp Belgium
| | - Maaike Alaerts
- Center of Medical Genetics, Faculty of Medicine and Health Sciences; University of Antwerp and Antwerp University Hospital; Antwerp Belgium
| | - Lut Van Laer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences; University of Antwerp and Antwerp University Hospital; Antwerp Belgium
| | - Bart Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences; University of Antwerp and Antwerp University Hospital; Antwerp Belgium
- Department of Human Genetics; Radboud University Nijmegen Medical Center; Nijmegen The Netherlands
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Aboyans V, De Carlo M, Kownator S, Mazzolai L, Meneveau N, Ricco JB, Vlachopoulos C, Brodmann M. The year in cardiology 2015: peripheral circulation. Eur Heart J 2016; 37:676-85. [PMID: 26726049 DOI: 10.1093/eurheartj/ehv709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/03/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2, Martin Luther King Avenue, 87042 Limoges, France Inserm 1094, Tropical Neuroepidemiology, University of Limoges, Limoges, France
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Lucia Mazzolai
- Department of Angiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, Besançon, France
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Poitiers, Poitiers, France
| | - Charalambos Vlachopoulos
- Peripheral Vessels and Hypertension Units, 1st Department Cardiology, Athens Medical School, Athens, Greece
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27
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Recent progress in understanding the natural and clinical histories of the Marfan syndrome. Trends Cardiovasc Med 2016; 26:423-8. [PMID: 26908026 DOI: 10.1016/j.tcm.2015.12.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/27/2015] [Accepted: 12/30/2015] [Indexed: 11/21/2022]
Abstract
Over the past 4 decades, remarkable progress in understanding the cause, pathogenesis, and management of the MFS has led to an increase in life expectancy to near normal for most patients. Accompanying this increased life span has been the emergence of previously rare or unanticipated clinical problems. Despite much more detailed knowledge of the molecular, cellular, and tissue effects of a mutation in FBN1, targeted, effective therapy remains elusive. Until such precision medicine takes hold, management will depend on early diagnosis, regular scrutiny by imaging, chronic β-blockade, and perhaps ARBs, and prophylactic cardiothoracic surgery. Without question, MFS will remain a fertile subject for basic, translational, and clinical research for the foreseeable future.
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Isekame Y, Gati S, Aragon-Martin JA, Bastiaenen R, Kondapally Seshasai SR, Child A. Cardiovascular Management of Adults with Marfan Syndrome. Eur Cardiol 2016; 11:102-110. [PMID: 30310455 DOI: 10.15420/ecr/2016:19:2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Marfan syndrome (MFS) is a disease in which connective tissue becomes weak secondary to fibrillin-1 mutations, resulting in aortic dilatation, aneurysm formation, aortic dissection, aortic regurgitation and mitral valve prolapse. This autosomal dominantly inherited condition, which was first reported in 1895 and was more fully described in 1931, is characterised by abnormal Fibrillin-1 protein (FBN1) (discovered in 1990), which is encoded by the FBN1 gene (reported in 1991). In the 1970s, the life expectancy of people with MFS was 40-50 years, mainly due to increased risk of aortic dissection or heart failure from aortic or mitral regurgitation. However, due to advances in medical and surgical therapy, life expectancy has improved dramatically and is now comparable to that of the general population. We discuss the cardiac manifestations of MFS, the incidence of arrhythmia in this population, the standard of medical care for arrhythmia and valve insufficiency, and a new use of preventive medication to preserve the integrity of the aortic wall in patients with MFS.
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Affiliation(s)
- Yukiko Isekame
- Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | - Sabiha Gati
- Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | | | - Rachel Bastiaenen
- Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | | | - Anne Child
- Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
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TGF-β signalopathies as a paradigm for translational medicine. Eur J Med Genet 2015; 58:695-703. [DOI: 10.1016/j.ejmg.2015.10.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/15/2015] [Accepted: 10/18/2015] [Indexed: 11/19/2022]
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Singh MN, Lacro RV. Recent Clinical Drug Trials Evidence in Marfan Syndrome and Clinical Implications. Can J Cardiol 2015; 32:66-77. [PMID: 26724512 DOI: 10.1016/j.cjca.2015.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 01/08/2023] Open
Abstract
Marfan syndrome is a genetic disorder of connective tissue with principal manifestations in the cardiovascular, ocular, and skeletal systems. Cardiovascular disease, mainly progressive aortic root dilation and aortic dissection, is the leading cause of morbidity and mortality. The primary aims of this report were to examine the evidence related to medical therapy for Marfan syndrome, including recently completed randomized clinical trials on the efficacy of β-blockers and angiotensin II receptor blockers for the prophylactic treatment of aortic enlargement in Marfan syndrome, and to provide recommendations for medical therapy on the basis of available evidence. Medical therapy for Marfan syndrome should be individualized according to patient tolerance and risk factors such as age, aortic size, and family history of aortic dissection. The Pediatric Heart Network trial showed that atenolol and losartan each reduced the rate of aortic dilation. All patients with known or suspected Marfan syndrome and aortic root dilation should receive medical therapy with adequate doses of either β-blocker or angiotensin receptor blocker. The Pediatric Heart Network trial also showed that atenolol and losartan are more effective at reduction of aortic root z score in younger subjects, which suggests that medical therapy should be prescribed even in the youngest children with aortic dilation. For patients with Marfan syndrome without aortic dilation, the available evidence is less clear. If aortic dilation is severe and/or progressive, therapy with a combination of β-blocker and angiotensin receptor blocker should be considered, although trial results are mixed with respect to the efficacy of combination therapy vs monotherapy.
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Affiliation(s)
- Michael N Singh
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald V Lacro
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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Forteza A, Evangelista A, Sánchez V, Teixidó-Turà G, Sanz P, Gutiérrez L, Gracia T, Centeno J, Rodríguez-Palomares J, Rufilanchas JJ, Cortina J, Ferreira-González I, García-Dorado D. Efficacy of losartan vs. atenolol for the prevention of aortic dilation in Marfan syndrome: a randomized clinical trial. Eur Heart J 2015; 37:978-85. [DOI: 10.1093/eurheartj/ehv575] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 10/06/2015] [Indexed: 01/16/2023] Open
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Andelfinger G, Loeys B, Dietz H. A Decade of Discovery in the Genetic Understanding of Thoracic Aortic Disease. Can J Cardiol 2015; 32:13-25. [PMID: 26724507 DOI: 10.1016/j.cjca.2015.10.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 12/23/2022] Open
Abstract
Aortic aneurysms are responsible for a significant number of all deaths in Western countries. In this review we provide a perspective on the important progress made over the past decade in the understanding of the genetics of this condition, with an emphasis on the more frequent forms of vascular smooth muscle and transforming growth factor β (TGF-β) signalling alterations. For several nonsyndromic and syndromic forms of thoracic aortic disease, a genetic basis has now been identified, with 3 main pathomechanisms that have emerged: perturbation of the TGF-β signalling pathway, disruption of the vascular smooth muscle cell (VSMC) contractile apparatus, and impairment of extracellular matrix synthesis. Because smooth muscle cells and proteins of the extracellular matrix directly regulate TGF-β signalling, this latter pathway emerges as a key component of thoracic aortic disease initiation and progression. These discoveries have revolutionized our understanding of thoracic aortic disease and provided inroads toward gene-specific stratification of treatment. Last, we outline how these genetic findings are translated into novel pharmaceutical approaches for thoracic aortic disease.
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Affiliation(s)
- Gregor Andelfinger
- Cardiovascular Genetics, Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.
| | - Bart Loeys
- Centre for Medical Genetics, University Hospital of Antwerp/University of Antwerp, Antwerp, Belgium; Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hal Dietz
- Howard Hughes Medical Institute and Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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