1
|
Salahuddin M, Shahid S, Tariq U, Aqeel M, Arif AU, Aslam M, Sattar S. Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases. Respir Investig 2024; 62:69-74. [PMID: 37952288 DOI: 10.1016/j.resinv.2023.10.001] [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: 03/02/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Pulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform. METHODS This retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP. RESULTS The study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis. CONCLUSION Elevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.
Collapse
Affiliation(s)
- Moiz Salahuddin
- Department of Medicine, Aga Khan University, Karachi, Pakistan.
| | - Shayan Shahid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Umar Tariq
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Masooma Aqeel
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Usman Arif
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Mehwish Aslam
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Saadia Sattar
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| |
Collapse
|
2
|
Desai R, Katukuri N, Kanagala SG, Ghadge N, James A, Tajdin B, Nalla A, Vutukuru SD, Kotharu DM, Kadiyala A, Vyas A, Prajjwal P, Ogbu I. Examining prevalence and predictors of pulmonary hypertension in adults with idiopathic pulmonary fibrosis: a population-based analysis in the United States. J Med Life 2024; 17:35-40. [PMID: 38737661 PMCID: PMC11080510 DOI: 10.25122/jml-2023-0324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/14/2023] [Indexed: 05/14/2024] Open
Abstract
Pulmonary hypertension (PH) often complicates idiopathic pulmonary fibrosis (IPF), a progressive parenchymal lung disease. We investigated predictors of PH in IPF hospitalizations in the United States. We identified IPF hospital- izations with or without PH using the National Inpatient Sample (2018) and relevant ICD-10-CM codes. We com- pared demographics, comorbidities, PH prevalence, and its multivariable predictors adjusted for confounders among patients with IPF. In 2018, 30,335 patients from 30,259,863 hospitalizations had IPF, of which 8,075 (26.6%) had PH. Black (41%), Hispanic (21.3%), and female (28.7%) patients had higher rates of PH compared to white patients (25%). The IPF-PH cohort was hospitalized more often in urban teaching (77.7% vs. 72.2%), Midwest, and West hospitals vs. non-PH cohort. Comorbidities including congestive heart failure (2.08 [1.81-2.39]), valvular disease (2.12 [1.74-2.58]), rheumatoid arthritis/collagen vascular disease (1.32 [1.08-1.61]) predicted higher odds of PH. The PH-IPF cohort was less often routinely discharged (35.4%) and more likely to be transferred to intermediate care facilities (22.6%) and home health care (27.1%) (P < 0.001). The PH-IPF group had higher rates of all-cause mortality (12.3% vs. 9.4%), cardiogenic shock (2.4% vs. 1%), dysrhythmia (37.6% vs. 29%), and cardiac arrest (2.7% vs. 1.5%) vs. non-PH cohort (all P < 0.001). Patients with PH-IPF also had longer hospital stays (9 vs. 8) and a higher median cost ($23,054 vs. $19,627, P < 0.001). Nearly 25% of IPF hospitalizations with PH were linked to higher mortality, extended stays, and costs, emphasizing the need to integrate demographic and comorbidity predictors into risk stratification for improved outcomes in patients with IPF-PH.
Collapse
Affiliation(s)
- Rupak Desai
- Independent Outcomes Researcher, Atlanta, GA, USA
| | | | - Sai Gautham Kanagala
- Department of Internal Medicine, New York Medical College, New York City Health Hospitals Metropolitan, NY, USA
| | | | - Alpha James
- Department of Medicine, Bukovinian State Medical University, Chernivtsi, Ukraine
| | | | - Akhila Nalla
- Department of Internal Medicine, MNR Medical College, Telangana, India
| | | | | | - Avinash Kadiyala
- Department of Medicine, Deccan College of Medical Sciences, Hyderabad, Telangana, India
| | - Ankit Vyas
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas Beaumont, TX, USA
| | - Priyadarshi Prajjwal
- Department of Internal Medicine, Bharati Vidyapeeth University Medical College, Pune, India
| | - Ikechukwu Ogbu
- Department of Internal Medicine, Mountainview Hospital Sunrise GME, Las Vegas, NV, USA
| |
Collapse
|
3
|
Averjanovaitė V, Gumbienė L, Zeleckienė I, Šileikienė V. Unmasking a Silent Threat: Improving Pulmonary Hypertension Screening Methods for Interstitial Lung Disease Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:58. [PMID: 38256318 PMCID: PMC10820938 DOI: 10.3390/medicina60010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
This article provides a comprehensive overview of the latest literature on the diagnostics and treatment of pulmonary hypertension (PH) associated with interstitial lung disease (ILD). Heightened suspicion for PH arises when the advancement of dyspnoea in ILD patients diverges from the expected pattern of decline in pulmonary function parameters. The complexity of PH associated with ILD (PH-ILD) diagnostics is emphasized by the limitations of transthoracic echocardiography in the ILD population, necessitating the exploration of alternative diagnostic approaches. Cardiac magnetic resonance imaging (MRI) emerges as a promising tool, offering insights into hemodynamic parameters and providing valuable prognostic information. The potential of biomarkers, alongside pulmonary function and cardiopulmonary exercise tests, is explored for enhanced diagnostic and prognostic precision. While specific treatments for PH-ILD remain limited, recent studies on inhaled treprostinil provide new hope for improved patient outcomes.
Collapse
Affiliation(s)
| | - Lina Gumbienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania;
| | | | - Virginija Šileikienė
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania;
| |
Collapse
|
4
|
Hereijgers MJ, van der Velden RM, el Moussaoui N, Verhaert DV, Habibi Z, Luermans J, den Uijl D, Chaldoupi SM, Vernooy K, Schotten U, Baumert M, Gietema HA, Mihl C, Koltowski L, Franssen FM, Simons SO, Linz D. Repurposing catheter ablation work-up to detect expiratory airflow limitation in patients with atrial fibrillation. IJC HEART & VASCULATURE 2023; 49:101305. [PMID: 38053981 PMCID: PMC10694302 DOI: 10.1016/j.ijcha.2023.101305] [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: 10/11/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023]
Abstract
Background In atrial fibrillation (AF) patients, presence of expiratory airflow limitation may negatively impact treatment outcomes. AF patients are not routinely screened for expiratory airflow limitation, but existing examinations can help identify at-risk individuals. We aimed to assess the diagnostic value of repurposing existing assessments from the pre-ablation work-up to identify and understand the characteristics of affected patients. Methods We screened 110 consecutive AF patients scheduled for catheter ablation with handheld spirometry. Routine pre-ablation work-up included cardiac computed tomographic angiography (CCTA), transthoracic echocardiography and polygraphy. CCTA was analyzed qualitatively for emphysema and airway abnormalities. Multivariate logistic regression analysis was performed to determine predictors of expiratory airflow limitation. Results We found that 25 % of patients had expiratory airflow limitation, which was undiagnosed in 86 % of these patients. These patients were more likely to have pulmonary abnormalities on CCTA, including emphysema (odds ratio [OR] 4.2, 95 % confidence interval [CI] 1.12-15.1, p < 0.05) and bronchial wall thickening (OR 2.6, 95 % CI 1.0-6.5, p < 0.05). The absence of pulmonary abnormalities on CCTA accurately distinguished patients with normal lung function from those with airflow limitation (negative predictive value: 85 %). Echocardiography and polygraphy did not contribute significantly to identifying airflow limitation. Conclusions In conclusion, routine pre-ablation CCTA can detect pulmonary abnormalities in AF patients with airflow limitation, guiding further pulmonary assessment. Future studies should investigate its impact on ablation procedure success.
Collapse
Affiliation(s)
- Maartje J.M. Hereijgers
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Rachel M.J. van der Velden
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Nora el Moussaoui
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dominique V.M. Verhaert
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zarina Habibi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Justin Luermans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dennis den Uijl
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Mathias Baumert
- Discipline of Biomedical Engineering, The University of Adelaide, Adelaide, Australia
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Casper Mihl
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lukasz Koltowski
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Frits M.E. Franssen
- Department of Research and Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sami O. Simons
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
5
|
Li C, Lv J, Wumaier G, Zhao Y, Dong L, Zeng Y, Zhu N, Zhang X, Wang J, Xia J, Li S. NDRG1 promotes endothelial dysfunction and hypoxia-induced pulmonary hypertension by targeting TAF15. PRECISION CLINICAL MEDICINE 2023; 6:pbad024. [PMID: 37885911 PMCID: PMC10599394 DOI: 10.1093/pcmedi/pbad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
Background Pulmonary hypertension (PH) represents a threatening pathophysiologic state that can be induced by chronic hypoxia and is characterized by extensive vascular remodeling. However, the mechanism underlying hypoxia-induced vascular remodeling is not fully elucidated. Methods and Results By using quantitative polymerase chain reactions, western blotting, and immunohistochemistry, we demonstrate that the expression of N-myc downstream regulated gene-1 (NDRG1) is markedly increased in hypoxia-stimulated endothelial cells in a time-dependent manner as well as in human and rat endothelium lesions. To determine the role of NDRG1 in endothelial dysfunction, we performed loss-of-function studies using NDRG1 short hairpin RNAs and NDRG1 over-expression plasmids. In vitro, silencing NDRG1 attenuated proliferation, migration, and tube formation of human pulmonary artery endothelial cells (HPAECs) under hypoxia, while NDRG1 over-expression promoted these behaviors of HPAECs. Mechanistically, NDRG1 can directly interact with TATA-box binding protein associated factor 15 (TAF15) and promote its nuclear localization. Knockdown of TAF15 abrogated the effect of NDRG1 on the proliferation, migration and tube formation capacity of HPAECs. Bioinformatics studies found that TAF15 was involved in regulating PI3K-Akt, p53, and hypoxia-inducible factor 1 (HIF-1) signaling pathways, which have been proved to be PH-related pathways. In addition, vascular remodeling and right ventricular hypertrophy induced by hypoxia were markedly alleviated in NDRG1 knock-down rats compared with their wild-type littermates. Conclusions Taken together, our results indicate that hypoxia-induced upregulation of NDRG1 contributes to endothelial dysfunction through targeting TAF15, which ultimately contributes to the development of hypoxia-induced PH.
Collapse
Affiliation(s)
- Chengwei Li
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Junzhu Lv
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Gulinuer Wumaier
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yu Zhao
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Liang Dong
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuzhen Zeng
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Ning Zhu
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiujuan Zhang
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Wang
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jingwen Xia
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Shengqing Li
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| |
Collapse
|
6
|
Weiss T, Near AM, Zhao X, Ramey DR, Banerji T, Xie H, Nathan SD. Healthcare resource utilization in patients with pulmonary hypertension associated with chronic obstructive pulmonary disease (PH-COPD): a real-world data analysis. BMC Pulm Med 2023; 23:455. [PMID: 37990203 PMCID: PMC10664271 DOI: 10.1186/s12890-023-02698-9] [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: 04/18/2023] [Accepted: 10/06/2023] [Indexed: 11/23/2023] Open
Abstract
RATIONALE There is a lack of real-world characterization of healthcare costs and associated cost drivers in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease (PH-COPD). OBJECTIVES To examine (1) excess healthcare resource utilization (HCRU) and associated costs in patients with PH-COPD compared to COPD patients without PH; and (2) patient characteristics that are associated with higher healthcare costs in patients with PH-COPD. METHODS This study analyzed data from the IQVIA PharMetrics® Plus database (OCT2014-MAY2020). Patients with PH-COPD were identified by a claims-based algorithm based on PH diagnosis (ICD-10-CM: I27.0, I27.2, I27.20, I27.21, I27.23) after COPD diagnosis. Patients aged ≥40 years and with data available ≥12 months before (baseline) and ≥6 months after (follow-up) the first observed PH diagnosis were included. Patients with other non-asthma chronic pulmonary diseases, PH associated with other causes, cancer, left-sided heart failure (HF), PH before the first observed COPD diagnosis, or right-sided/unspecified HF during baseline were excluded. Patients in the PH-COPD cohort were matched 1:1 to COPD patients without PH based on propensity scores derived from baseline patient characteristics. Annualized all-cause and COPD/PH-related (indicated by a primary diagnosis of COPD or PH) HCRU and costs during follow-up were compared between the matched cohorts. Baseline patient characteristics associated with higher total costs were examined in a generalized linear model in the PH-COPD cohort. RESULTS A total of 2,224 patients with PH-COPD were identified and matched to COPD patients without PH. Patients with PH-COPD had higher all-cause HCRU and annual healthcare costs ($51,435 vs. $18,412, p<0.001) than matched COPD patients without PH. Among patients with PH-COPD, costs were primarily driven by hospitalizations (57%), while COPD/PH-related costs accounted for 13% of all-cause costs. Having a higher comorbidity burden and a prior history of COPD exacerbation were major risk factors for higher total all-cause costs among patients with PH-COPD. CONCLUSIONS Treatment strategies focusing on preventing hospitalizations and managing comorbidities may help reduce the burden of PH-COPD.
Collapse
Affiliation(s)
- Tracey Weiss
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 351 N Sumneytown Pike, PA, North Wales, 19454, USA.
| | | | | | - Dena Rosen Ramey
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 351 N Sumneytown Pike, PA, North Wales, 19454, USA
| | | | | | - Steven D Nathan
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| |
Collapse
|
7
|
Haynes ZA, Chandel A, King CS. Pulmonary Hypertension in Interstitial Lung Disease: Updates in Disease, Diagnosis, and Therapeutics. Cells 2023; 12:2394. [PMID: 37830608 PMCID: PMC10572438 DOI: 10.3390/cells12192394] [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: 07/02/2023] [Revised: 08/15/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
Pulmonary hypertension is a debilitating condition that frequently develops in the setting of interstitial lung disease, likely related to chronic alveolar hypoxemia and pulmonary vascular remodeling. This disease process is likely to be identified more frequently by providers given recent advancements in definitions and diagnostic modalities, and provides practitioners with emerging opportunities to improve patient outcomes and quality of life. Despite years of data suggesting against the efficacy of pulmonary vasodilator therapy in patients with pulmonary hypertension due to interstitial lung disease, new data have emerged identifying promising advancements in therapeutics. The authors present to you a comprehensive review of pulmonary hypertension in interstitial lung disease, reviewing our current understanding of pathophysiology, updates in diagnostic approaches, and highlights of recent clinical trials which provide an effective approach for medical management.
Collapse
Affiliation(s)
- Zachary A. Haynes
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Fairfax, VA 22031, USA;
| |
Collapse
|
8
|
Olsson KM, Corte TJ, Kamp JC, Montani D, Nathan SD, Neubert L, Price LC, Kiely DG. Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:820-835. [PMID: 37591300 DOI: 10.1016/s2213-2600(23)00259-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/19/2023]
Abstract
Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.
Collapse
Affiliation(s)
- Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany.
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Jan C Kamp
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, INSERM Unité Mixte de Recherche 999, Université Paris-Saclay, Paris, France
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; NIHR Biomedical Research Centre, Sheffield, UK
| |
Collapse
|
9
|
Oliveira AC, Karas MM, Alves M, He J, de Kloet AD, Krause EG, Richards EM, Bryant AJ, Raizada MK. ACE2 overexpression in corticotropin-releasing-hormone cells offers protection against pulmonary hypertension. Front Neurosci 2023; 17:1223733. [PMID: 37638323 PMCID: PMC10447887 DOI: 10.3389/fnins.2023.1223733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 08/29/2023] Open
Abstract
Background Pulmonary hypertension (PH), characterized by elevated pulmonary pressure and right heart failure, is a systemic disease involving inappropriate sympathetic activation and an impaired gut-brain-lung axis. Global overexpression of angiotensin converting enzyme 2 (ACE2), a cardiopulmonary protective enzyme of the renin-angiotensin system, attenuates PH induced by chronic hypoxia. Neurons within the paraventricular nucleus of the hypothalamus (PVN) that synthesize corticotropin-releasing hormone (CRH) are activated by stressors, like hypoxia, and this activation augments sympathetic outflow to cardiovascular tissues. These data coupled with our observations that ACE2 overexpression in CRH cells (CRH-ACE2KI mice) decreases anxiety-like behavior via suppression of hypothalamic-pituitary-adrenal (HPA) axis activity by decreasing CRH synthesis, led us to hypothesize that selective ACE2 overexpression in CRH neurons would protect against hypoxia-induced PH. Methods CRH-ACE2KI and WT male and female mice were exposed to chronic hypoxia (10%O2) or normoxia (21%O2) for 4 weeks in a ventilated chamber with continuous monitoring of oxygen and carbon dioxide concentrations (n = 7-10/group). Pulmonary hemodynamics were measured with Millar pressure catheters then tissues were collected for histological analyses. Results Chronic hypoxia induced a significant increase (36.4%) in right ventricular (RV) systolic pressure (RVSP) in WT mice, which was not observed in CRH-ACE2KI mice. No significant differences in RVSP were observed between male and female mice in any of the groups. Conclusion Overexpression of ACE2 in CRH cells was protective against hypoxia-induced PH. Since the majority of expression of CRH is in brain nuclei such as paraventricular nucleus of the hypothalamus (PVN) and/or central nucleus of the amygdala (CeA) these data indicate that the protective effects of ACE2 are, at least in part, centrally mediated. This contributes to the systemic nature of PH disease and that CRH neurons may play an important role in PH.
Collapse
Affiliation(s)
- Aline C. Oliveira
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Marianthi M. Karas
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Matthew Alves
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Jacky He
- Evelyn F. and William L. McKnight Brain Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Annette D. de Kloet
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Eric G. Krause
- Evelyn F. and William L. McKnight Brain Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville, FL, United States
| | - Elaine M. Richards
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Andrew J. Bryant
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mohan K. Raizada
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL, United States
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville, FL, United States
| |
Collapse
|
10
|
Antwi-Boasiako C, Kollie MF, Kyeremeh KA, Osei-Tutu JK, Musah L, Vormatu P, Tei RK, Hanson T, Sackitey-Ninye SE, Quartey-Papafio TR, Hayfron-Benjamin CF. Associations between spirometric measures and exercise capacity in type 2 diabetes. Diabetes Metab Syndr 2023; 17:102831. [PMID: 37487361 DOI: 10.1016/j.dsx.2023.102831] [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: 04/30/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Physical exercise aids glycemic control and the prevention of diabetes-related complications. However, exercise beyond an individual's pulmonary functional capacity may be detrimental. To date, little is known about the relationship between pulmonary function and exercise capacity in people with type 2 diabetes (T2D). We investigated the relationship between pulmonary function and exercise capacity in T2D. METHODS Spirometry and 6-min walk test (6MWT) were conducted for 263 systematically sampled adults with T2D without primary heart/lung disease. The primary measure of exercise capacity was the 6-min walk distance (6MWD); impaired exercise capacity was defined as 6MWD<400 m. Logistic regression analyses were used to assess the associations between spirometric measures and exercise capacity with adjustments for age, sex, height, body mass index, diabetes duration, glycated hemoglobin concentration, smoking, suboptimum blood pressure control, and total cholesterol concentration. RESULTS Compared with individuals with normal spirometry, those with pulmonary restriction/obstruction had significantly lower 6MWD (404.67 m vs. 451.70),p < 0.001). The proportion of individuals with impaired exercise capacity was higher in individuals with impaired pulmonary function compared with those with normal pulmonary function (39.8% vs. 20.7%,p = 0.001). In the unadjusted models, decreasing Z-score FEV1 [odds ratio 1.40, 95% confidence interval (1.07-1.83),p = 0.013] and Z-score FVC [1.37 (1.06-1.76),0.016], but not Z-score FEV1/FVC ratio [1.00 (0.78-1.27),0.972] were significantly associated with impaired exercise capacity. In the fully adjusted model, the strength of association remained statistically significant for Z-score FEV1 [1.60 (1.06-2.41),0.025] but not Z-score FVC [1.48 (0.98-2.23),0.065]. CONCLUSIONS Our study shows inverse associations between FEV1 and impaired exercise capacity in T2D, Future research could characterize optimal exercise levels based on a patient's FEV1.
Collapse
Affiliation(s)
- Charles Antwi-Boasiako
- Department of Physiology, University of Ghana Medical School, Ghana; College of Nursing, University of Wisconsin-Milwaukee, United States
| | - Mulbah Fasama Kollie
- Department of Physiology, University of Ghana Medical School, Ghana; AM Dogliotti College of Medicine, University of Liberia, Liberia
| | | | | | - Latif Musah
- Department of Physiology, University of Ghana Medical School, Ghana
| | - Patience Vormatu
- Department of Biomedical Sciences, University of Cape Coast, Ghana
| | - Ruth Korkor Tei
- Department of Medicine and Therapeutics, University of Ghana Medical School, Ghana
| | - Tracy Hanson
- Department of Physiology, University of Ghana Medical School, Ghana
| | | | - Theresa Ruby Quartey-Papafio
- Department of Anaesthesia and Critical Care, University of Ghana Medical School and Korle Bu Teaching Hospital, Ghana
| | - Charles F Hayfron-Benjamin
- Department of Physiology, University of Ghana Medical School, Ghana; Department of Respiratory Medicine and Department of Pediatric Respiratory Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Internal and Vascular Medicine, Amsterdam UMC, University of Amsterdam, Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Anaesthesia and Critical Care, University of Ghana Medical School and Korle Bu Teaching Hospital, Ghana.
| |
Collapse
|
11
|
Santos-Ribeiro D, Lecocq M, de Beukelaer M, Verleden S, Bouzin C, Ambroise J, Dorfmuller P, Yakoub Y, Huaux F, Quarck R, Karmouty-Quintana H, Ghigna MR, Bignard J, Nadaud S, Soubrier F, Horman S, Perros F, Godinas L, Pilette C. Disruption of GCN2 Pathway Aggravates Vascular and Parenchymal Remodeling during Pulmonary Fibrosis. Am J Respir Cell Mol Biol 2023; 68:326-338. [PMID: 36476191 DOI: 10.1165/rcmb.2021-0541oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pulmonary fibrosis (PF) and pulmonary hypertension (PH) are chronic diseases of the pulmonary parenchyma and circulation, respectively, which may coexist, but underlying mechanisms remain elusive. Mutations in the GCN2 (general control nonderepressible 2) gene (EIF2AK4 [eukaryotic translation initiation factor 2 alpha kinase 4]) were recently associated with pulmonary veno-occlusive disease. The aim of this study is to explore the involvement of the GCN2/eIF2α (eukaryotic initiation factor 2α) pathway in the development of PH during PF, in both human disease and in a laboratory animal model. Lung tissue from patients with PF with or without PH was collected at the time of lung transplantation, and control tissue was obtained from tumor resection surgery. Experimental lung disease was induced in either male wild-type or EIF2AK4-mutated Sprague-Dawley rats, randomly receiving a single intratracheal instillation of bleomycin or saline. Hemodynamic studies and organ collection were performed 3 weeks after instillation. Only significant results (P < 0.05) are presented. In PF lung tissue, GCN2 protein expression was decreased compared with control tissue. GCN2 expression was reduced in CD31+ endothelial cells. In line with human data, GCN2 protein expression was decreased in the lung of bleomycin rats compared with saline. EIF2AK4-mutated rats treated with bleomycin showed increased parenchymal fibrosis (hydroxyproline concentrations) and vascular remodeling (media wall thickness) as well as increased right ventricular systolic pressure compared with wild-type animals. Our data show that GCN2 is dysregulated in both humans and in an animal model of combined PF and PH. The possibility of a causative implication of GCN2 dysregulation in PF and/or PH development should be further studied.
Collapse
Affiliation(s)
| | | | | | - Stijn Verleden
- Laboratory of Respiratory Diseases & Thoracic Surgery, Department of Chronic Diseases and Metabolism, and
| | | | | | - Peter Dorfmuller
- Department of Pathology, University of Giessen and Marburg Lung Center, Justus-Liebig University Giessen, German Center for Lung Research, Giessen, Germany
| | - Yousef Yakoub
- Louvain Center for Toxicology and Applied Pharmacology, and
| | - François Huaux
- Louvain Center for Toxicology and Applied Pharmacology, and
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals - University of Leuven, Leuven, Belgium
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology and.,Division of Critical Care and.,Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Maria-Rosa Ghigna
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Département de Pathologie and.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | | | - Sophie Nadaud
- UMR_S 1166-ICAN, INSERM, Sorbonne Université, Paris, France
| | | | - Sandrine Horman
- Cardiovascular Research Unit, Institute of Experimental and Clinical Research, Catholic University of Louvain, Brussels, Belgium
| | - Frederic Perros
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique-Hôpitaux de Paris, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Laboratoire CarMeN, UMR INSERM U1060/INRA U1397, Université Claude Bernard Lyon1, Pierre-Bénite and Bron, France; and
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals - University of Leuven, Leuven, Belgium
| | - Charles Pilette
- Pneumology, ENT and Dermatology.,Département de Pneumologie, Cliniques Universitaires St-Luc, Brussels, Belgium
| |
Collapse
|
12
|
Lung Volume Reduction Surgery Reduces Pulmonary Arterial Hypertension Associated With Severe Lung Emphysema and Hypercapnia. ASAIO J 2023; 69:218-224. [PMID: 35417422 DOI: 10.1097/mat.0000000000001735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Lung volume reduction surgery (LVRS) represents a standard surgical approach for patients with severe pulmonary emphysema. One of the relevant risk factors for LVRS is the presence of pulmonary arterial hypertension (PAH). The aim of this study is to assess the postoperative changes in pulmonary arterial pressure (PAP) after LVRS for patients with severe pulmonary emphysema compared with preoperative measures. N = 61 consecutive patients with severe pulmonary emphysema and preoperative evidence for PAH (pulmonary arterial systolic pressure [PASP] ≥ 35 mmHg) were prospectively included into this study. In all patients, thoracoscopic LVRS was performed. PASP was assessed by echocardiography before surgery, early postoperatively, and 3 months after surgery. Data were prospectively recorded and analyzed retrospectively. Primary end points were the postoperative changes in PASP as well as the 90 day mortality rate. Secondary endpoints included: pulmonary function test, exercise capacity, quality of life, and dyspnea symptoms (Borg scale). Early after surgery, a significant reduction in PASP was observed at the day of discharge and at 3 month follow-up. In n = 34 patients, no tricuspid valve regurgitation was detectable anymore suggesting normal PAP. In n = 3 patients, venovenous extracorporeal lung support (VV ECLS) was already implemented preoperatively. In the remaining cases, VV ECLS was applied intraoperatively and continued postoperatively. Mean duration of postoperative ECLS support was 2 days. Four patients died due to acute right heart failure, two patients from sepsis with multiorgan failure, and one patient from acute pulmonary embolism. Ninety day mortality was 11.5 %. A significant improvement was postoperatively observed regarding the performance status, dyspnea scale, as well as quality of life. This study suggests a beneficial effect of LVRS on PAP, which may ultimately help to protect and stabilize right ventricular function. Further studies, implementing pre- and postoperative right heart catheterizations including invasive PAP evaluation, are necessary to support the findings in this study in greater detail.
Collapse
|
13
|
Li C, Xia J, Yiminniyaze R, Dong L, Li S. Hub Genes and Immune Cell Infiltration in Hypoxia-Induced Pulmonary Hypertension: Bioinformatics Analysis and In Vivo Validation. Comb Chem High Throughput Screen 2023; 26:2085-2097. [PMID: 36718060 DOI: 10.2174/1386207326666230130093325] [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: 09/23/2022] [Revised: 12/27/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hypoxia-induced pulmonary hypertension (HPH) represents a severe pulmonary disorder with high morbidity and mortality, which necessitates identifying the critical molecular mechanisms underlying HPH pathogenesis. METHODS The mRNA expression microarray GSE15197 (containing 8 pulmonary tissues from HPH and 13 normal controls) was downloaded from Gene Expression Omnibus (GEO). Gene ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) were executed by RStudio software. The Protein-Protein Interaction (PPI) network was visualized and established using Cytoscape, and the cytoHubba app from Cytoscape was used to pick out the hub modules. The infiltration of immune cells in HPH was analyzed using the CIBERSORTx. To confirm the potential hub genes, real-time quantitative reverse transcription PCR (qRT-PCR) was conducted using lung tissues of rat HPH models and controls. RESULTS A total of 852 upregulated and 547 downregulated genes were identified. The top terms in biological processes were apoptosis, proliferation, and regulation of the MAPK cascade, including ERK1/2. Cytoplasm, cytosol, and membrane were enriched in cellular component groups. Molecular functions mainly focus on protein binding, protein serine/threonine kinase activity and identical protein binding. KEGG analysis identified pathways in cancer, regulation of actin cytoskeleton and rap1 signaling pathway. There was significantly different immune cell infiltration between HPH and normal control samples. High proportions of the memory subsets of B cells and CD4 cells, Macrophages M2 subtype, and resting Dendritic cells were found in HPH samples, while high proportions of naive CD4 cells and resting mast cells were found in normal control samples. The qRT-PCR results showed that among the ten identified hub modules, FBXL3, FBXL13 and XCL1 mRNA levels were upregulated, while NEDD4L, NPFFR2 and EDN3 were downregulated in HPH rats compared with control rats. CONCLUSION Our study revealed the key genes and the involvement of immune cell infiltration in HPH, thus providing new insight into the pathogenesis of HPH and potential treatment targets for patients with HPH.
Collapse
Affiliation(s)
- Chengwei Li
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Jingwen Xia
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Ruzetuoheti Yiminniyaze
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Liang Dong
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Shengqing Li
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| |
Collapse
|
14
|
Krompa A, Marino P. Diagnosis and management of pulmonary hypertension related to chronic respiratory disease. Breathe (Sheff) 2022; 18:220205. [PMID: 36865930 PMCID: PMC9973528 DOI: 10.1183/20734735.0205-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/03/2022] [Indexed: 01/12/2023] Open
Abstract
Pulmonary hypertension (PH) is a recognised and significant complication of chronic lung disease (CLD) and hypoxia (referred to as group 3 PH) that is associated with increased morbidity, decreased quality of life and worse survival. The prevalence and severity of group 3 PH varies within the current literature, with the majority of CLD-PH patients tending to have non-severe disease. The aetiology of this condition is multifactorial and complex, while the prevailing pathogenetic mechanisms include hypoxic vasoconstriction, parenchymal lung (and vascular bed) destruction, vascular remodelling and inflammation. Comorbidities such as left heart dysfunction and thromboembolic disease can further confound the clinical picture. Noninvasive assessment is initially undertaken in suspected cases (e.g. cardiac biomarkers, lung function, echocardiogram), while haemodynamic evaluation with right heart catheterisation remains the diagnostic gold standard. For patients with suspected severe PH, those with a pulmonary vascular phenotype or when there is uncertainty regarding further management, referral to specialist PH centres for further investigation and definitive management is mandated. No disease-specific therapy is currently available for group 3 PH and the focus of management remains optimisation of the underlying lung therapy, along with treating hypoventilation syndromes as indicated.
Collapse
Affiliation(s)
- Anastasia Krompa
- Lane Fox Respiratory Service, Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Philip Marino
- Lane Fox Respiratory Service, Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK,Corresponding author: Philip Marino ()
| |
Collapse
|
15
|
Waxman AB, Elia D, Adir Y, Humbert M, Harari S. Recent advances in the management of pulmonary hypertension with interstitial lung disease. Eur Respir Rev 2022; 31:31/165/210220. [PMID: 35831007 DOI: 10.1183/16000617.0220-2021] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 05/23/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary hypertension (PH) is known to complicate various forms of interstitial lung disease (ILD), including idiopathic pulmonary fibrosis, the interstitial pneumonias and chronic hypersensitivity pneumonitis. Pathogenesis of PH-ILD remains incompletely understood, and probably has overlap with other forms of pre-capillary pulmonary hypertension. PH-ILD carries a poor prognosis, and is associated with increased oxygen requirements, and a decline in functional capacity and exercise tolerance. Despite most patients having mild-moderate pulmonary hypertension, more severe pulmonary hypertension and signs of right heart failure are observed in a subset of cases. Clinical suspicion and findings on pulmonary function, computed tomography and echocardiography are often the initial steps towards diagnosis. Definitive diagnosis is obtained by right heart catheterisation demonstrating pre-capillary pulmonary hypertension. Drugs approved for pulmonary arterial hypertension have been investigated in several randomised controlled trials in PH-ILD patients, leading to discouraging results until the recent INCREASE study. This review provides an overview of the current understanding, approach to diagnosis and recent advances in treatment.
Collapse
Affiliation(s)
- Aaron B Waxman
- Center for Pulmonary Heart Disease, Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Davide Elia
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Milan, Italy
| | - Yochai Adir
- Pulmonology Division, Lady Davis-Carmel Medical Center, Haifa, Israel.,Bruce and Ruth Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Marc Humbert
- Université Paris-Saclay, INSERM UMR_S 999, Assistance Publique Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sergio Harari
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Milan, Italy.,Dept of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
16
|
Singh B, Singh S, Bhatia JK, Kapoor R, Bhatia K. Role of Matrix Degradation, Oxidative Stress, Inflammation & Trace Elements in COVID-19 Patients: A Multivariate Study from India. Indian J Clin Biochem 2022; 38:193-203. [PMID: 36090302 PMCID: PMC9446610 DOI: 10.1007/s12291-022-01059-3] [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: 04/18/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
The interrelationship between matrix degradation, oxidative stress, inflammation and trace elements can be speculated in COVID-19. The objective of the study was to evaluate the oxidative stress, inflammation and matrix degradation markers and trace elements in COVID-19 positive patients. A group of confirmed severe COVID-19 positive patients (n = 30) along with COVID-19 negative patients (n = 30) with similar symptoms were included. Both group of patients were assessed for oxidative stress markers, inflammatory cytokines, matrix metalloproteinase (MMP)s and their inhibitors along with trace elements in blood. All the data were subjected to univariate as well as multivariate analysis including PCA, PLS-DA, OPLS-DA. Diagnostic accuracy was tested by ROC curve analysis. Further relationship with Neutrophil/ lymphocyte (N/L) ratio was established if any. Increased oxidative stress, inflammation and matrix degradation is evidenced by significant rise in oxidative markers, inflammatory cytokines and MMP9/TIMP-1 ratio. Decreased Cu/Zn ratio is also observed in COVID-19 positive patients. Multivariate analysis identified SOD, Cu/Zn ratio, IL-6 and TOS, as effective discriminant among the two groups of patients. Further, accuracy was confirmed by ROC curves. Neutrophil/ lymphocyte (N/L) ratio, shows significant negative association with SOD (r= -0.75, p < 0.005) and Cu/Zn ratio (r = -0.88, p < 0.005). These data suggest the attributes of these biomarkers in disease severity. The potential use of these blood-based laboratory markers in disease prognosis seems promising and warrants further attention. Given by the symptoms and severity of the disease, it will be promising to monitor Cu/Zn ratio along with other prognostic indicators.
Collapse
Affiliation(s)
- Brajesh Singh
- Department of Lab Sciences, Command Hospital (EC), Kolkata, West Bengal India
| | - Smiti Singh
- School of Public health, KIIT University, Bhubaneswar, Odisha India
| | - J K Bhatia
- Department of Lab Sciences, Command Hospital (EC), Kolkata, West Bengal India
| | - Rajan Kapoor
- Department of Lab Sciences, Command Hospital (EC), Kolkata, West Bengal India
| | - Kapil Bhatia
- Department of Lab Sciences, Command Hospital (EC), Kolkata, West Bengal India
| |
Collapse
|
17
|
Nikkho SM, Richter MJ, Shen E, Abman SH, Antoniou K, Chung J, Fernandes P, Hassoun P, Lazarus HM, Olschewski H, Piccari L, Psotka M, Saggar R, Shlobin OA, Stockbridge N, Vitulo P, Vizza CD, John Wort S, Nathan SD. CLINICAL SIGNIFICANCE OF PULMONARY HYPERTENSION IN INTERSTITIAL LUNG DISEASE A Consensus Statement from The Pulmonary Vascular Research Institute's Innovative Drug Development Initiative ‐ Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12127. [PMID: 36016668 PMCID: PMC9395696 DOI: 10.1002/pul2.12127] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Pulmonary hypertension (PH) has been linked to worse outcomes in chronic lung diseases. The presence of PH in the setting of underlying Interstitial Lung Disease (ILD) is strongly associated with decreased exercise and functional capacity, an increased risk of hospitalizations and death. Examining the scope of this issue and its impact on patients is the first step in trying to define a roadmap to facilitate and encourage future research in this area. The aim of our working group is to strengthen the communities understanding of PH due to lung diseases and to improve the care and quality of life of affected patients. This introductory statement provides a broad overview and lays the foundation for further in‐depth papers on specific topics pertaining to PH‐ILD.
Collapse
Affiliation(s)
| | - Manuel J. Richter
- Department of Internal Medicine Pulmonary Hypertension Division Universities of Giessen and Marburg Lung Center (UGMLC) Germany
| | - Eric Shen
- United Therapeutics Corporation, Global Medical Affairs Silver Spring MD USA
| | - Steven H. Abman
- University of Colorado ‐ Anschutz Medical Campus School of Medicine and Children's Hospital Aurora CO USA
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic Medicine Heraklion Crete Greece
| | - Jonathan Chung
- Department of Radiology The University of Chicago Medicine Chicago IL USA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc, Regulatory Safety and Quality Department Warren NJ USA
| | - Paul Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Johns Hopkins University Baltimore MD
| | | | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine Medical University of Graz Graz Steiermark Austria
| | - Lucilla Piccari
- Department of Pulmonary Medicine Hospital del Mar, Pulmonary Hypertension Unit Barcelona Catalunya Spain
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; 2. Division of Cardiology and Nephrology Food and Drug Administration Silver Spring MD
| | - Rajan Saggar
- University of California Los Angeles David Geffen School of Medicine Lung & Heart‐Lung Transplant and Pulmonary Hypertension Programs Los Angeles CA USA
| | - Oksana A. Shlobin
- Inova Health System, Advanced Lung Disease and Transplant Program Falls Church VA USA
| | - Norman Stockbridge
- US Food and Drug Administration Division of Cardiology and Nephrology Silver Spring MD USA
| | - Patrizio Vitulo
- IRCCS Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Department of Pulmonary Medicine Palermo Sicilia Italy
| | | | - S. John Wort
- National Pulmonary Hypertension Service at Royal Brompton Hospital London. UK. National Heart and Lung Institute, Imperial College London UK
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program Inova Heart and Vascular Institute Falls Church Virginia
| |
Collapse
|
18
|
Bryant AJ, Ebrahimi E, Nguyen A, Wolff CA, Gumz ML, Liu AC, Esser KA. A wrinkle in time: circadian biology in pulmonary vascular health and disease. Am J Physiol Lung Cell Mol Physiol 2022; 322:L84-L101. [PMID: 34850650 PMCID: PMC8759967 DOI: 10.1152/ajplung.00037.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
An often overlooked element of pulmonary vascular disease is time. Cellular responses to time, which are regulated directly by the core circadian clock, have only recently been elucidated. Despite an extensive collection of data regarding the role of rhythmic contribution to disease pathogenesis (such as systemic hypertension, coronary artery, and renal disease), the roles of key circadian transcription factors in pulmonary hypertension remain understudied. This is despite a large degree of overlap in the pulmonary hypertension and circadian rhythm fields, not only including shared signaling pathways, but also cell-specific effects of the core clock that are known to result in both protective and adverse lung vessel changes. Therefore, the goal of this review is to summarize the current dialogue regarding common pathways in circadian biology, with a specific emphasis on its implications in the progression of pulmonary hypertension. In this work, we emphasize specific proteins involved in the regulation of the core molecular clock while noting the circadian cell-specific changes relevant to vascular remodeling. Finally, we apply this knowledge to the optimization of medical therapy, with a focus on sleep hygiene and the role of chronopharmacology in patients with this disease. In dissecting the unique relationship between time and cellular biology, we aim to provide valuable insight into the practical implications of considering time as a therapeutic variable. Armed with this information, physicians will be positioned to more efficiently use the full four dimensions of patient care, resulting in improved morbidity and mortality of pulmonary hypertension patients.
Collapse
Affiliation(s)
- Andrew J. Bryant
- 1Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Elnaz Ebrahimi
- 1Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Amy Nguyen
- 1Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Christopher A. Wolff
- 2Department of Physiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michelle L. Gumz
- 2Department of Physiology, University of Florida College of Medicine, Gainesville, Florida
| | - Andrew C. Liu
- 2Department of Physiology, University of Florida College of Medicine, Gainesville, Florida
| | - Karyn A. Esser
- 2Department of Physiology, University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
19
|
Cook DP, Xu M, Martucci VL, Annis JS, Aldrich MC, Hemnes AR, Brittain EL. Clinical insights into pulmonary hypertension in chronic obstructive pulmonary disease. Pulm Circ 2022; 12:e12006. [PMID: 35506103 PMCID: PMC9052979 DOI: 10.1002/pul2.12006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD). Little is known about the prevalence and clinical profiles of patients with COPD-PH. We report the clinical characteristics, hemodynamic profiles, and prognosis in a large population of patients with COPD referred for right heart catheterization (RHC). We extracted data from all patients referred for RHC between 1997 and 2017 in Vanderbilt's deidentified medical record. PH was defined as mean pulmonary artery pressure >20 mmHg. Pre- and postcapillary PH were defined according to contemporary guidelines. COPD was identified using a validated rules-based algorithm requiring international classification of diseases codes relevant to COPD. We identified 6065 patients referred for RHC, of whom 1509 (24.9%) had COPD and 1213 had COPD and PH. Patients with COPD-PH had a higher prevalence of diabetes, atrial fibrillation, and heart failure compared with COPD without PH. Approximately 55% of patients with COPD-PH had elevated left ventricle (LV) filling pressure. Pulmonary function testing data from individuals with COPD-PH revealed subtype differences, with precapillary COPD-PH having lower diffusion capacity of the lungs for carbon monoxide (DLCO) values than the other COPD-PH subtypes. Patients with COPD-PH had significantly increased mortality compared with COPD alone (hazard ratio [HR]: 1.70, 95% confidence interval [CI]: 1.28-2.26) with the highest mortality among the combined pre- and postcapillary COPD-PH subgroup (HR: 2.39; 95% CI: 1.64-3.47). PH is common among patients with COPD referred for RHC. The etiology of PH in patients with COPD is often mixed due to multimorbidity and is associated with high mortality, which may have implications for risk factor management.
Collapse
Affiliation(s)
- Daniel P. Cook
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Meng Xu
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Victoria L. Martucci
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jeffrey S. Annis
- Department of Vanderbilt Institute for Clinical and Translational ResearchVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Melinda C. Aldrich
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Evan L. Brittain
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| |
Collapse
|
20
|
Abstract
Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.
Collapse
Affiliation(s)
- Kareem Ahmad
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Vikramjit Khangoora
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Steven D Nathan
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
| |
Collapse
|
21
|
Applegate TJ, Krafsur GM, Boon JA, Zhang H, Li M, Holt TN, Ambler SK, Abrams BA, Gustafson DL, Bartels K, Garry FB, Stenmark KR, Brown RD. Brief Report: Case Comparison of Therapy With the Histone Deacetylase Inhibitor Vorinostat in a Neonatal Calf Model of Pulmonary Hypertension. Front Physiol 2021; 12:712583. [PMID: 34552503 PMCID: PMC8450341 DOI: 10.3389/fphys.2021.712583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension (PH) is an incurable condition in humans; driven by pulmonary vascular remodeling partially mediated by epigenetic mechanisms; and leading to right ventricular hypertrophy, failure, and death. We hypothesized that targeting chromatin-modifying histone deacetylases may provide benefit. In this Brief Report we describe case comparison studies using the histone deacetylase inhibitor vorinostat (suberanilohydroxamic acid, 5 mg/kg/day for the first 5 study days) in an established model of severe neonatal bovine PH induced by 14 days of environmental hypoxia. Echocardiographic, hemodynamic, and pharmacokinetic data were obtained in hypoxia-exposed (one each, vorinostat-treated vs. untreated) and normoxic vorinostat-treated control animals (n = 2). Echocardiography detected PH changes by day 4 and severe PH over 14 days of continued hypoxic exposure. RV dysfunction at day 4 was less severe in vorinostat-treated compared to untreated hypoxic calves. Cardioprotective effects were partially maintained following cessation of treatment through the duration of hypoxic exposure, accompanied by hemodynamic evidence suggestive of reduced pulmonary vascular stiffening, and modulated expression of HDAC1 protein and genes involved in RV and pulmonary vascular remodeling and pathological RV hypertrophy. Control calves did not develop PH, nor show adverse cardiac or clinical effects. These results provide novel translation of epigenetic-directed therapy to a large animal severe PH model that recapitulates important features of human disease.
Collapse
Affiliation(s)
- Tanya J Applegate
- Department of Clinical Sciences, Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, CO, United States
| | - Greta M Krafsur
- Division of Clinical Research, Medicine and Pathobiologic Services, RTI, L.L.C., Brookings, SD, United States.,Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| | - June A Boon
- Department of Clinical Sciences, Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, CO, United States
| | - Hui Zhang
- Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| | - Min Li
- Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| | - Timothy N Holt
- Department of Clinical Sciences, Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, CO, United States
| | - S Kelly Ambler
- Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, United States
| | - Daniel L Gustafson
- Department of Clinical Sciences, Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, CO, United States
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, United States
| | - Franklyn B Garry
- Department of Clinical Sciences, Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, CO, United States
| | - Kurt R Stenmark
- Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| | - R Dale Brown
- Departments of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO, United States
| |
Collapse
|
22
|
Roberts MJ, May LT, Keen AC, Liu B, Lam T, Charlton SJ, Rosethorne EM, Halls ML. Inhibition of the Proliferation of Human Lung Fibroblasts by Prostacyclin Receptor Agonists is Linked to a Sustained cAMP Signal in the Nucleus. Front Pharmacol 2021; 12:669227. [PMID: 33995100 PMCID: PMC8116805 DOI: 10.3389/fphar.2021.669227] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/16/2021] [Indexed: 12/21/2022] Open
Abstract
Idiopathic pulmonary fibrosis is a chronic and progressive fibrotic lung disease, and current treatments are limited by their side effects. Proliferation of human lung fibroblasts in the pulmonary interstitial tissue is a hallmark of this disease and is driven by prolonged ERK signalling in the nucleus in response to growth factors such as platelet-derived growth factor (PDGF). Agents that increase cAMP have been suggested as alternative therapies, as this second messenger can inhibit the ERK cascade. We previously examined a panel of eight Gαs-cAMP-coupled G protein-coupled receptors (GPCRs) endogenously expressed in human lung fibroblasts. Although the cAMP response was important for the anti-fibrotic effects of GPCR agonists, the magnitude of the acute cAMP response was not predictive of anti-fibrotic efficacy. Here we examined the reason for this apparent disconnect by stimulating the Gαs-coupled prostacyclin receptor and measuring downstream signalling at a sub-cellular level. MRE-269 and treprostinil caused sustained cAMP signalling in the nucleus and complete inhibition of PDGF-induced nuclear ERK and fibroblast proliferation. In contrast, iloprost caused a transient increase in nuclear cAMP, there was no effect of iloprost on PDGF-induced ERK in the nucleus, and this agonist was much less effective at reversing PDGF-induced proliferation. This suggests that sustained elevation of cAMP in the nucleus is necessary for efficient inhibition of PDGF-induced nuclear ERK and fibroblast proliferation. This is an important first step towards understanding of the signalling events that drive GPCR inhibition of fibrosis.
Collapse
Affiliation(s)
- Maxine J Roberts
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom.,Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| | - Lauren T May
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| | - Alastair C Keen
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| | - Bonan Liu
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| | - Terrance Lam
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| | - Steven J Charlton
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom.,Excellerate Bioscience Ltd., BioCity, Nottingham, United Kingdom
| | - Elizabeth M Rosethorne
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | - Michelle L Halls
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Vic, Australia
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Despite worse outcomes associated with the development of pulmonary hypertension in chronic lung disease, there are no approved treatments for this population. The present review summarizes the recent clinical trials in World Symposium on Pulmonary Hypertension (WSPH) Group 3 pulmonary hypertension, with a particular focus on the study of pulmonary arterial hypertension (PAH)-targeted therapy. RECENT FINDINGS Multiple recent randomized controlled trials have studied a host of PAH-specific medications in the treatment of WSPH Group 3 pulmonary hypertension, including endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins. In pulmonary hypertension associated with chronic obstructive lung disease (PH-COPD) and with interstitial lung disease (PH-ILD), most trials have shown conflicting or negative results, although they have been limited by variable patient populations and small sample sizes. Recent large-scale trial data demonstrate that inhaled treprostinil is associated with improved outcomes in the PH-ILD population. SUMMARY Although most PAH medications have not shown consistent benefit in the WSPH Group 3 population, recent work suggests that inhaled treprostinil has an important role in the treatment of PH-ILD. Efforts are ongoing to evaluate the efficacy of other medications, identify optimal treatment candidates, and define clinically meaningful endpoints in WSPH Group 3 pulmonary hypertension.
Collapse
|
24
|
DuBrock HM, Nathan SD, Reeve BB, Kolaitis NA, Mathai SC, Classi PM, Nelsen AC, Olayinka-Amao B, Norcross LN, Martin SA. Pulmonary hypertension due to interstitial lung disease or chronic obstructive pulmonary disease: a patient experience study of symptoms and their impact on quality of life. Pulm Circ 2021; 11:20458940211005641. [PMID: 33868642 PMCID: PMC8020242 DOI: 10.1177/20458940211005641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension resulting from chronic lung disease such as chronic obstructive pulmonary disease and interstitial lung disease is categorized by the World Health Organization as Group 3 pulmonary hypertension. To identify the symptoms and impacts of World Health Organization Group 3 pulmonary hypertension and to capture data related to the patient experience of this disease, qualitative research interviews were undertaken with 3 clinical experts and 14 individuals with pulmonary hypertension secondary to chronic obstructive pulmonary disease or interstitial lung disease. Shortness of breath, fatigue, cough, and swelling were the most frequently reported symptoms of pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease, and shortness of breath was further identified as the single most bothersome symptom for most patients (71.4%). Interview participants also described experiencing a number of impacts related to pulmonary hypertension and pulmonary hypertension symptoms, including limitations in the ability to perform activities of daily living and impacts on physical functioning, family life, and social life as well as emotional impacts, which included frustration, depression, anxiety, isolation, and sadness. Results of these qualitative interviews offer an understanding of the patient experience of pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease, including insight into the symptoms and impacts that are most important to patients in this population. As such, these results may help guide priorities in clinical treatment and assist researchers in their selection of patient-reported outcome measures for clinical trials in patients with pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease.
Collapse
Affiliation(s)
- Hilary M. DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic,
Rochester, MN, USA
| | | | - Bryce B. Reeve
- Department of Population Health Sciences, Duke University School
of Medicine, Durham, NC, USA
| | - Nicholas A. Kolaitis
- Division of Pulmonary, Critical Care, Allergy, and Sleep
Medicine, San Francisco Medical Center, University of California, San Francisco,
CA, USA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Peter M. Classi
- Global Medical Affairs, United Therapeutics, Durham, NC,
USA
| | | | | | | | - Susan A. Martin
- Patient-Centered Outcomes Assessment, RTI Health Solutions, Ann
Arbor, MI, USA
| |
Collapse
|
25
|
Liu H, Wang N, Li J, Wang W, Han W, Li Q. AAV1-Mediated shRNA Knockdown of SASH1 in Rat Bronchus Attenuates Hypoxia-Induced Pulmonary Artery Remodeling. Hum Gene Ther 2021; 32:796-805. [PMID: 33297837 DOI: 10.1089/hum.2020.242] [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: 11/13/2022] Open
Abstract
Pulmonary hypertension (PH) is a proliferative disease characterized by pulmonary arterial remodeling (PAR). SAM and SH3 domain containing 1 (SASH1) is a novel tumor suppressor gene whose biological function in PH is unclear. In this study, a hypoxia-induced pulmonary hypertension (HPH) rat model was constructed to explore the role of SASH1 in PAR. Histopathological changes in the lung tissue and hemodynamic alteration were detected in SASH1-knockdown rats through adeno-associated virus type-1 (AAV1) infection. In vitro, primary human pulmonary arterial smooth muscle cells (HPASMCs) were transfected with SASH1siRNA to investigate the effects of SASH1 on hypoxia-induced proliferation and migration. The molecular mechanisms associated with SASH1 were explored through knockdown and overexpression approaches. We found that SASH1 expression was significantly increased in rat pulmonary arteries and HPASMCs after hypoxia exposure. In vivo, silencing the SASH1 gene expression improved HPH in rats. The SASH1 downregulation inhibited proliferation and migration of hypoxia-induced HPASMCs. The protein expression of phospho-AKT (known as protein kinase B), proliferating cell nuclear antigen, and matrix metalloproteinase 9 (MMP9) in HPASMCs were increased after SASH1 overexpression, whereas these effects were inhibited by SASH1 knockdown. In conclusion, SASH1 downregulation improved hypoxia-induced PAR and PH. SASH1 may be a novel target for PH gene therapy in the era of precision medicine.
Collapse
Affiliation(s)
- Hong Liu
- Departments of Respiratory and Critical Care Medicine and.,Departments of Respiratory Disease Key Laboratory of Qingdao, Qingdao Municipal Hospital, Qingdao, China
| | - Ning Wang
- Departments of Respiratory and Critical Care Medicine and
| | - Jun Li
- Departments of Respiratory and Critical Care Medicine and
| | - Wenting Wang
- Departments of Oncology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Wei Han
- Departments of Respiratory and Critical Care Medicine and.,Departments of Respiratory Disease Key Laboratory of Qingdao, Qingdao Municipal Hospital, Qingdao, China
| | - Qinghai Li
- Departments of Respiratory and Critical Care Medicine and.,Departments of Respiratory Disease Key Laboratory of Qingdao, Qingdao Municipal Hospital, Qingdao, China
| |
Collapse
|
26
|
Krakowski JC, Arora H. Con: General Anesthesia Is Not Superior to Regional Anesthesia for Patients With Pulmonary Hypertension Undergoing Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:1888-1891. [PMID: 33478879 DOI: 10.1053/j.jvca.2020.12.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022]
Affiliation(s)
- James C Krakowski
- Department of Anesthesiology, University of North Carolina School of Medicine, UNC Hospitals, Chapel Hill, NC.
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, UNC Hospitals, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
27
|
Rudyk O, Aaronson PI. Redox Regulation, Oxidative Stress, and Inflammation in Group 3 Pulmonary Hypertension. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:209-241. [PMID: 33788196 DOI: 10.1007/978-3-030-63046-1_13] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Group 3 pulmonary hypertension (PH), which occurs secondary to hypoxia lung diseases, is one of the most common causes of PH worldwide and has a high unmet clinical need. A deeper understanding of the integrative pathological and adaptive molecular mechanisms within this group is required to inform the development of novel drug targets and effective treatments. The production of oxidants is increased in PH Group 3, and their pleiotropic roles include contributing to disease progression by promoting prolonged hypoxic pulmonary vasoconstriction and pathological pulmonary vascular remodeling, but also stimulating adaptation to pathological stress that limits the severity of this disease. Inflammation, which is increasingly being viewed as a key pathological feature of Group 3 PH, is subject to complex regulation by redox mechanisms and is exacerbated by, but also augments oxidative stress. In this review, we investigate aspects of this complex crosstalk between inflammation and oxidative stress in Group 3 PH, focusing on the redox-regulated transcription factor NF-κB and its upstream regulators toll-like receptor 4 and high mobility group box protein 1. Ultimately, we propose that the development of specific therapeutic interventions targeting redox-regulated signaling pathways related to inflammation could be explored as novel treatments for Group 3 PH.
Collapse
Affiliation(s)
- Olena Rudyk
- School of Cardiovascular Medicine & Sciences, King's College London, British Heart Foundation Centre of Research Excellence, London, UK.
| | - Philip I Aaronson
- School of Immunology and Microbial Sciences, King's College London, London, UK
| |
Collapse
|
28
|
Cobra SDB, Rodrigues MP, de Melo FX, Ferreira NMC, Passini VV, Amado VM, Melo-Silva CA. Right ventricular dysfunction in patients with non-severe idiopathic pulmonary fibrosis: a cross-sectional prospective single-center study. Expert Rev Respir Med 2020; 15:249-256. [PMID: 33070645 DOI: 10.1080/17476348.2021.1834856] [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: 10/23/2022]
Abstract
BACKGROUND Little is known about right ventricular dysfunction in non-advanced idiopathic pulmonary fibrosis (IPF) patients without hypoxemia at rest. We evaluated it at rest and during exercise. RESEARCH DESIGN AND METHODS 123 IPF patients were evaluated, and 27 met all the following criteria: Gender-Age-Physiology Index score ≤5, modified Medical Research Council dyspnea score ≤3, peripheral oxygen saturation ≥92% at rest, and no history of oxygen therapy. They were submitted to two-dimensional speckle-tracking echocardiography at rest and during cardiopulmonary exercise to analyze right ventricular global longitudinal strain. RESULTS Abnormal speckle-tracking echocardiography findings were identified in 10/27 patients (37%), indicating right ventricular (RV) dysfunction. No patients had abnormalities observed in conventional echocardiographic parameters. Significant differences in mPAP were observed between patients with RV dysfunction and those without dysfunction (at rest: 26.0 ± 4.8 vs. 19.1 ± 4.2 mmHg, p = 0.001; during exercise: 51.3 ± 6.4 vs. 36.9 ± 14.7 mmHg, p = 0.002). CONCLUSIONS RV dysfunction was detected in 37% of non-advanced IPF patients and early recognition was only possible using speckle-tracking echocardiography. Special attention should be given to these patients as RV dysfunction is suggestive of worse prognosis. These patients could benefit from new specific drugs or even oxygen therapy for transitory hypoxia.
Collapse
Affiliation(s)
- Sandra de Barros Cobra
- Federal District Base Hospital Institute and School of Medicine, University of Brasília , Brasília, Brazil
| | | | | | | | | | | | | |
Collapse
|
29
|
Yang J, Pan X, Wang L, Yu G. Alveolar cells under mechanical stressed niche: critical contributors to pulmonary fibrosis. Mol Med 2020; 26:95. [PMID: 33054759 PMCID: PMC7556585 DOI: 10.1186/s10020-020-00223-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022] Open
Abstract
Pulmonary fibrosis arises from the repeated epithelial mild injuries and insufficient repair lead to over activation of fibroblasts and excessive deposition of extracellular matrix, which result in a mechanical stretched niche. However, increasing mechanical stress likely exists before the establishment of fibrosis since early micro injuries increase local vascular permeability and prompt cytoskeletal remodeling which alter cellular mechanical forces. It is noteworthy that COVID-19 patients with severe hypoxemia will receive mechanical ventilation as supportive treatment and subsequent pathology studies indicate lung fibrosis pattern. At advanced stages, mechanical stress originates mainly from the stiff matrix since boundaries between stiff and compliant parts of the tissue could generate mechanical stress. Therefore, mechanical stress has a significant role in the whole development process of pulmonary fibrosis. The alveoli are covered by abundant capillaries and function as the main gas exchange unit. Constantly subject to variety of damages, the alveolar epithelium injuries were recently recognized to play a vital role in the onset and development of idiopathic pulmonary fibrosis. In this review, we summarize the literature regarding the effects of mechanical stress on the fundamental cells constituting the alveoli in the process of pulmonary fibrosis, particularly on epithelial cells, capillary endothelial cells, fibroblasts, mast cells, macrophages and stem cells. Finally, we briefly review this issue from a more comprehensive perspective: the metabolic and epigenetic regulation.
Collapse
Affiliation(s)
- Juntang Yang
- State Key Laboratory of Cell Differentiation and Regulation, Henan International Joint Laboratory of Pulmonary Fibrosis, Outstanding Overseas Scientists Center for Pulmonary Fibrosis of Henan Province, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang, Henan, China
| | - Xin Pan
- State Key Laboratory of Cell Differentiation and Regulation, Henan International Joint Laboratory of Pulmonary Fibrosis, Outstanding Overseas Scientists Center for Pulmonary Fibrosis of Henan Province, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang, Henan, China
| | - Lan Wang
- State Key Laboratory of Cell Differentiation and Regulation, Henan International Joint Laboratory of Pulmonary Fibrosis, Outstanding Overseas Scientists Center for Pulmonary Fibrosis of Henan Province, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang, Henan, China
| | - Guoying Yu
- State Key Laboratory of Cell Differentiation and Regulation, Henan International Joint Laboratory of Pulmonary Fibrosis, Outstanding Overseas Scientists Center for Pulmonary Fibrosis of Henan Province, College of Life Science, Institute of Biomedical Science, Henan Normal University, Xinxiang, Henan, China.
| |
Collapse
|
30
|
Mandoli GE, Sciaccaluga C, Bandera F, Cameli P, Esposito R, D'Andrea A, Evola V, Sorrentino R, Malagoli A, Sisti N, Nistor D, Santoro C, Bargagli E, Mondillo S, Galderisi M, Cameli M. Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings. Heart Fail Rev 2020; 26:263-275. [PMID: 32860180 PMCID: PMC7895796 DOI: 10.1007/s10741-020-10014-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.
Collapse
Affiliation(s)
- Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy.
| | - Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS, Policlinico San Donato, San Donato Milanese and Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neuroscience, University of Siena, Siena, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Antonello D'Andrea
- Cardiology Department, Echocardiography Lab and Rehabilitation Unit, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Vincenzo Evola
- Department of Health Promotion Sciences, Maternal-Infant Care, Internal Medicine and Specialities of Excellence "G. D'Alessandro", University of Palermo, Cardiology Unit, University Hospital P. Giaccone, Palermo, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, "S. Agostino-Estense" Public Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicolò Sisti
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Dan Nistor
- Institute for Emergency Cardiovascular Diseases and Transplant Targu Mures, Targu Mures, Romania
| | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neuroscience, University of Siena, Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| |
Collapse
|
31
|
Efficacy and safety of Sildenafil treatment in pulmonary hypertension caused by chronic obstructive pulmonary disease: A meta-analysis. Life Sci 2020; 257:118001. [PMID: 32634428 DOI: 10.1016/j.lfs.2020.118001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 12/29/2022]
Abstract
AIMS Pulmonary hypertension (PH) is a severe and prevalent complication of chronic obstructive pulmonary disease (COPD), with low quality of life and poor prognosis. This study was designed to evaluate the efficacy and safety of Sildenafil in the treatment of PH caused by COPD (COPD-PH) and provide reference for clinical treatment. MATERIALS AND METHODS We systematically searched PubMed, EMBASE, Cochrane Library, Clinical Trials.gov databases, Wanfang Data and CNKI for comprehensive literature reporting Sildenafil for randomized controlled trials (RCT) of COPD-PH. Quality assessment, data analysis used the modified Jadad scale and RevMan5.3 software. KEY FINDINGS A total of 9 RCTs involving 579 patients were included in our study. The primary outcome measure was Six minutes walking distance (6MWD). Secondary observations were Pulmonary artery systolic pressure (PASP), Borg dyspnea index, and Survey scale (SF-36). Our data demonstrate that Sildenafil can improve 6WMD [29.64, 95% CI (13.78, 45.50), P < 0.00001] and PASP [-7.86, 95% CI (-11.26, -4.46) P < 0.00001] of COPD-PH, compared with the control group. However, SF-36 [2.64, 95% CI (-6.85, 12.14) P = 0.59] and Borg dyspnea index [-0.28, 95% CI (-1.08, 0.52) P = 0.49] have no significant difference between those two groups. Adverse reactions in the Sildenafil treatment group were tolerated headaches and digestive symptoms, which were relatively safe. SIGNIFICANCE Available clinical evidence indicates that Sildenafil seems to be safe and effective for COPD-PH and can improve the patients' 6WMD. However, large-sample, high-quality multicenter RCTs are still needed to provide stronger evidence-based medical evidence.
Collapse
|
32
|
Wang Y, Wu F, Hu F, Wu Y, Zhou J, Xu Y, Shao X, Hu T. Drag-reducing polymers attenuates pulmonary vascular remodeling and right ventricular dysfunction in a rat model of chronic hypoxia-induced pulmonary hypertension. Clin Hemorheol Microcirc 2020; 74:189-200. [PMID: 31476149 DOI: 10.3233/ch-190668] [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: 11/15/2022]
Abstract
Drag-reducing polymers (DRPs) was previously demonstrated to increase blood flow, tissue perfusion, and reduce vascular resistance. The purpose of this study was to investigate the effect of DRPs on pulmonary vascular remodeling and right ventricular dysfunction in a rat model of chronic hypoxia-induced pulmonary hypertension (HPH). A total of forty male Wistar rats were randomly and equally assigned into four experimental groups (Group I: normoxia + saline, Group II: normoxia + PEO, Group III: hypoxia + saline, Group IV: hypoxia + PEO) and maintained in normoxia (21% O2) or hypobaric hypoxia (10% O2). After four weeks, comparisons were made of the following aspects: the mean pulmonary arterial pressure (mPAP), right ventricular systolic pressure (RVSP), right ventricular hypertrophy, wall thickness of pulmonary trunk and arteries, internal diameter of pulmonary arteries, cardiomyocyte cross-sectional area (CM CSA), and ultrastructure of right ventricular. Treatment with PEO in Group IV attenuated the increases in RVSP and mPAP (40.5±7.2 and 34.7±7.0 mmHg, respectively, both P < 0.05), compared with Group III. Distal vascular remodeling was visible as a significant increase in medial wall thickness (64.2±12.3% vs. 43.95±7.0%, P < 0.01) and a remarkable decrease in internal diameter of small pulmonary arteries (35.2±9.7μ m vs. 50.4±14.7μ m, P < 0.01) in Group III, to a greater extent than that detected in Group IV. Nevertheless, no significant histopathological differences in medial wall thickness was observed in pulmonary trunk between Group III and Group IV (P > 0.05), denoting that PEO chiefly attenuated the remodeling of small pulmonary arteries rather than main arteries in hypoxic environment. Infusion of DRPs (intravenous injection twice weekly) also attenuated the index of right ventricular hypertrophy, protected against the increase of cardiomyocyte cross-sectional area, and provided protection for cardiac ultrastructure. DRP treatment with intravenous injection elicited a protective effect against pulmonary vascular remodeling and right ventricular dysfunction in the rat model of HPH. DRPs may offer a new potential approach for the treatment of HPH, which may have theoretical significance and application value to society.
Collapse
Affiliation(s)
- Yali Wang
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Feng Wu
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Feng Hu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunjiang Wu
- Department of Thoracic Surgery, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Jun Zhou
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Yan Xu
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xiangrong Shao
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Tao Hu
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| |
Collapse
|
33
|
King CS, Shlobin OA. The Trouble With Group 3 Pulmonary Hypertension in Interstitial Lung Disease: Dilemmas in Diagnosis and the Conundrum of Treatment. Chest 2020; 158:1651-1664. [PMID: 32387520 DOI: 10.1016/j.chest.2020.04.046] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022] Open
Abstract
Pulmonary hypertension (PH) due to interstitial lung disease (ILD; PH-ILD) can complicate a multitude of ILDs, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis, and nonspecific interstitial pneumonia. Development of PH-ILD is associated with increased need for supplemental oxygen, reduced mobility, and decreased survival. A high index of suspicion is required to make the diagnosis, given the substantial overlap in symptoms with those of ILD without PH. Severely reduced diffusing capacity or 6-min walk test distance, prominent exertional desaturation, and impaired heart rate recovery after exercise are all suggestive of the development of PH-ILD. Traditional transthoracic echocardiography is the most commonly used screening test for PH-ILD, but it lacks sensitivity and specificity. Newer echocardiographic tools involving 3-dimensional assessment of the right ventricle may have a role in both prognosis and the monitoring of patients with PH-ILD. Right-sided heart catheterization remains the gold standard for confirming a diagnosis of PH-ILD. Although there is little debate about the use of supplemental oxygen and diuretic therapy in the treatment of PH-ILD, treatment with pulmonary vasodilator therapy remains controversial. Although several studies have been terminated prematurely for harm, the recently completed INCREASE trial of inhaled treprostinil appears to validate the concept of treating PH-ILD with pulmonary vasodilators and, we hope, will serve as a foundation from which future studies can be developed.
Collapse
Affiliation(s)
- Christopher S King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Pulmonary Hypertension Program, Inova Fairfax Hospital, Falls Church, VA.
| |
Collapse
|
34
|
Synn AJ, Li W, San José Estépar R, Zhang C, Washko GR, O'Connor GT, Araki T, Hatabu H, Bankier AA, Mittleman MA, Rice MB. Radiographic pulmonary vessel volume, lung function and airways disease in the Framingham Heart Study. Eur Respir J 2019; 54:13993003.00408-2019. [PMID: 31248956 DOI: 10.1183/13993003.00408-2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/24/2019] [Indexed: 01/24/2023]
Abstract
Radiographic abnormalities of the pulmonary vessels, such as vascular pruning, are common in advanced airways disease, but it is unknown if pulmonary vascular volumes are related to measures of lung health and airways disease in healthier populations.In 2388 participants of the Framingham Heart Study computed tomography (CT) sub-study, we calculated total vessel volumes and the small vessel fraction using automated CT image analysis. We evaluated associations with measures of lung function, airflow obstruction on spirometry and emphysema on CT. We further tested if associations of vascular volumes with lung function were present among those with normal forced expiratory volume in 1 s and forced vital capacity.In fully adjusted linear and logistic models, we found that lower total and small vessel volumes were consistently associated with worse measures of lung health, including lower spirometric volumes, lower diffusing capacity and/or higher odds of airflow obstruction. For example, each standard deviation lower small vessel fraction (indicating more severe pruning) was associated with a 37% greater odds of obstruction (OR 1.37, 95% CI 1.11-1.71, p=0.004). A similar pattern was observed in the subset of participants with normal spirometry.Lower total and small vessel pulmonary vascular volumes were associated with poorer measures of lung health and/or greater odds of airflow obstruction in this cohort of generally healthy adults without high burdens of smoking or airways disease. Our findings suggest that quantitative CT assessment may detect subtle pulmonary vasculopathy that occurs in the setting of subclinical and early pulmonary and airways pathology.
Collapse
Affiliation(s)
- Andrew J Synn
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA .,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wenyuan Li
- Dept of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Raúl San José Estépar
- Dept of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chunyi Zhang
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,The NHLBI's Framingham Heart Study, Framingham, MA, USA
| | - George T O'Connor
- The NHLBI's Framingham Heart Study, Framingham, MA, USA.,Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Tetsuro Araki
- Dept of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroto Hatabu
- Dept of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,The NHLBI's Framingham Heart Study, Framingham, MA, USA
| | - Alexander A Bankier
- Dept of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Murray A Mittleman
- Dept of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mary B Rice
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Pulmonary hypertension has been reported to complicate the course of a number of fibrotic lung diseases, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis and nonspecific interstitial pneumonitis. Most commonly, mild elevations in the mean pulmonary artery pressure are seen in patients with advanced pulmonary fibrosis. However, some patients may develop severe pulmonary hypertension, which appears out of proportion to the degree of their restrictive lung disease. RECENT FINDINGS The benefits of pulmonary vasodilator therapy have yet to be established in pulmonary hypertension complicating fibrotic lung disease. In fact, one recent clinical trial examining riociguat in patients with pulmonary hypertension complicating idiopathic interstitial pneumonias was terminated early for an increased risk of death or hospitalization. Multiple clinical trials on this topic are currently ongoing, including studies examining inhaled pulmonary vasodilator therapies. SUMMARY The development of pulmonary hypertension is associated with increased exertional oxygen requirements, worsened functional capacity and attenuated life expectancy. It is hoped that continued research will find an effective therapy for this condition, which will improve quality of life and extend life expectancy in patients with this condition.
Collapse
Affiliation(s)
- Christopher S King
- Inova Fairfax Advanced Lung Disease and Transplant Clinic, Falls Church, Virginia, USA
| | | |
Collapse
|
36
|
Jaffey JA, Wiggen K, Leach SB, Masseau I, Girens RE, Reinero CR. Pulmonary hypertension secondary to respiratory disease and/or hypoxia in dogs: Clinical features, diagnostic testing and survival. Vet J 2019; 251:105347. [PMID: 31492386 DOI: 10.1016/j.tvjl.2019.105347] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/29/2022]
Abstract
Pulmonary hypertension (PH) is associated with substantial morbidity and if untreated, mortality. The human classification of PH is based on pathological, hemodynamic characteristics, and therapeutic approaches. Despite being a leading cause of PH, little is known about dogs with respiratory disease and/or hypoxia (RD/H)-associated PH. Therefore, our objectives were to retrospectively describe clinical features, diagnostic evaluations, final diagnoses and identify prognostic variables in dogs with RD/H and PH. In 47 dogs identified with RD/H and PH, chronic airway obstructive disorders, bronchiectasis, bronchiolar disease, emphysema, pulmonary fibrosis, neoplasia and other parenchymal disorders were identified using thoracic radiography, computed tomography, fluoroscopy, tracheobronchoscopy, bronchoalveolar lavage, and histopathology. PH was diagnosed using transthoracic echocardiography. Overall median survival was 276.0 days (SE, 95% CI; 216, 0-699 days). Dogs with an estimated systolic pulmonary arterial pressure (sPAP) ≥47mmHg (n=21; 9 days; 95% CI, 0-85 days) had significantly shorter survival times than those <47mmHg (n=16; P=0.001). Estimated sPAP at a cutoff of ≥47mmHg was a fair predictor of non-survival with sensitivity of 0.78 (95% CI, 0.52-0.94) and specificity of 0.63 (95% CI, 0.38-0.84). Phosphodiesterase-5 (PDE5) inhibitor administration was the sole independent predictor of survival in a multivariable analysis (hazard ratio: 4.0, P=0.02). Canine PH is present in a diverse spectrum of respiratory diseases, most commonly obstructive disorders. Similar to people, severity of PH is prognostic in dogs with RD/H and PDE5 inhibition could be a viable therapy to improve outcome.
Collapse
Affiliation(s)
- J A Jaffey
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA
| | - K Wiggen
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA
| | - S B Leach
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA
| | - I Masseau
- Department of Science Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, St-Hyacinthe, Canada
| | - R E Girens
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA
| | - C R Reinero
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA.
| |
Collapse
|
37
|
Darwiche T, Collum SD, Bi W, Reynolds JO, Wilson C, Wareing N, Hernandez AM, Mertens TCJ, Zhou Z, Pandit LM, Karmouty-Quintana H. Alterations in cardiovascular function in an experimental model of lung fibrosis and pulmonary hypertension. Exp Physiol 2019; 104:568-579. [PMID: 30663834 DOI: 10.1113/ep087321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/18/2019] [Indexed: 01/02/2023]
Abstract
NEW FINDINGS What is the central question of this study? We have evaluated changes in cardiovascular physiology using echocardiography in an experimental model of lung fibrosis. What is the main finding and its importance? Remarkably, we report changes in cardiovascular function as early as day 7, concomitant with evidence of vascular remodelling. We also report that isolated pulmonary arteries were hypercontractile in response to a thromboxane A2 agonist. These findings are significant because the development of pulmonary hypertension is one of the most significant predictors of mortality in patients with lung fibrosis, where there are no available therapies and a lack of animal models. ABSTRACT Group III pulmonary hypertension is observed in patients with chronic lung diseases such as chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) develops as a result of extensive pulmonary vascular remodelling and resultant changes in vascular tone that can lead to right ventricle hypertrophy. This eventually leads to right heart failure, which is the leading indicator of mortality in patients with idiopathic pulmonary fibrosis. Treatments for group III PH are not available, in part owing to a lack of viable animal models. Here, we have evaluated the cardiovascular changes in a model of lung fibrosis and PH. Data obtained from this study indicated that structural alterations in the right heart, such as right ventricular wall hypertrophy, occurred as early as day 14, and similar increases in right ventricle chamber size were seen between days 21 and 28. These structural changes were correlated with decreases in the systolic function of the right ventricle and right ventricular cardiac output, which also occurred between the same time points. Characterization of pulmonary artery dynamics also highlighted that PH might be occurring as early as day 21, indicated by reductions in the velocity-time integral; however, evidence for PH is apparent as early as day 7, indicated by the significant reduction in pulmonary acceleration time values. These changes are consistent with evidence of vascular remodelling observed histologically starting on day 7. In addition, we report hyperactivity of bleomycin-exposed pulmonary arteries to a thromboxane A2 receptor (Tbxa2r) agonist.
Collapse
Affiliation(s)
- Tamara Darwiche
- Department of Pharmacology, School of Biomedical Sciences, King's College London, London, UK.,Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Scott D Collum
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Weizhen Bi
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julia O Reynolds
- Department of Medicine, Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Cory Wilson
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nancy Wareing
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Adriana M Hernandez
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tinne C J Mertens
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Zhen Zhou
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lavannya M Pandit
- Department of Medicine, Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
38
|
Li Y, Ren W, Wang X, Yu X, Cui L, Li X, Zhang X, Shi B. MicroRNA-150 relieves vascular remodeling and fibrosis in hypoxia-induced pulmonary hypertension. Biomed Pharmacother 2019; 109:1740-1749. [DOI: 10.1016/j.biopha.2018.11.058] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 12/11/2022] Open
|
39
|
Pulmonary arterial hypertension and the potential roles of metallothioneins: A focused review. Life Sci 2018; 214:77-83. [PMID: 30355531 DOI: 10.1016/j.lfs.2018.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/10/2018] [Accepted: 10/19/2018] [Indexed: 12/17/2022]
Abstract
The pathophysiology of pulmonary arterial hypertension (PAH) is underlined by cell proliferation and vasoconstriction of pulmonary arterioles this involves multiple molecular factors or proteins, but it is not clear what the exact roles of these factors/proteins are. In addition, there may be other factors/proteins that have not been identified that contribute to PAH pathophysiology. Therefore, research has focused on investigating novel role players, in order to facilitate a better understanding of how PAH develop. Evidence suggest that mitochondrial regulators are key role players in PAH pathophysiology, but regulators that have not received sufficient attention in PAH are metallothioneins (MTs). In PAH patients, MT expression is elevated compared to healthy individuals, suggesting that MTs may be possible biomarkers. In other disease-models, MTs have been shown to regulate cell proliferation and vasoconstriction, processes that are instrumental in PAH pathophysiology. Due to the involvement of these processes in PAH pathophysiology and the ability of MTs to modulate them, this paper propose that cellular MTs may also play a role in PAH development. This paper suggests that PAH-research should perhaps begin to investigate the involvement of cellular MTs in the development of PAH.
Collapse
|
40
|
Opitz I, Ulrich S. Pulmonary hypertension in chronic obstructive pulmonary disease and emphysema patients: prevalence, therapeutic options and pulmonary circulatory effects of lung volume reduction surgery. J Thorac Dis 2018; 10:S2763-S2774. [PMID: 30210830 PMCID: PMC6129805 DOI: 10.21037/jtd.2018.07.63] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/12/2018] [Indexed: 11/06/2022]
Abstract
The exact prevalence of pulmonary hypertension (PH) and cor pulmonale (CP) in chronic obstructive pulmonary disease (COPD) is unknown, and varies considerably from 20-91%. Usually, mean pulmonary artery pressure (mPAP) does not exceed 30 mmHg, and PH is not severe. However, PH and CP are important predictors of mortality in COPD and contribute to disability in this disease. Many factors contribute to the development of PH in chronic lung disease, including reduction of the pulmonary vascular cross-sectional area due to parenchymal loss and accompanying hypoxia, effects of abnormal pulmonary mechanics due to hyperinflation, but also vascular remodeling processes. So far, PH associated with chronic lung disease cannot be treated medically. Therefore, it is indicated to treat the underlying pulmonary disease. Patients with severe PH should be referred to centers experienced in the management of PH and enrollment in clinical trials should be considered. Lung volume reduction surgery (LVRS) theoretically further increases pulmonary vascular resistance (PVR) by reducing the vascular bed when resecting lung tissue, however, this might be compensated by better pulmonary mechanics through reduction of hyperinflation, which will be discussed in the present article.
Collapse
Affiliation(s)
- Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Diseases, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
41
|
Mertens TCJ, Hanmandlu A, Tu L, Phan C, Collum SD, Chen NY, Weng T, Davies J, Liu C, Eltzschig HK, Jyothula SSK, Rajagopal K, Xia Y, Guha A, Bruckner BA, Blackburn MR, Guignabert C, Karmouty-Quintana H. Switching-Off Adora2b in Vascular Smooth Muscle Cells Halts the Development of Pulmonary Hypertension. Front Physiol 2018; 9:555. [PMID: 29910735 PMCID: PMC5992271 DOI: 10.3389/fphys.2018.00555] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/30/2018] [Indexed: 11/26/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is a devastating and progressive disease characterized by excessive proliferation of pulmonary artery smooth muscle cells (PASMCs) and remodeling of the lung vasculature. Adenosine signaling through the ADORA2B receptor has previously been implicated in disease progression and tissue remodeling in chronic lung disease. In experimental models of PH associated with chronic lung injury, pharmacological or genetic inhibition of ADORA2B improved markers of chronic lung injury and hallmarks of PH. However, the contribution of ADORA2B expression in the PASMC was not fully evaluated. Hypothesis: We hypothesized that adenosine signaling through the ADORA2B receptor in PASMC mediates the development of PH. Methods: PASMCs from controls and patients with idiopathic pulmonary arterial hypertension (iPAH) were characterized for expression levels of all adenosine receptors. Next, we evaluated the development of PH in ADORA2Bf/f-Transgelin (Tagln)cre mice. These mice or adequate controls were exposed to a combination of SUGEN (SU5416, 20 mg/kg/b.w. IP) and hypoxia (10% O2) for 28 days (HX-SU) or to chronic low doses of bleomycin (BLM, 0.035U/kg/b.w. IP). Cardiovascular readouts including right ventricle systolic pressures (RVSPs), Fulton indices and vascular remodeling were determined. Using PASMCs we identified ADORA2B-dependent mediators involved in vascular remodeling. These mediators: IL-6, hyaluronan synthase 2 (HAS2) and tissue transglutaminase (Tgm2) were determined by RT-PCR and validated in our HX-SU and BLM models. Results: Increased levels of ADORA2B were observed in PASMC from iPAH patients. ADORA2Bf/f-Taglncre mice were protected from the development of PH following HX-SU or BLM exposure. In the BLM model of PH, ADORA2Bf/f- Taglncre mice were not protected from the development of fibrosis. Increased expression of IL-6, HAS2 and Tgm2 was observed in PASMC in an ADORA2B-dependent manner. These mediators were also reduced in ADORA2Bf/f- Taglncre mice exposed to HX-SU or BLM. Conclusions: Our studies revealed ADORA2B-dependent increased levels of IL-6, hyaluronan and Tgm2 in PASMC, consistent with reduced levels in ADORA2Bf/f- Taglncre mice exposed to HX-SU or BLM. Taken together, our data indicates that ADORA2B on PASMC mediates the development of PH through the induction of IL-6, hyaluronan and Tgm2. These studies point at ADORA2B as a therapeutic target to treat PH.
Collapse
Affiliation(s)
- Tinne C J Mertens
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ankit Hanmandlu
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ly Tu
- Institut National de la Santé et de la Recherche Médicale UMR_S 999, Le Plessis-Robinson, France.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Carole Phan
- Institut National de la Santé et de la Recherche Médicale UMR_S 999, Le Plessis-Robinson, France.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Scott D Collum
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ning-Yuan Chen
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Tingting Weng
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jonathan Davies
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Chen Liu
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Holger K Eltzschig
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Soma S K Jyothula
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Keshava Rajagopal
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yang Xia
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ashrith Guha
- Methodist Debakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Brian A Bruckner
- Methodist Debakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Michael R Blackburn
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Christophe Guignabert
- Institut National de la Santé et de la Recherche Médicale UMR_S 999, Le Plessis-Robinson, France.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| |
Collapse
|
42
|
Rathinasabapathy A, Bryant AJ, Suzuki T, Moore C, Shay S, Gladson S, West JD, Carrier EJ. rhACE2 Therapy Modifies Bleomycin-Induced Pulmonary Hypertension via Rescue of Vascular Remodeling. Front Physiol 2018; 9:271. [PMID: 29731719 PMCID: PMC5922219 DOI: 10.3389/fphys.2018.00271] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/08/2018] [Indexed: 12/25/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is a progressive cardiovascular disease, characterized by endothelial and smooth muscle dysfunction and vascular remodeling, followed by right heart failure. Group III PH develops secondarily to chronic lung disease such as idiopathic pulmonary fibrosis (IPF), and both hastens and predicts mortality despite of all known pharmacological interventions. Thus, there is urgent need for development of newer treatment strategies. Objective: Angiotensin converting enzyme 2 (ACE2), a member of the renin angiotensin family, is therapeutically beneficial in animal models of pulmonary vascular diseases and is currently in human clinical trials for primary PH. Although previous studies suggest that administration of ACE2 prevents PH secondary to bleomycin-induced murine IPF, it is unknown whether ACE2 can reverse or treat existing disease. Therefore, in the present study, we tested the efficacy of ACE2 in arresting the progression of group 3 PH. Methods: To establish pulmonary fibrosis, we administered 0.018 U/g bleomycin 2x/week for 4 weeks in adult FVB/N mice, and sacrificed 5 weeks following the first injection. ACE2 or vehicle was administered via osmotic pump for the final 2 weeks, beginning 3 weeks after bleomycin. Echocardiography and hemodynamic assessment was performed prior to sacrifice and tissue collection. Results: Administration of bleomycin significantly increased lung collagen expression, pulmonary vascular remodeling, and pulmonary arterial pressure, and led to mild right ventricular hypertrophy. Acute treatment with ACE2 significantly attenuated vascular remodeling and increased pulmonary SOD2 expression without measurable effects on pulmonary fibrosis. This was associated with nonsignificant positive effects on pulmonary arterial pressure and cardiac function. Conclusion: Collectively, our findings enumerate that ACE2 treatment improved pulmonary vascular muscularization following bleomycin exposure, concomitant with increased SOD2 expression. Although it may not alter the pulmonary disease course of IPF, ACE2 could be an effective therapeutic strategy for the treatment of group 3 PH.
Collapse
Affiliation(s)
| | - Andrew J. Bryant
- Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Toshio Suzuki
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christy Moore
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sheila Shay
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Santhi Gladson
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - James D. West
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Erica J. Carrier
- Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
43
|
Pi L, Fu C, Lu Y, Zhou J, Jorgensen M, Shenoy V, Lipson KE, Scott EW, Bryant AJ. Vascular Endothelial Cell-Specific Connective Tissue Growth Factor (CTGF) Is Necessary for Development of Chronic Hypoxia-Induced Pulmonary Hypertension. Front Physiol 2018. [PMID: 29535639 PMCID: PMC5835098 DOI: 10.3389/fphys.2018.00138] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Chronic hypoxia frequently complicates the care of patients with interstitial lung disease, contributing to the development of pulmonary hypertension (PH), and premature death. Connective tissue growth factor (CTGF), a matricellular protein of the Cyr61/CTGF/Nov (CCN) family, is known to exacerbate vascular remodeling within the lung. We have previously demonstrated that vascular endothelial-cell specific down-regulation of CTGF is associated with protection against the development of PH associated with hypoxia, though the mechanism for this effect is unknown. In this study, we generated a transgenic mouse line in which the Ctgf gene was floxed and deleted in vascular endothelial cells that expressed Cre recombinase under the control of VE-Cadherin promoter (eCTGF KO mice). Lack of vascular endothelial-derived CTGF protected against the development of PH secondary to chronic hypoxia, as well as in another model of bleomycin-induced pulmonary hypertension. Importantly, attenuation of PH was associated with a decrease in infiltrating inflammatory cells expressing CD11b or integrin αM (ITGAM), a known adhesion receptor for CTGF, in the lungs of hypoxia-exposed eCTGF KO mice. Moreover, these pathological changes were associated with activation of—Rho GTPase family member—cell division control protein 42 homolog (Cdc42) signaling, known to be associated with alteration in endothelial barrier function. These data indicate that endothelial-specific deletion of CTGF results in protection against development of chronic-hypoxia induced PH. This protection is conferred by both a decrease in inflammatory cell recruitment to the lung, and a reduction in lung Cdc42 activity. Based on our studies, CTGF inhibitor treatment should be investigated in patients with PH associated with chronic hypoxia secondary to chronic lung disease.
Collapse
Affiliation(s)
- Liya Pi
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Chunhua Fu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Yuanquing Lu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Junmei Zhou
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Marda Jorgensen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Vinayak Shenoy
- Department of Pharmaceutical and Biomedical Sciences, California Health Sciences University, Clovis, CA, United States
| | | | - Edward W Scott
- Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, United States
| | - Andrew J Bryant
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| |
Collapse
|
44
|
Aluja Jaramillo F, Gutierrez FR, Díaz Telli FG, Yevenes Aravena S, Javidan-Nejad C, Bhalla S. Approach to Pulmonary Hypertension: From CT to Clinical Diagnosis. Radiographics 2018; 38:357-373. [PMID: 29432063 DOI: 10.1148/rg.2018170046] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pulmonary hypertension (PH) is a condition characterized by increased pressure in the pulmonary circulation. It may be idiopathic or arise in the setting of other clinical conditions. Patients with PH tend to present with nonspecific cardiovascular or respiratory symptoms. The clinical classification of PH was recently revised at the World Health Organization symposium in Nice, France, in 2013. That consensus statement provided an updated classification based on the shared hemodynamic characteristics and management of the different categories of PH. Some features seen at computed tomography (CT) can suggest a subtype or probable cause of PH that may facilitate placing the patient in the correct category. These features include findings in the pulmonary arteries (peripheral calcification, peripheral dilatation, eccentric filling defects, intra-arterial soft tissue), lung parenchyma (centrilobular nodules, mosaic attenuation, interlobular septal thickening, bronchiectasis, subpleural peripheral opacities, ground-glass opacities, diffuse nodules), heart (congenital lesions, left heart disease, valvular disease), and mediastinum (hypertrophied bronchial arteries). An approach based on identification of these CT features in patients with PH will allow the radiologist to play an important role in diagnosis and help guide the clinician in management of PH. ©RSNA, 2018.
Collapse
Affiliation(s)
- Felipe Aluja Jaramillo
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Fernando R Gutierrez
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Federico G Díaz Telli
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Sebastian Yevenes Aravena
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Cylen Javidan-Nejad
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| | - Sanjeev Bhalla
- From the Department of Radiology, Country Scan, Carrera 16 # 84a - 09 Cons. 323, Bogotá, Colombia (F.A.J.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (F.R.G., C.J.N., S.B.); Department of Radiology, Hospital Austral de Buenos Aires, Pilar Centro, Buenos Aires, Argentina (F.G.D.T.); and Department of Radiology, Clínica Las Condes, Las Condes, Región Metropolitana, Chile (S.Y.A.)
| |
Collapse
|
45
|
Xiong PY, Potus F, Chan W, Archer SL. Models and Molecular Mechanisms of World Health Organization Group 2 to 4 Pulmonary Hypertension. Hypertension 2018; 71:34-55. [PMID: 29158355 PMCID: PMC5777609 DOI: 10.1161/hypertensionaha.117.08824] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Ping Yu Xiong
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Francois Potus
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Winnie Chan
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada.
| |
Collapse
|
46
|
Mora AL, Rojas M, Pardo A, Selman M. Emerging therapies for idiopathic pulmonary fibrosis, a progressive age-related disease. Nat Rev Drug Discov 2017; 16:810. [PMID: 29081515 DOI: 10.1038/nrd.2017.225] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
47
|
Mora AL, Rojas M, Pardo A, Selman M. Emerging therapies for idiopathic pulmonary fibrosis, a progressive age-related disease. Nat Rev Drug Discov 2017; 16:755-772. [DOI: 10.1038/nrd.2017.170] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
48
|
Collum SD, Chen NY, Hernandez AM, Hanmandlu A, Sweeney H, Mertens TCJ, Weng T, Luo F, Molina JG, Davies J, Horan IP, Morrell NW, Amione-Guerra J, Al-Jabbari O, Youker K, Sun W, Rajadas J, Bollyky PL, Akkanti BH, Jyothula S, Sinha N, Guha A, Karmouty-Quintana H. Inhibition of hyaluronan synthesis attenuates pulmonary hypertension associated with lung fibrosis. Br J Pharmacol 2017; 174:3284-3301. [PMID: 28688167 PMCID: PMC5595757 DOI: 10.1111/bph.13947] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 07/02/2017] [Accepted: 07/04/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Group III pulmonary hypertension (PH) is a highly lethal and widespread lung disorder that is a common complication in idiopathic pulmonary fibrosis (IPF) where it is considered to be the single most significant predictor of mortality. While increased levels of hyaluronan have been observed in IPF patients, hyaluronan-mediated vascular remodelling and the hyaluronan-mediated mechanisms promoting PH associated with IPF are not fully understood. EXPERIMENTAL APPROACH Explanted lung tissue from patients with IPF with and without a diagnosis of PH was used to identify increased levels of hyaluronan. In addition, an experimental model of lung fibrosis and PH was used to test the capacity of 4-methylumbeliferone (4MU), a hyaluronan synthase inhibitor to attenuate PH. Human pulmonary artery smooth muscle cells (PASMC) were used to identify the hyaluronan-specific mechanisms that lead to the development of PH associated with lung fibrosis. KEY RESULTS In patients with IPF and PH, increased levels of hyaluronan and expression of hyaluronan synthase genes are present. Interestingly, we also report increased levels of hyaluronidases in patients with IPF and IPF with PH. Remarkably, our data also show that 4MU is able to inhibit PH in our model either prophylactically or therapeutically, without affecting fibrosis. Studies to determine the hyaluronan-specific mechanisms revealed that hyaluronan fragments result in increased PASMC stiffness and proliferation but reduced cell motility in a RhoA-dependent manner. CONCLUSIONS AND IMPLICATIONS Taken together, our results show evidence of a unique mechanism contributing to PH in the context of lung fibrosis.
Collapse
Affiliation(s)
- Scott D Collum
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Ning-Yuan Chen
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Adriana M Hernandez
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Ankit Hanmandlu
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Heather Sweeney
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Tinne C J Mertens
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Tingting Weng
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Fayong Luo
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Jose G Molina
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Jonathan Davies
- Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ian P Horan
- Cambridge BHF Centre for Cardiovascular Research Excellence, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Nick W Morrell
- Cambridge BHF Centre for Cardiovascular Research Excellence, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Odeaa Al-Jabbari
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Keith Youker
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Wenchao Sun
- Biomaterials and Advanced Drug Delivery Lab, Stanford University School of Medicine, Stanford, CA, USA
| | - Jayakumar Rajadas
- Biomaterials and Advanced Drug Delivery Lab, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul L Bollyky
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Neeraj Sinha
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ashrith Guha
- Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, UTHealth, Houston, TX, USA
| |
Collapse
|
49
|
Pulmonary Hypertension Associated with Idiopathic Pulmonary Fibrosis: Current and Future Perspectives. Can Respir J 2017; 2017:1430350. [PMID: 28286407 PMCID: PMC5327768 DOI: 10.1155/2017/1430350] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/19/2017] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is commonly present in patients with chronic lung diseases such as Chronic Obstructive Pulmonary Disease (COPD) or Idiopathic Pulmonary Fibrosis (IPF) where it is classified as Group III PH by the World Health Organization (WHO). PH has been identified to be present in as much as 40% of patients with COPD or IPF and it is considered as one of the principal predictors of mortality in patients with COPD or IPF. However, despite the prevalence and fatal consequences of PH in the setting of chronic lung diseases, there are limited therapies available for patients with Group III PH, with lung transplantation remaining as the most viable option. This highlights our need to enhance our understanding of the molecular mechanisms that lead to the development of Group III PH. In this review we have chosen to focus on the current understating of PH in IPF, we will revisit the main mediators that have been shown to play a role in the development of the disease. We will also discuss the experimental models available to study PH associated with lung fibrosis and address the role of the right ventricle in IPF. Finally we will summarize the current available treatment options for Group III PH outside of lung transplantation.
Collapse
|