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Manzi G, Recchioni T, Badagliacca R, Papa S, Vizza CD. Fixed-dose combination therapy in pulmonary arterial hypertension: Pros & cons. Int J Cardiol 2024; 406:132003. [PMID: 38561109 DOI: 10.1016/j.ijcard.2024.132003] [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: 02/22/2024] [Revised: 03/13/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024]
Abstract
Quality of life of patients suffering from chronic diseases is inevitably conditioned by the number of pills taken during the day. To improve patients' tolerability, compliance and quality of life and reduce healthcare costs, pharmaceutical companies are focusing on the commercialization of fixed-dose combination (FDC) therapies. The last ESC/ERS guidelines for the treatment of pulmonary arterial hypertension (PAH) recommend initial dual combination therapy for newly diagnosed patients at low or intermediate mortality risk. In this regard, polypills including an endothelin receptor antagonist (ERA) and a phosphodiesterase 5 inhibitor (PDE5-i) could represent an useful therapeutic strategy, although with some limitations. To date, evidence about the use of FDCs in PAH is limited but future studies evaluating their safety and efficacy are welcome.
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Affiliation(s)
- Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy.
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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Recchioni T, Manzi G, Mihai A, Vizza CD. Is Cardiopulmonary Exercise Test Really Representative of Pulmonary Arterial Hypertension Patients' Quality of Life? Arch Bronconeumol 2024:S0300-2896(24)00121-2. [PMID: 38714382 DOI: 10.1016/j.arbres.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy.
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Alexandra Mihai
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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3
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Gigante A, Papa S, Rosato E, Badagliacca R, Marra AM. When pulmonary arterial hypertension complicates connective tissue diseases: we still have not found what we are looking for. Intern Emerg Med 2024:10.1007/s11739-024-03598-4. [PMID: 38637488 DOI: 10.1007/s11739-024-03598-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.
| | - Silvia Papa
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alberto Maria Marra
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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Papa S, Scoccia G, Serino G, Adamo FI, Jabbour JP, Caputo A, Boromei M, Filomena D, Laviola D, Maggio E, Manzi G, Mihai A, Recchioni T, Sabusco A, Valeri L, Vinciullo S, Vizza CD, Badagliacca R. Impact of Parenteral Prostanoids in Pulmonary Arterial Hypertension: The Relevance of Timing. J Clin Med 2023; 12:6840. [PMID: 37959305 PMCID: PMC10648828 DOI: 10.3390/jcm12216840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Parenteral prostanoids are being recommended in pulmonary arterial hypertension (PAH) treatment, but the prognostic relevance of delayed treatment initiation is still debated. This study assessed the impact of the timing of prostacyclin treatment initiation on reducing PVR and achieving a low-risk profile in PAH patients. The study enrolled 151 patients who started on parenteral prostanoids with different treatment strategies. All patients underwent right heart catheterization, clinical evaluation, and risk assessments at baseline and after 1-year follow-up. Patients with an upfront strategy including parenteral prostanoid plus one oral drug had -5.3 ± 6.2 WU (-50 ± 19%) reduction in PVR, patients with an upfront strategy including parenteral prostanoid plus double oral drug had -12.8 ± 5.9 WU (-68 ± 17%) reduction in PVR, while patients with an add-on strategy including parenteral prostanoid after oral drugs had -3.9 ± 3.5 WU (-23 ± 19%) reduction in PVR. An upfront strategy including parenteral prostanoids was independently associated with an increased likelihood of achieving the greater reduction of PVR compared with an add-on strategy. Additionally, the greater the severity of PH at the time of diagnosis, in terms of PVR and RV reverse remodeling, the higher the probability of treatment failure. An upfront strategy including a parenteral prostanoid is associated with the highest likelihood of achieving a low-risk profile and a greater reduction of PVR compared with parenteral prostanoid as an add-on to oral treatment.
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Affiliation(s)
- Silvia Papa
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Gianmarco Scoccia
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giorgia Serino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Francesca Ileana Adamo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Jean Pierre Jabbour
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Annalisa Caputo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Michela Boromei
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Filomena
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Domenico Laviola
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Enrico Maggio
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Giovanna Manzi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Mihai
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Tommaso Recchioni
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Alexandra Sabusco
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy;
| | - Livia Valeri
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Sara Vinciullo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Carmine Dario Vizza
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
| | - Roberto Badagliacca
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (G.S.); (G.S.); (F.I.A.); (J.P.J.); (A.C.); (M.B.); (D.F.); (D.L.); (E.M.); (G.M.); (A.M.); (T.R.); (L.V.); (S.V.); (C.D.V.); (R.B.)
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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Hu X, Ding N, Songchen W, Wang R, Chen J, Zhong A, Nan J, Zuo Y, Huang H, Tian D. Lung Transplantation for Pulmonary Arterial Hypertension: Optimized Referral and Listing Based on an Evolving Disease Concept. J Cardiovasc Dev Dis 2023; 10:350. [PMID: 37623363 PMCID: PMC10455552 DOI: 10.3390/jcdd10080350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/31/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023] Open
Abstract
Pulmonary hypertension (PH) was once a devastating and fatal disease entity, the outlook of which has been significantly improved by the continued progress of medical treatment algorithms. However, some patients still ultimately fail to achieve an adequate clinical response despite receiving maximal medical treatment. Historically, lung transplantation (LTx) has been the only effective therapeutic option that could lead to satisfactory outcomes and save these advanced patients' lives. However, patients with PH tend to have the highest mortality rates on the transplant waiting list; especially after comprehensive medical treatment, they continue to deteriorate very rapidly, eventually missing optimal transplantation windows. Balancing optimized medical treatment with the appropriate timing of referral and listing has been highly controversial in LTx for patients with PH. The 2021 consensus document for the selection of lung transplant candidates from the International Society for Heart and Lung Transplantation (ISHLT) updated the specific recommendations for the LTx referral and listing time for patients with PH based on objective risk stratification. Herein, we review the evolving PH-related concepts and highlight the optimization of LTx referral and listing for patients with PH, as well as their management on the waiting list.
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Affiliation(s)
- Xiaokun Hu
- Outpatient Department, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Ningying Ding
- Anesthesia Operation Center of West China Hospital/West China School of Nursing, Sichuan University, Chengdu 610041, China;
| | - Wanqiu Songchen
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Ruifeng Wang
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Jing Chen
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Ailing Zhong
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Jinzhu Nan
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Yujie Zuo
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Heng Huang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
- Lung Transplant Research Laboratory, Institute of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Dong Tian
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
- Lung Transplant Research Laboratory, Institute of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu 610041, China
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Caputo A, Papa S, Manzi G, Laviola D, Recchioni T, Severino P, Lavalle C, Maestrini V, Mancone M, Badagliacca R, Vizza CD. Medical Management of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. Curr Heart Fail Rep 2023; 20:263-270. [PMID: 37486563 PMCID: PMC10421820 DOI: 10.1007/s11897-023-00612-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to overview the most relevant and recent knowledge regarding medical management in pulmonary arterial hypertension (PAH). RECENT FINDINGS Evidence has shown that PAH patients' quality of life and prognosis depend on the capability of the RV to adapt to increased afterload and to fully recover in response to substantially reduced pulmonary vascular resistance obtained with medical therapy. Data from recent clinical studies show that more aggressive treatment strategies, especially in higher risk categories, determine larger afterload reductions, consequentially increasing the probability of achieving right heart reverse remodeling, therefore improving the patients' survival and quality of life. Remarkable progress has been observed over the past decades in the medical treatment of PAH, related to the development of drugs that target multiple biological pathways, strategies for earlier and more aggressive treatment interventions. New hopes for treatment of patients who are unable to achieve low-risk status have been derived from the phase 2 trial PULSAR and the phase 3 trial STELLAR, which show improvement in the hemodynamic status of patients treated with sotatercept on top of background therapy. Promising results are expected from several ongoing clinical trials targeting new pathways involved in the pathophysiology of PAH.
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Affiliation(s)
- Annalisa Caputo
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy.
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Domenico Laviola
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Tommaso Recchioni
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Severino
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
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8
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Jin Q, Chen D, Zhang X, Zhang F, Zhong D, Lin D, Guan L, Pan W, Zhou D, Ge J. Medical Management of Pulmonary Arterial Hypertension: Current Approaches and Investigational Drugs. Pharmaceutics 2023; 15:1579. [PMID: 37376028 DOI: 10.3390/pharmaceutics15061579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a malignant pulmonary vascular syndrome characterized by a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, which eventually leads to right heart failure and even death. Although the exact mechanism of PAH is not fully understood, pulmonary vasoconstriction, vascular remodeling, immune and inflammatory responses, and thrombosis are thought to be involved in the development and progression of PAH. In the era of non-targeted agents, PAH had a very dismal prognosis with a median survival time of only 2.8 years. With the deep understanding of the pathophysiological mechanism of PAH as well as advances in drug research, PAH-specific therapeutic drugs have developed rapidly in the past 30 years, but they primarily focus on the three classical signaling pathways, namely the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. These drugs dramatically improved pulmonary hemodynamics, cardiac function, exercise tolerance, quality of life, and prognosis in PAH patients, but could only reduce pulmonary arterial pressure and right ventricular afterload to a limited extent. Current targeted agents delay the progression of PAH but cannot fundamentally reverse pulmonary vascular remodeling. Through unremitting efforts, new therapeutic drugs such as sotatercept have emerged, injecting new vitality into this field. This review comprehensively summarizes the general treatments for PAH, including inotropes and vasopressors, diuretics, anticoagulants, general vasodilators, and anemia management. Additionally, this review elaborates the pharmacological properties and recent research progress of twelve specific drugs targeting three classical signaling pathways, as well as dual-, sequential triple-, and initial triple-therapy strategies based on the aforementioned targeted agents. More crucially, the search for novel therapeutic targets for PAH has never stopped, with great progress in recent years, and this review outlines the potential PAH therapeutic agents currently in the exploratory stage to provide new directions for the treatment of PAH and improve the long-term prognosis of PAH patients.
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Affiliation(s)
- Qi Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Dandan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai 201508, China
| | - Dongxiang Zhong
- Department of Cardiology, Shanghai East Hospital, Shanghai Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China
| | - Dawei Lin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Lihua Guan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
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9
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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10
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 383] [Impact Index Per Article: 383.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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11
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Rubin LJ, Naeije R. Sotatercept for pulmonary arterial hypertension: something old and something new. Eur Respir J 2023; 61:61/1/2201972. [PMID: 36609525 DOI: 10.1183/13993003.01972-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Lewis J Rubin
- University of California San Diego School of Medicine, San Diego, CA, USA
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12
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D'Alto M, Naeije R. Pulmonary artery pressure-directed therapies in pulmonary arterial hypertension? Vascul Pharmacol 2022; 147:107124. [PMID: 36270620 DOI: 10.1016/j.vph.2022.107124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension is a rare dyspnea-fatigue syndrome defined by an increase in mean pulmonary artery pressure above 20 mmHg combined with an increase in pulmonary vascular resistance higher than 2 Wood units. The condition is of poor prognosis and still incurable in spite of progress achieved in recent decades. The approach is currently optimized by multi-drug combinations titrated on serial risk assessments using recently validated scores. In this issue of Vascular Pharmacology argument is made based on retrospective registry data from three reference centers in favor of initial multi-drug therapies including a parenteral prostanoid dosed to decrease mPAP to normal. This objective was achieved in only a minority of patients, but improved outcome was demonstrated when mPAP can be brought to below 35 mmHg. This data suggest that pulmonary artery pressure-directed multi-drug therapies in PAH may reverse right heart remodeling and limit progression, or even reverse pulmonary vascular disease. However, further studies are needed to validate mPAP as a primary endpoint in PAH drug trials. In the meantime, aggressive initial prescription of parenteral prostanoids combined with one or two oral drugs targeting the pulmonary circulation under careful clinical, imaging and hemodynamic follow-up may be the best therapeutic strategy.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, 80131 Naples, Italy.
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, 1090 Brussels, Belgium
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13
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 920] [Impact Index Per Article: 460.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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14
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Cui X, Lu W, Zhang D, Qie L, Li H, Li X, Liu H, Ji Q. Selexipag-based triple combination therapy improves prognosis in Chinese pulmonary arterial hypertension patients. Front Cardiovasc Med 2022; 9:991586. [PMID: 36204579 PMCID: PMC9530145 DOI: 10.3389/fcvm.2022.991586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/01/2022] [Indexed: 11/15/2022] Open
Abstract
Aim Selexipag is an oral selective prostacyclin receptor agonist approved for treatment of patients with pulmonary arterial hypertension (PAH). In the present study, we aim to assess the safety and efficacy of selexipag in triple combination therapy with endothelial receptor antagonists (ERAs) and PDE5is for Chinese PAH patients. Methods and results A single center retrospective study was performed on group 1 PAH patients (n = 68) initiating triple combination therapy with selexipag from 1 February 2020 to 31 August 2021 in Qilu Hospital of Shandong University (Shandong, China). Adolescents, children, and PAH patients with unrepaired congenital heart disease were excluded. The French pulmonary hypertension network (FPHN) non-invasive risk assessment, echocardiogram parameters, and clinical data, including tolerability, safety, and death/hospitalization events associated with PAH, were collected. Of the 68 patients, 31 (45.6%) patients had tolerable side effects while only a single patient discontinued selexipag due to severe diarrhea. In the analysis of the efficacy set of 62 patients, the median selexipag treatment time from selexipag initiation to last risk assessment was 27 (21, 33) weeks. Compared to baseline parameters, the percentage of WHO FC III/IV decreased from 77.4% (48) to 24.2% (15) (p = 0.000), median 6-min walk distance (6MWD) increased 82 m [from 398 (318, 450) to 480 (420, 506) m; p = 0.000], and NT-proBNP levels decreased from 1,216 (329, 2,159) to 455 (134, 1,678) pg/mL (p = 0.007). Patients who improved to three low-risk criteria increased from 9.7 to 38.7%. Right ventricular diameter (RV) diameter also decreased and was accompanied by an improved tricuspid annular plane systolic excursion (TAPSE). Patients transitioning from subcutaneous treprostinil to selexipag continued to show improvements in WHO FC, 6MWD (404 ± 94 vs. 383 ± 127 m) and NT-proBNP levels (2,319 ± 2,448 vs. 2,987 ± 3,770 pg/mL). Finally, the 1-year event free survival rate was 96.7% for patients initiating the triple combination therapy within 3 years of PAH diagnosis. Conclusion Triple combination therapy with selexipag was safe and effective in Chinese PAH patients, which was confirmed by acceptable tolerability, and improved exercise capacity, right heart function, risk assessment, and prognosis.
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Affiliation(s)
- Xiaopei Cui
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Weida Lu
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Deyuan Zhang
- Huantai County People’s Hospital, Huantai, Shandong, China
| | - Liangyi Qie
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Haijun Li
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiao Li
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hui Liu
- Department of General Practice, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Qiushang Ji
- Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- *Correspondence: Qiushang Ji,
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15
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Badagliacca R, Vizza CD, Lang I, Sadushi-Kolici R, Papa S, Manzi G, Filomena D, Ogawa A, Shimokawahara H, Matsubara H. Pulmonary pressure recovery in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension: Determinants and clinical impact. Vascul Pharmacol 2022; 146:107099. [PMID: 36058492 DOI: 10.1016/j.vph.2022.107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Over the past two decades randomized controlled trials of combination treatments for Pulmonary Arterial Hypertension (PAH) have demonstrated improvements of clinical status but only modest reductions in mean pulmonary pressure (mPAP). Recent experiences with upfront combination treatments including parenteral prostacyclins have shown more substantial mPAP reductions, and have provided grounds for reconsiderations of treatment. OBJECTIVES To evaluate the possibility of achieving mPAP <25 mmHg with current treatments, its determinants and the prognostic impact of mPAP reduction. METHODS 267 consecutive idiopathic, hereditary and drug and toxin-induced PAH patients treated with targeted therapies from three expert centers were followed with periodic clinical and hemodynamic assessments for survival detection. RESULTS Fifty-four (20.2%) patients achieved a mPAP <25 mmHg over 58 months (IQR 27-90) of treatment. Determinants of mPAP <25 mmHg were mPAP at diagnosis (HR 0.96, 95C.I. 0.93-0.98, p = 0.002) and an upfront combination strategy (double oral combination: HR 2.3, 95C.I. 1.10-4.76, p = 0.02; one oral plus parenteral prostanoid: HR 3.6, 95C.I. 1.39-9.37, p = 0.008; triple combination employing parenteral prostanoids: HR 12.9, 95C.I. 4.9-33.2, p = 0.0001). Seventy-three patients (27.3%) died. Survival rates were 90%, 79%, 70%, 55%, and 42% at 1, 3, 5, 10, and 15 years, respectively. Mean PAP during follow-up, days from diagnosis to prostanoid initiation and prostanoid maximum dose emerged as independent predictors of survival (Uno-C-index: 0.85). A mPAP ≤35 mmHg during follow-up was identified as the best cutoff value for prediction of survival. CONCLUSIONS Reduction to a mean PAP ≤ 35 mmHg appears to be a meaningful treatment target in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension.
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Affiliation(s)
- Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy.
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Irene Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Aiko Ogawa
- Department of Clinical Science, Okayama Medical Center, Japan
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16
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Langleben D, Orfanos SE, Fox BD, Messas N, Giovinazzo M, Catravas JD. The Paradox of Pulmonary Vascular Resistance: Restoration of Pulmonary Capillary Recruitment as a Sine Qua Non for True Therapeutic Success in Pulmonary Arterial Hypertension. J Clin Med 2022; 11:jcm11154568. [PMID: 35956182 PMCID: PMC9369805 DOI: 10.3390/jcm11154568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Exercise-induced increases in pulmonary blood flow normally increase pulmonary arterial pressure only minimally, largely due to a reserve of pulmonary capillaries that are available for recruitment to carry the flow. In pulmonary arterial hypertension, due to precapillary arteriolar obstruction, such recruitment is greatly reduced. In exercising pulmonary arterial hypertension patients, pulmonary arterial pressure remains high and may even increase further. Current pulmonary arterial hypertension therapies, acting principally as vasodilators, decrease calculated pulmonary vascular resistance by increasing pulmonary blood flow but have a minimal effect in lowering pulmonary arterial pressure and do not restore significant capillary recruitment. Novel pulmonary arterial hypertension therapies that have mainly antiproliferative properties are being developed to try and diminish proliferative cellular obstruction in precapillary arterioles. If effective, those agents should restore capillary recruitment and, during exercise testing, pulmonary arterial pressure should remain low despite increasing pulmonary blood flow. The effectiveness of every novel therapy for pulmonary arterial hypertension should be evaluated not only at rest, but with measurement of exercise pulmonary hemodynamics during clinical trials.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-514-340-7531
| | - Stylianos E. Orfanos
- 1st Department of Critical Care and Pulmonary Services, Pulmonary Hypertension Center, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 10676 Athens, Greece
| | - Benjamin D. Fox
- Pulmonary Division, Yitzchak Shamir Hospital, Tel Aviv University, Tzrifin 69978, Israel
| | - Nathan Messas
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Michele Giovinazzo
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - John D. Catravas
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23529, USA
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17
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Mercurio V, Hassan HJ, Naranjo M, Cuomo A, Mazurek JA, Forfia PR, Balasubramanian A, Simpson CE, Damico RL, Kolb TM, Mathai SC, Hsu S, Mukherjee M, Hassoun PM. Risk Stratification of Patients with Pulmonary Arterial Hypertension: The Role of Echocardiography. J Clin Med 2022; 11:4034. [PMID: 35887800 PMCID: PMC9323074 DOI: 10.3390/jcm11144034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/28/2022] [Accepted: 07/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Given the morbidity and mortality associated with pulmonary arterial hypertension (PAH), risk stratification approaches that guide therapeutic management have been previously employed. However, most patients remain in the intermediate-risk category despite initial therapy. Herein, we sought to determine whether echocardiographic parameters could improve the risk stratification of intermediate-risk patients. Methods: Prevalent PAH patients previously enrolled in observational studies at 3 pulmonary hypertension centers were included in this study. A validated PAH risk stratification approach was used to stratify patients into low-, intermediate-, and high-risk groups. Right ventricular echocardiographic parameters were used to further stratify intermediate-risk patients into intermediate-low- and intermediate-high-risk groups based on transplant-free survival. Results: From a total of 146 patients included in our study, 38 patients died over a median follow-up of 2.5 years. Patients with intermediate-/high-risk had worse echocardiographic parameters. Tricuspid annular plane systolic excursion (TAPSE) and the degree of tricuspid regurgitation (TR) were highly associated with survival (p < 0.01, p = 0.04, respectively) and were subsequently used to further stratify intermediate-risk patients. Among intermediate-risk patients, survival was worse for patients with TAPSE < 19 mm compared to those with TAPSE ≥ 19 mm (estimated one-year survival 74% vs. 96%, p < 0.01) and for patients with moderate/severe TR compared to those with no/trace/mild TR (estimated one-year survival 70% vs. 93%, p < 0.01). Furthermore, among intermediate-risk patients, those with both TAPSE < 19 mm and moderate/severe TR had an estimated one-year survival (56%) similar to that of high-risk patients (56%), and those with both TAPSE ≥ 19 mm and no/trace/mild TR had an estimated one-year survival (97%) similar to that of low-risk patients (95%). Conclusions: Echocardiography, a routinely performed, non-invasive imaging modality, plays a pivotal role in discriminating distinct survival phenotypes among prevalent intermediate-risk PAH patients using TAPSE and degree of TR. This can potentially help guide subsequent therapy.
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Affiliation(s)
- Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
| | - Hussein J. Hassan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Mario Naranjo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
| | - Jeremy A. Mazurek
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Paul R. Forfia
- Pulmonary Hypertension, Right Heart Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital, Philadelphia, PA 19140, USA;
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Rachel L. Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (M.M.)
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (M.M.)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
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18
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Telehealth: A winning weapon to face the COVID-19 outbreak for patients with pulmonary arterial hypertension. Vascul Pharmacol 2022; 145:107024. [PMID: 35716991 PMCID: PMC9212864 DOI: 10.1016/j.vph.2022.107024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022]
Abstract
Background COVID-19 pandemic severely affected national health systems, altering the modality and the type of care of patients with acute and chronic diseases. To minimize the risk of exposure to SARS-CoV2 for patients and health professionals, face-to-face visits were cancelled or postponed and the use of telemedicine was strongly encouraged. This reorganization involved especially patients with rare diseases needing periodic comprehensive assessment, such as pulmonary arterial hypertension (PAH). Main body The paper reports a proposal of strategy adopted for patients followed at our PAH center in Rome, where patients management was diversified based on clinical risk according to the European Society of Cardiology/European Respiratory Society PH guidelines-derived score and the REVEAL 2.0 score. A close monitoring and support of these patients were made possible by policy changes reducing barriers to telehealth access and promoting the use of telemedicine. Synchronous/asynchronous modalities and remote monitoring were used to collect and transfer medical data in order to guide physicians in therapeutic-decision making. Conversely, the use of implantable monitors providing hemodynamic information and echocardiography-mobile devices wirelessly connecting was limited by the poor experience existing in this setting. Large surveys and clinical trials are welcome to test the potential benefit of the optimal balance between traditional PAH management and telemedicine opportunities. Conclusion Italy was found unprepared to manage the dramatic effects caused by COVID-19 on healthcare systems. In this emergency situation telemedicine represented a promising tool especially in rare diseases as PAH, but was limited by its scattered availability and legal and ethical issues. Cohesive partnership of health care providers with regional public health officials is needed to prioritize PAH patients for telemedicine by dedicated tools.
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19
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Suzuki S, Asano R, Aoki T, Nakayama S, Ueda J, Tsuji A, Noguchi T, Ogo T. Prognostic impact of follow-up pulmonary vascular resistance in pulmonary arterial hypertension. Open Heart 2022; 9:openhrt-2022-002054. [PMID: 35675988 PMCID: PMC9185661 DOI: 10.1136/openhrt-2022-002054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Pulmonary arterial hypertension (PAH), caused by pulmonary artery remodelling and increased pulmonary vascular resistance (PVR) due to an unknown mechanism, is an intractable disease with a poor prognosis. The recent development of PAH-specific treatment medications may allow for higher PVR reduction than previously achieved. This study aimed to identify the prognostic significance of follow-up PVR levels achieved shortly after the initiation of targeted treatment in patients with idiopathic/heritable pulmonary arterial hypertension (I/H-PAH). Methods We analysed the data of all patients with I/H-PAH admitted to our hospital between 1998 and 2019. We collected data at baseline and during the first invasive haemodynamic evaluation. The primary outcome was death or lung transplantation. Results Of the 133 treatment-naïve patients enrolled in this study, 47 experienced adverse events during a median follow-up period of 6.4 (IQR 3.5–11.5) years. The median time interval to first follow-up from diagnosis was 162 (IQR 117–253) days. Incidence of the primary outcome was significantly lower in patients who achieved low PVR at follow-up. Of risk factors evaluated at follow-up, the multivariate Cox regression analysis revealed PVR as an independent predictor of the primary outcome (HR 1.103, 95% CI 1.029 to 1.183; p=0.006). The results were consistent across risk profiles according to the simplified risk stratification recommended by the European Society of Cardiology and European Respiratory Society guidelines. Conclusion Follow-up PVR was an independent predictor of transplant-free survival in patients with I/H-PAH. Evaluation of haemodynamic status shortly after initiating treatment may help predict long-term prognosis.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryotaro Asano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sayuri Nakayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jin Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Tsuji
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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20
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D'Alto M, Badagliacca R. The importance of right ventricular remodelling in pulmonary arterial hypertension. BRITISH HEART JOURNAL 2022; 108:1338-1339. [PMID: 35606110 DOI: 10.1136/heartjnl-2022-321143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Disease, University of Rome La Sapienza, Rome, Italy
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21
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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22
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Badagliacca R, Rischard F, Giudice FL, Howard L, Papa S, Valli G, Manzi G, Sciomer S, Palange P, Garcia JG, Vanderpool R, Rinaldo R, Vigo B, Insel M, Fedele F, Vizza CD. INCREMENTAL VALUE OF CARDIOPULMONARY EXERCISE TESTING IN INTERMEDIATE-RISK PULMONARY ARTERIAL HYPERTENSION. J Heart Lung Transplant 2022; 41:780-790. [DOI: 10.1016/j.healun.2022.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 02/02/2022] [Accepted: 02/28/2022] [Indexed: 01/29/2023] Open
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23
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Computational Simulator Models and Invasive Hemodynamic Monitoring as Tools for Precision Medicine in Pulmonary Arterial Hypertension. J Clin Med 2021; 11:jcm11010082. [PMID: 35011825 PMCID: PMC8745441 DOI: 10.3390/jcm11010082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/11/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Precision medicine, providing the right therapeutic strategy for the right patient, could revolutionize management and prognosis of patients affected by cardiovascular diseases. Big data and artificial intelligence are pivotal for the realization of this ambitious design. In the setting of pulmonary arterial hypertension (PAH), the use of computational models and data derived from ambulatory implantable hemodynamic monitors could provide useful information for tailored treatment, as requested by precision medicine.
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24
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Miotti C, Papa S, Manzi G, Scoccia G, Luongo F, Toto F, Malerba C, Cedrone N, Sciomer S, Ciciarello F, Fedele F, Vizza CD, Badagliacca R. The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece. J Clin Med 2021; 10:jcm10040619. [PMID: 33561999 PMCID: PMC7915820 DOI: 10.3390/jcm10040619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare, progressive disease with a poor prognosis. The pathophysiologic model is mainly characterized by an afterload mismatch in which an increased right ventricle afterload, driven by increased pulmonary vascular resistance (PVR), leads to right heart failure. International guidelines recommend optimization of treatment based on regular risk assessments to achieve or maintain a low-risk status. Current risk scores are based on a multi-modality approach, including demographic, clinical, functional, exercise, laboratory, and hemodynamic parameters, which lack significant echocardiographic parameters. The originality of echocardiography relies on the opportunity to assess in a non-invasive way a physiologically meaningful combination of easy to measure variables tightly related to right ventricle adaptation/maladaptation to increased afterload, the main determinant of a patient's prognosis. Echo-derived morphological and functional parameters have been investigated in PAH, proving to have prognostic relevance. Different therapeutic strategies proved to have different effects in reducing PVR. An upfront combination of drugs, including a parenteral prostacyclin, has shown to be associated with right heart reverse remodeling in a greater proportion of patients than other treatment strategies as a function of PVR reduction. Adding echocardiographic data to current risk scores would allow better identification of right ventricle (RV) adaptation in PAH patients' follow-up. This additional information would allow better stratification of the patient, leading to optimized and personalized therapeutic management.
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Affiliation(s)
- Cristiano Miotti
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Gianmarco Scoccia
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Federico Luongo
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Federica Toto
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Claudia Malerba
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Nadia Cedrone
- Internal Medicine Department, Ospedale S. Pertini, 00157 Rome, Italy;
| | - Susanna Sciomer
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Francesco Ciciarello
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
- Correspondence: ; Tel.: +39-06-4997-9016
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