1
|
Al-Naamani N, Thenappan T. Left Heart Disease Phenotype in Pulmonary Arterial Hypertension: Considerations for Therapy. Chest 2024; 165:766-768. [PMID: 38599749 DOI: 10.1016/j.chest.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Nadine Al-Naamani
- Department of Medicine, University of Pennsylvania, Philadelphia, PA.
| | | |
Collapse
|
2
|
Grünig E, Rahaghi F, Elwing J, Vizza CD, Pepke-Zaba J, Shen J, Yao H, Hage A, Rosenkranz S, Vonk M, Balasubramanian V, Yuanhua Y, Yu Z, Lordan J, Cadaret L, Grover R, Ousmanou A, Seaman S, Deng C, Broderick M, White RJ. Oral Treprostinil is Associated with Improved Survival in FREEDOM-EV and its Open-Label Extension. Adv Ther 2024; 41:618-637. [PMID: 38055186 PMCID: PMC10838815 DOI: 10.1007/s12325-023-02711-x] [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: 07/29/2023] [Accepted: 10/09/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION In the event-driven FREEDOM-EV trial, oral treprostinil delayed clinical worsening in patients with pulmonary arterial hypertension (PAH). Open-label extension studies offer additional data about tolerability, efficacy, and survival, especially for those initially assigned placebo. The aim of the current study was to determine if oral treprostinil changed survival when considering the parent and extension study, if treprostinil provides functional benefits for participants initially assigned to placebo, and if the benefits observed for those treated with treprostinil were durable. METHODS Both active and placebo participants from FREEDOM-EV could enroll in the FREEDOM-EV open-label extension (OLE) study after experiencing an investigator-assessed clinical worsening event or after parent study closure. All participants in the OLE were offered open-label oral treprostinil. Previously assigned placebo participants titrated to maximally tolerated doses; previously assigned treprostinil participants continued dose titration. We repeated assessments including functional class and 6-min walk distance (6MWD) at 12-week intervals and measured N-terminal pro-brain natriuretic peptide (NT-proBNP) at week 48. Survival was estimated by Kaplan-Meier analysis, and we estimated hazard ratio (HR) using Cox proportional hazards. RESULTS Of 690 FREEDOM-EV participants, 470 enrolled in the OLE; vital status was available for 89% of initial Freedom-EV participants. When considering the combined parent and open-label data, initial assignment to oral treprostinil reduced mortality (HR 0.64, 95% confidence interval 0.46-0.91, p = 0.013); absolute risk reduction was 9%. Participants randomized to placebo who initiated oral treprostinil after clinical worsening and tolerated treatment through week 48 demonstrated favorable shifts in functional class (p < 0.0001), 6MWD improvements of + 84 m (p < 0.0001), and a reduction in NT-proBNP of - 778 pg/mL (p = 0.02), compared to OLE baseline. Modest trends toward benefit were measured for those initially assigned placebo who did not have clinical worsening, and 132/144 (92%) of treprostinil assigned participants without clinical worsening remained on drug at week 48 in the OLE study. Adverse events were consistent with FREEDOM-EV. CONCLUSION Initial treprostinil assignment improved survival in the entire data set; those who began treprostinil after a clinical worsening in the placebo arm and tolerated drug to week 48 enjoyed substantial functional gains. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01560637.
Collapse
Affiliation(s)
- Ekkehard Grünig
- Thoraxklinik-Heidelberg gGmbH, and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franck Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida, Weston, FL, USA
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza Università di Roma, Rome, Italy
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Yao
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Antoine Hage
- Pulmonary Hypertension Program, Department of Pulmonology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University of Cologne, Cologne, Germany
| | - Madelon Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Yang Yuanhua
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - James Lordan
- Cardiopulmonary Transplantation, Institute of Transplantation, Institute of Cellular Medicine, Newcastle University and the Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Linda Cadaret
- Division of Cardiology, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Rob Grover
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Aliou Ousmanou
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Scott Seaman
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Chunqin Deng
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine and the Mary M. Parkes Center, University of Rochester Medical Center, Rochester, NY, USA.
- Mary M. Parkes Center for Asthma, Allergy, and Pulmonary Care, University of Rochester Medical Center, 400 Red Creek Drive, Rochester, NY, 14623, USA.
| |
Collapse
|
3
|
Fauvel C, Liu Y, Correa-Jaque P, Kanwar MK, Vizza CD, Lin S, Benza RL. Do Patients With Low-Risk Pulmonary Arterial Hypertension Really Benefit From Upfront Combination Therapy?: Insight From the AMBITION Trial. Chest 2023; 164:1518-1530. [PMID: 37356711 PMCID: PMC10716797 DOI: 10.1016/j.chest.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Based on results of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial, upfront combination therapy is recommended for treatment-naive patients with low-risk pulmonary arterial hypertension (PAH). However, conflicting data exist whether adopting this treatment strategy in this risk group is beneficial or well tolerated. RESEARCH QUESTION Do patients with low-risk PAH really benefit from upfront combination therapy? STUDY DESIGN AND METHODS Using the data from the original AMBITION trial, patients with PAH were classified as low, intermediate, or high risk using the Registry to Evaluate Early and Long-term PAH Disease Management 2.0 (REVEAL 2.0) score and the Pulmonary Hypertension Outcomes and Risk Assessment (PHORA) tool. The primary end point was time to clinical worsening (including death, hospitalization for PAH worsening, and disease progression) censored at 1- and 3-year post-enrollment. Side effects that led to withdrawal of treatment were also considered. RESULTS Patients with low-risk PAH categorized by REVEAL 2.0 and PHORA did not see a statistically significant benefit of upfront combination therapy vs monotherapy for time to clinical worsening at 1 and 3 years' post-enrollment using Cox proportional analysis (3-year hazard ratio of 0.40 [95% CI, 0.15-1.06; P = .07] and 0.55 [95% CI, 0.26-1.18; P = .12] for REVEAL 2.0 and PHORA, respectively) or considering time to clinical worsening or side effects (3-year hazard ratio of 0.75 [95% CI, 0.39-1.47; P = .4] and 0.87 [95% CI, 0.49-1.54; P = .63] for REVEAL 2.0 and PHORA). Patients with low-risk PAH on upfront combination therapy experienced a higher but not significant incidence of side effects using REVEAL 2.0 and PHORA. In contrast, patients at intermediate or high risk saw a statistically significant benefit of upfront combination therapy considering each of the end points regardless of side effects. INTERPRETATION This analysis suggests that perhaps some patients with low-risk PAH should be further stratified using other modalities prior to committing to upfront combination therapy, especially when the occurrence of side effects is considered. Further prospective data are needed to validate this hypothesis prior to changes in current guideline directed therapy are contemplated.
Collapse
Affiliation(s)
- Charles Fauvel
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH; Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Yongqi Liu
- Department of Statistics, The Ohio State University, Columbus, OH
| | - Priscilla Correa-Jaque
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
| | | | - Shili Lin
- Department of Cardiology, Normandie University, UNIROUEN, Rouen, France
| | - Raymond L Benza
- ICAHN School of Medicine at Mount Sinai, Mount Sinai Heart, New York, New York.
| |
Collapse
|
4
|
Parab S, Setten E, Astanina E, Bussolino F, Doronzo G. The tissue-specific transcriptional landscape underlines the involvement of endothelial cells in health and disease. Pharmacol Ther 2023; 246:108418. [PMID: 37088448 DOI: 10.1016/j.pharmthera.2023.108418] [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: 11/05/2022] [Revised: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 04/25/2023]
Abstract
Endothelial cells (ECs) that line vascular and lymphatic vessels are being increasingly recognized as important to organ function in health and disease. ECs participate not only in the trafficking of gases, metabolites, and cells between the bloodstream and tissues but also in the angiocrine-based induction of heterogeneous parenchymal cells, which are unique to their specific tissue functions. The molecular mechanisms regulating EC heterogeneity between and within different tissues are modeled during embryogenesis and become fully established in adults. Any changes in adult tissue homeostasis induced by aging, stress conditions, and various noxae may reshape EC heterogeneity and induce specific transcriptional features that condition a functional phenotype. Heterogeneity is sustained via specific genetic programs organized through the combinatory effects of a discrete number of transcription factors (TFs) that, at the single tissue-level, constitute dynamic networks that are post-transcriptionally and epigenetically regulated. This review is focused on outlining the TF-based networks involved in EC specialization and physiological and pathological stressors thought to modify their architecture.
Collapse
Affiliation(s)
- Sushant Parab
- Department of Oncology, University of Torino, IT, Italy; Candiolo Cancer Institute-IRCCS-FPO, Candiolo, Torino, IT, Italy
| | - Elisa Setten
- Department of Oncology, University of Torino, IT, Italy; Candiolo Cancer Institute-IRCCS-FPO, Candiolo, Torino, IT, Italy
| | - Elena Astanina
- Candiolo Cancer Institute-IRCCS-FPO, Candiolo, Torino, IT, Italy
| | - Federico Bussolino
- Department of Oncology, University of Torino, IT, Italy; Candiolo Cancer Institute-IRCCS-FPO, Candiolo, Torino, IT, Italy.
| | - Gabriella Doronzo
- Department of Oncology, University of Torino, IT, Italy; Candiolo Cancer Institute-IRCCS-FPO, Candiolo, Torino, IT, Italy
| |
Collapse
|
5
|
Bousseau S, Sobrano Fais R, Gu S, Frump A, Lahm T. Pathophysiology and new advances in pulmonary hypertension. BMJ MEDICINE 2023; 2:e000137. [PMID: 37051026 PMCID: PMC10083754 DOI: 10.1136/bmjmed-2022-000137] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.
Collapse
Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Rafael Sobrano Fais
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Sue Gu
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiovascular Pulmonary Research Lab, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrea Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| |
Collapse
|
6
|
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
| | | |
Collapse
|
7
|
Tamura Y, Kumamaru H, Nishimura S, Nakajima Y, Matsubara H, Taniguchi Y, Tsujino I, Shigeta A, Kinugawa K, Kimura K, Tatsumi K. Initial Triple Combination Therapy Including Intravenous Prostaglandin I 2 for the Treatment of Patients with Severe Pulmonary Arterial Hypertension. Int Heart J 2023; 64:684-692. [PMID: 37518350 DOI: 10.1536/ihj.23-047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Upfront combination therapy including intravenous prostaglandin I2 (PGI2-IV) is recognized as the most appropriate treatment for patients with severe pulmonary arterial hypertension (PAH). This retrospective study aimed to determine reasons why this therapy is not used for some patients with severe PAH and describe the hemodynamic and clinical prognoses of patients receiving initial combination treatment with (PGI2-IV+) or without (PGI2-IV-) PGI2-IV.Data for patients with severe PAH (World Health Organization Functional Class III/IV and mean pulmonary arterial pressure [mPAP] ≥ 40 mmHg) were extracted from the Japan Pulmonary Hypertension Registry. Overall, 73 patients were included (PGI2-IV + n = 17; PGI2-IV- n = 56). The PGI2-IV+ cohort was younger than the PGI2-IV- cohort (33.8 ± 10.6 versus 52.6 ± 18.2 years) and had higher mPAP (58.1 ± 12.9 versus 51.8 ± 9.0 mmHg), greater prevalence of idiopathic PAH (88% versus 32%), and less prevalence of connective tissue disease-associated PAH (0% versus 29%). Hemodynamic measures, including mPAP, showed improvement in both cohorts (post-treatment median [interquartile range] 38.5 [17.0-40.0] for the PGI2-IV + cohort and 33.0 [25.0-43.0] mmHg for the PGI2-IV - cohort). Deaths (8/56) and lung transplantation (1/56) occurred only in the PGI2-IV - cohort.These Japanese registry data indicate that older age, lower mPAP, and non-idiopathic PAH may influence clinicians against using upfront combination therapy including PGI2-IV for patients with severe PAH. Early combination therapy including PGI2-IV was associated with improved hemodynamics from baseline, but interpretation is limited by the small sample size.
Collapse
Affiliation(s)
- Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital
- Japan Pulmonary Hypertension Registry (JAPHR) Network
| | - Hiraku Kumamaru
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo
| | - Shiori Nishimura
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo
| | | | - Hiromi Matsubara
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- National Hospital Organization Okayama Medical Center
| | - Yu Taniguchi
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Ichizo Tsujino
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University
| | - Ayako Shigeta
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Respirology, Graduate School of Medicine, Chiba University
| | - Koichiro Kinugawa
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Second Department of Internal Medicine, University of Toyama
| | - Kazuhiro Kimura
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Koichiro Tatsumi
- Japan Pulmonary Hypertension Registry (JAPHR) Network
- Department of Respirology, Graduate School of Medicine, Chiba University
| |
Collapse
|
8
|
Li J, Yang ZY, Wang S, Yuan P, Zhao QH, Gong SG, Qiu HL, Luo CJ, Li HT, Zhang R, Wu WH, Liu JM, Wang L, Liu SS, Jiang R. Efficacy and safety of switching from bosentan or ambrisentan to macitentan in pulmonary arterial hypertension: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:977110. [PMID: 36568539 PMCID: PMC9767980 DOI: 10.3389/fcvm.2022.977110] [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: 06/29/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
Background There is little evidence of the effectiveness of switching from the endothelin receptor antagonists (ERAs) bosentan and ambrisentan to a novel ERA, macitentan, in patients with pulmonary arterial hypertension (PAH). Therefore, a systematic review and meta-analysis was performed to evaluate the efficacy and safety of patients with PAH switching from other ERAs to macitentan. Methods We retrieved the relevant literature published before January 2022 for the meta-analysis from the PubMed, EMBASE, and Cochrane Library databases. Efficacy included changes in the 6-min walk distance (6MWD), World Health Organization functional class (WHO-FC), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, hemodynamics, echocardiography and survival. Results Nine studies, consisting of 408 PAH patients, that met the inclusion criteria were included. The switch from bosentan or ambrisentan to macitentan effectively increased the 6MWD by 20.71 m (95% CI: 10.35-31.07, P < 0.00001, I 2 = 0%). Six months after conversion, the tricuspid annular plane systolic excursion was found to improve from 19.0 ± 4.0 to 21.0 ± 5.0 mm in adults and from 16.00 ± 5.0 to 18.25 ± 4.8 mm in children. Ordinal logistic regression showed that the WHO-FC significantly improved by 0.412 (95% CI: 0.187-0.908, P = 0.028). The switch did not show significant improvement in NT-proBNP levels. In addition, the switch was well tolerated. Conclusion The switch from bosentan or ambrisentan to macitentan significantly increased the 6MWD in PAH patients, improved the WHO-FC, and exerted safety benefits. The effects of the switch on NT-proBNP levels, hemodynamics, and echocardiography still need to be further confirmed. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021292554].
Collapse
Affiliation(s)
- Jie Li
- Department of School of Medicine, Tongji University, Shanghai, China
| | - Zu-Yuan Yang
- Department of School of Medicine, Tongji University, Shanghai, China
| | - Shang Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hui-Ting Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shan-Shan Liu
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao, China,Shan-Shan Liu,
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China,*Correspondence: Rong Jiang, ,
| |
Collapse
|
9
|
Reddy YNV. Portopulmonary Hypertension-Rethinking Our Current Approach. Mayo Clin Proc 2022; 97:2189-2191. [PMID: 36464461 DOI: 10.1016/j.mayocp.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
10
|
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: 926] [Impact Index Per Article: 463.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
|
11
|
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.
Collapse
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,
| |
Collapse
|
12
|
Tremblay É, Gosselin C, Mai V, Lajoie AC, Kilo R, Weatherald J, Lacasse Y, Bonnet S, Lega JC, Provencher S. Assessment of Clinical Worsening End Points as a Surrogate for Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circulation 2022; 146:597-612. [PMID: 35862151 DOI: 10.1161/circulationaha.121.058635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical worsening (CW) is a composite end point commonly used in pulmonary arterial hypertension (PAH) trials. We aimed to assess the trial-level surrogacy of CW for mortality in PAH trials, and whether the various CW components were similar in terms of frequency of occurrence, treatment-related relative risk (RR) reduction, and importance to patients. METHODS We searched MEDLINE, Embase, and the Cochrane Library (January 1990 to December 2020) for trials evaluating the effects of PAH therapies on CW. The coefficient of determination between the RR for CW and mortality was assessed by regression analysis. The frequency of occurrence, RR reduction, and importance to patients of the CW components were assessed. RESULTS We included 35 independent cohorts (9450 patients). PAH therapies significantly reduced CW events (RR, 0.64 [95% CI, 0.55-0.73]), including PAH-related hospitalizations (RR, 0.61 [95% CI, 0.47-0.79]), treatment escalation (RR, 0.57 [95% CI, 0.38-0.84]) and symptomatic progression (RR, 0.58 [95% CI, 0.48-0.69]), and modestly reduced all-cause mortality when incorporating deaths occurring after a primary CW-defining event (RR, 0.860 [95% CI, 0.742-0.997]). However, the effects of PAH-specific therapies on CW only modestly correlated with their effects on mortality (R2trial, 0.35 [95% CI, 0.10-0.59]; P<0.0001), and the gradient in the treatment effect across component end points was large in the majority of trials. The weighted proportions of CW-defining events were hospitalization (33.5%) and symptomatic progression (32.3%), whereas death (6.7%), treatment escalation (5.6%), and transplantation/atrioseptostomy (0.2%) were infrequent. CW events were driven by the occurrence of events of major (49%) and mild-to-moderate (37%) importance to patients, with 14% of the events valued as critical. CONCLUSIONS PAH therapies significantly reduced CW events, but study-level CW is not a surrogate for mortality in PAH trials. Moreover, components of CW largely vary in frequency, response to therapy, and importance to patients and are thus not interchangeable. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42020178949.
Collapse
Affiliation(s)
- Élodie Tremblay
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| | - Camille Gosselin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| | - Vicky Mai
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| | - Annie C Lajoie
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| | - Roubi Kilo
- Pôle De Santé Publique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310, Pierre-Bénite, France (R.K.)
| | - Jason Weatherald
- Department of Medicine, Division of Respiratory Medicine, Libin Cardiovascular Institute, University of Calgary, Canada (J.W.)
| | - Yves Lacasse
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Department of Medicine (Y.L., S.B., S.P.), Université Laval, Quebec City, Canada
| | - Sebastien Bonnet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Department of Medicine (Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| | - Jean-Christophe Lega
- Université de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Centre national de la recherche scientifique, F-69100, Groupe d'Etude Multidisciplinaire des Maladies Thrombotiques, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310, Lyon, France (J.-C.L.)
| | - Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center (E.T., C.G., V.M., A.C.L., Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Department of Medicine (Y.L., S.B., S.P.), Université Laval, Quebec City, Canada.,Pulmonary Hypertension Research Group Quebec City, Canada (E.T., C.G., V.M., A.C.L., S.B., S.P.)
| |
Collapse
|
13
|
Wissmüller M, Xanthouli P, Benjamin N, Grünig E, Richter MJ, Gall H, Ghofrani HA, Herkenrath S, Skowasch D, Pizarro C, Halank M, Hohmann C, Hellmich M, Gerhardt F, Rosenkranz S. Profiles and treatment patterns of patients with pulmonary arterial hypertension on monotherapy at experienced centres. ESC Heart Fail 2022; 9:2873-2885. [PMID: 35706353 DOI: 10.1002/ehf2.13804] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Guideline recommendations highlight the critical role of combination therapy for the treatment of pulmonary arterial hypertension (PAH). Conversely, registry data demonstrate that a considerable number of PAH patients remain on monotherapy. The reasons for this discrepancy remain elusive. The aim of this study was to assess the patient profiles, treatment patterns, and disease characteristics of patients diagnosed with PAH who were kept on monotherapy at experienced pulmonary hypertension (PH) centres and to capture potential reasons for monotherapy. METHODS AND RESULTS We analysed the patient profiles of 182 patients on monotherapy with PAH-targeted drugs, managed at experienced PH expert centres (Cologne, Giessen, Heidelberg, and Dresden). Patients were identified based on their latest follow-up visit and analysed retrospectively from the time of PAH diagnosis to last follow-up. Patients were dichotomized by age, and patient characteristics, treatment patterns, response to therapy, change in risk status, and drug tolerability were recorded during the course of their disease. Patients' mean age was 69.1 ± 13.1 years at the most recent follow-up (Key Time Point 1) and 64.5 ± 14.9 years at the time of diagnosis (Key Time Point 2). The mean time on monotherapy was 60.7 ± 53.8 months; 35.7/64.3% of patients were male/female. The majority (66.5%) had idiopathic PAH, followed by PAH associated with connective tissue disease (17.0%) and portopulmonary PH (8.2%). Among patients on monotherapy, there were five main clusters: (i) patients with failed escalation attempts mostly because of intolerability (26.9%); (ii) low risk on monotherapy, favourable response, and no reason for escalation (24.2%); (iii) patients with mild PAH (36.3%); (iv) elderly patients with PAH and multiple co-morbidities (38.5%); and (v) patients with associated forms of PAH where the level of evidence for combination therapies is considered low (16.5%). There were substantial differences between patients above or below the median age (68 years). The most frequently used monotherapy for PAH was phosphodiesterase type 5 inhibitors (75.3%). CONCLUSIONS A considerable number of PAH patients are on monotherapy at large PH expert centres, characterized by specific reasons that justify this kind of treatment. Nevertheless, as comprehensive treatment strategies have shown improved long-term outcomes even in mildly symptomatic patients, each case of monotherapy should be justified.
Collapse
Affiliation(s)
- Max Wissmüller
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Nicola Benjamin
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Ekkehard Grünig
- Zentrum für pulmonale Hypertonie, Thoraxklinik, Universitätsklinikum Heidelberg und Translational Lung Research Centre, Heidelberg, Germany
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Manuel J Richter
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Henning Gall
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
- Abt. Pneumologie, Medizinische Klink II, Universitätsklinikum Gießen und Marburg, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Simon Herkenrath
- Institute for Pneumology, University of Cologne, Solingen, Germany
- Bethanien Hospital, Clinic of Pneumology and Allergology Center for Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Dirk Skowasch
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Carmen Pizarro
- Medizinische Klinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Michael Halank
- Medizinische Klinik I, Universitätsklinik Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Christopher Hohmann
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Martin Hellmich
- Institut für Medizinische Statistik, Informatik und Epidemiologie (IMSIE), Universität zu Köln, Cologne, Germany
| | - Felix Gerhardt
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
| | - Stephan Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, Cologne, 50935, Germany
- Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Universität zu Köln, Cologne, Germany
| |
Collapse
|
14
|
Boucly A, Humbert M, Sitbon O. To be or not to be… treated with initial combination therapy, that is the (PAH) question. Eur Respir J 2022; 59:59/6/2200390. [PMID: 35654453 DOI: 10.1183/13993003.00390-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France.,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France.,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculté de Médicine, Le Kremlin-Bicêtre, France .,AP-HP, DMU "Thorinno", Hôpital Bicêtre, Service de Pneumologie et Soins Intensifs, Centre de Référence de l'Hypertension Pulmonaire, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Hypertension Pulmonaire: Physiopathologie et Nouvelles Thérapies", Hôpital Marie Lannelongue, Le Plessis Robinson, France
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Hoeper MM, Pausch C, Grünig E, Staehler G, Huscher D, Pittrow D, Olsson KM, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Rosenkranz S, Park DH, Ewert R, Kaemmerer H, Lange TJ, Kabitz HJ, Skowasch D, Skride A, Claussen M, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H. Temporal trends in pulmonary arterial hypertension: results from the COMPERA registry. Eur Respir J 2022; 59:2102024. [PMID: 34675047 PMCID: PMC9160392 DOI: 10.1183/13993003.02024-2021] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Since 2015, the European pulmonary hypertension guidelines recommend the use of combination therapy in most patients with pulmonary arterial hypertension (PAH). However, it is unclear to what extent this treatment strategy is adopted in clinical practice and if it is associated with improved long-term survival. METHODS We analysed data from COMPERA, a large European pulmonary hypertension registry, to assess temporal trends in the use of combination therapy and survival of patients with newly diagnosed PAH between 2010 and 2019. For survival analyses, we looked at annualised data and at cumulated data comparing the periods 2010-2014 and 2015-2019. RESULTS A total of 2531 patients were included. The use of early combination therapy (within 3 months after diagnosis) increased from 10.0% in patients diagnosed with PAH in 2010 to 25.0% in patients diagnosed with PAH in 2019. The proportion of patients receiving combination therapy 1 year after diagnosis increased from 27.7% to 46.3%. When comparing the 2010-2014 and 2015-2019 periods, 1-year survival estimates were similar (89.0% (95% CI 87.2-90.9%) and 90.8% (95% CI 89.3-92.4%), respectively), whereas there was a slight but nonsignificant improvement in 3-year survival estimates (67.8% (95% CI 65.0-70.8%) and 70.5% (95% CI 67.8-73.4%), respectively). CONCLUSIONS The use of combination therapy increased from 2010 to 2019, but most patients still received monotherapy. Survival rates at 1 year after diagnosis did not change over time. Future studies need to determine if the observed trend suggesting improved 3-year survival rates can be confirmed.
Collapse
Affiliation(s)
- Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Hannover, Germany
| | | | - Ekkehard Grünig
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Centre for Pulmonary Hypertension, Thoraxclinic Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany
| | | | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany
- Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Karen M Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Carmine Dario Vizza
- Dept of Cardiovascular and Respiratory Diseases, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Dept of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Dept of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Dept of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J Simon R Gibbs
- Dept of Cardiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - H Ardeschir Ghofrani
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Dept of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
- Dept of Medicine, Imperial College London, London, UK
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - Da-Hee Park
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Dept of Respiratory Medicine, Ernst Moritz Arndt University Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für Angeborene Herzfehler und Kinder Kardiologie, TU München, Munich, Germany
| | - Tobias J Lange
- Dept of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Joachim Kabitz
- Medizinische Klinik II, Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Konstanz, Germany
| | - Dirk Skowasch
- Medizinische Klinik und Poliklinik II, Innere Medizin - Kardiologie/Pneumologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Andris Skride
- VSIA Pauls Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Martin Claussen
- Fachabteilung Pneumologie, LungenClinic Grosshansdorf, Grosshansdorf, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungen Forschungsambulanz, Helmholtz Zentrum, Munich, Germany
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Matthias Held
- Dept of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- 2nd Critical Care Dept, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Dept of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| |
Collapse
|
17
|
Wang RR, Yuan TY, Chen D, Chen YC, Sun SC, Wang SB, Kong LL, Fang LH, Du GH. Dan-Shen-Yin Granules Prevent Hypoxia-Induced Pulmonary Hypertension via STAT3/HIF-1α/VEGF and FAK/AKT Signaling Pathways. Front Pharmacol 2022; 13:844400. [PMID: 35479305 PMCID: PMC9035666 DOI: 10.3389/fphar.2022.844400] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Traditional Chinese medicine (TCM) plays an important role in the treatment of complex diseases, especially cardiovascular diseases. However, it is hard to identify their modes of action on account of their multiple components. The present study aims to evaluate the effects of Dan-Shen-Yin (DSY) granules on hypoxia-induced pulmonary hypertension (HPH), and then to decipher the molecular mechanisms of DSY. Systematic pharmacology was employed to identify the targets of DSY on HPH. Furthermore, core genes were identified by constructing a protein-protein interaction (PPI) network and analyzed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes (KEGG) analysis. Related genes and pathways were verified using a hypoxia-induced mouse model and hypoxia-treated pulmonary artery cells. Based on network pharmacology, 147 potential targets of DSY on HPH were found, constructing a PPI network, and 13 hub genes were predicted. The results showed that the effect of DSY may be closely associated with AKT serine/threonine kinase 1 (AKT1), signal transducer and activator of transcription 3 (STAT3), and HIF-1 signaling pathways, as well as biological processes such as cell proliferation. Consistent with network pharmacology analysis, experiments in vivo demonstrated that DSY could prevent the development of HPH in a hypoxia-induced mouse model and alleviate pulmonary vascular remodeling. In addition, inhibition of STAT3/HIF-1α/VEGF and FAK/AKT signaling pathways might serve as mechanisms. Taken together, the network pharmacology analysis suggested that DSY exhibited therapeutic effects through multiple targets in the treatment of HPH. The inferences were initially confirmed by subsequent in vivo and in vitro studies. This study provides a novel perspective for studying the relevance of TCM and disease processes and illustrates the advantage of this approach and the multitargeted anti-HPH effect of DSY.
Collapse
Affiliation(s)
- Ran-Ran Wang
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tian-Yi Yuan
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Di Chen
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Cai Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Shu-Chan Sun
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shou-Bao Wang
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ling-Lei Kong
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lian-Hua Fang
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guan-Hua Du
- State Key Laboratory of Bioactive Substances and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
18
|
Chen Y, Luo J, Chen J, Kotlyar E, Li Z, Chen W, Li J. The Transition From Ambrisentan to Macitentan in Patients With Pulmonary Arterial Hypertension: A Real-word Prospective Study. Front Pharmacol 2022. [PMID: 35095523 DOI: 10.3389/fphar.2021.811700)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: In a long-term event-driven trial, macitentan has demonstrated beneficial time to clinical worsening in patients with pulmonary arterial hypertension (PAH) and reduced PAH-related hospitalization rates compared with placebo. Macitentan is the most recently approved endothelin receptor antagonist (ERA) and is the first ERA that has shown efficacy for morbidity and mortality in PAH patients; therefore, patients and physicians may consider converting treatment from ambrisentan to macitentan. Our study evaluated the safety, efficacy, and quality of life in PAH patients transitioning from ambrisentan to macitentan. Methods: This was a real-world, prospective study with a 12-month follow-up. PAH patients who had received stable doses of ambrisentan for over 3 months, were within the World Health Organization Functional Class II/III, and 6-min walk distance ≥ of 250 m were enrolled. The study included a screening period, followed by a transition phase, after which patients entered the long-term follow-up. Clinical data and treatment satisfaction outcomes were collected to assess and monitor the safety and efficacy of the transition. The trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn; No. ChiCTR2000034898). Results: One hundred and fifty-seven enrolled PAH patients completed the transition. All criteria for continuous treatment transition were met by 145 patients (92.4%). Results showed improvements in exercise capacity, cardiac function, and hemodynamics compared with baseline. During the process, 4 patients discontinued macitentan due to adverse events. There was no statistical difference in the overall incidence of adverse events before and after the transition. Conclusion: Transition to macitentan from ambrisentan was successful and well-tolerated by PAH patients, and was associated with greater efficacy and satisfaction.
Collapse
Affiliation(s)
- Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun Luo
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jingyuan Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | | | - Zilu Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Wenjie Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
19
|
Chen Y, Luo J, Chen J, Kotlyar E, Li Z, Chen W, Li J. The Transition From Ambrisentan to Macitentan in Patients With Pulmonary Arterial Hypertension: A Real-word Prospective Study. Front Pharmacol 2022; 12:811700. [PMID: 35095523 PMCID: PMC8790043 DOI: 10.3389/fphar.2021.811700] [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: 11/09/2021] [Accepted: 12/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background: In a long-term event-driven trial, macitentan has demonstrated beneficial time to clinical worsening in patients with pulmonary arterial hypertension (PAH) and reduced PAH-related hospitalization rates compared with placebo. Macitentan is the most recently approved endothelin receptor antagonist (ERA) and is the first ERA that has shown efficacy for morbidity and mortality in PAH patients; therefore, patients and physicians may consider converting treatment from ambrisentan to macitentan. Our study evaluated the safety, efficacy, and quality of life in PAH patients transitioning from ambrisentan to macitentan. Methods: This was a real-world, prospective study with a 12-month follow-up. PAH patients who had received stable doses of ambrisentan for over 3 months, were within the World Health Organization Functional Class II/III, and 6-min walk distance ≥ of 250 m were enrolled. The study included a screening period, followed by a transition phase, after which patients entered the long-term follow-up. Clinical data and treatment satisfaction outcomes were collected to assess and monitor the safety and efficacy of the transition. The trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn; No. ChiCTR2000034898). Results: One hundred and fifty-seven enrolled PAH patients completed the transition. All criteria for continuous treatment transition were met by 145 patients (92.4%). Results showed improvements in exercise capacity, cardiac function, and hemodynamics compared with baseline. During the process, 4 patients discontinued macitentan due to adverse events. There was no statistical difference in the overall incidence of adverse events before and after the transition. Conclusion: Transition to macitentan from ambrisentan was successful and well-tolerated by PAH patients, and was associated with greater efficacy and satisfaction.
Collapse
Affiliation(s)
- Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun Luo
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jingyuan Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | | | - Zilu Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Wenjie Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
- *Correspondence: Jiang Li, , orcid.org/0000-0003-4904-6635
| |
Collapse
|
20
|
Zelt JGE, Sugarman J, Weatherald J, Partridge ACR, Liang JC, Swiston J, Brunner N, Chandy G, Stewart DJ, Contreras-Dominguez V, Thakrar M, Helmersen D, Varughese R, Hirani N, Umar F, Dunne R, Doyle-Cox C, Foxall J, Mielniczuk L. Mortality trends in pulmonary arterial hypertension in canada: a temporal analysis of survival per ESC/ERS Guideline Era. Eur Respir J 2021; 59:13993003.01552-2021. [PMID: 34675044 PMCID: PMC9160389 DOI: 10.1183/13993003.01552-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/06/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The evolution in pulmonary arterial hypertension (PAH) management has been summarized in three iterations of the European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines. No study has assessed whether changes in management, as reflected in the changing guidelines, has translated to improved long-term survival in PAH. METHODS Mixed retrospective/prospective analysis of treatment naïve, incident PAH patients (n=392) diagnosed at three major centers in Canada from 2009-2021. Patients were divided into two groups based on their diagnosis date and in accordance with three ESC/ERS guideline iterations: 2009 and 2015. Overall survival was assessed based on date of diagnosis and initial treatment strategy (i.e. mono versus combination). RESULTS In Canada, there was a shift towards more aggressive upfront management with combination therapy after the publication of the 2015 guidelines (10.4% and 30.8% in 2009-2015 patients, and 36.0% and 57.4% in 2016-2021 patients, for baseline and 2-year follow-up respectively). A key factor associated with combination therapy after 2015 was higher pulmonary vascular resistance (p=0.009). The 1, 3 and 5 year survival rates in Canada were 89.2%, 75.6%. and 56.0%, respectively. Despite changes in management, there was no improvement in long-term survival before and after publication of the 2015 ESC/ERS guideline (p=0.53). CONCLUSIONS There was an increase in the use of initial and sequential combination therapy in Canada after publication of the 2015 ESC/ERS guidelines, which was not associated with improved long-term survival. These data highlight the continued difficulties of managing this aggressive pulmonary disease in an era without a cure.
Collapse
Affiliation(s)
- Jason G E Zelt
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada .,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Jordan Sugarman
- Internal Medicine Residency Program, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Arun C R Partridge
- Internal Medicine Residency Program, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jiaming Calvin Liang
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - John Swiston
- Division of Respirology, University of British Columbia, Vancouver, Canada
| | - Nathan Brunner
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - George Chandy
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa.,Division of Respirology and Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Duncan J Stewart
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa.,Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Mitesh Thakrar
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmersen
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Naushad Hirani
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fraz Umar
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Rosemary Dunne
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Caroyln Doyle-Cox
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Julia Foxall
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Lisa Mielniczuk
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| |
Collapse
|
21
|
Deshwal H, Weinstein T, Sulica R. Advances in the management of pulmonary arterial hypertension. J Investig Med 2021; 69:1270-1280. [PMID: 34580123 PMCID: PMC8485135 DOI: 10.1136/jim-2021-002027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
The management of pulmonary arterial hypertension (PAH) has significantly evolved over the last decades in the wake of more sensitive diagnostics and specialized clinical programs that can provide focused medical care. In the current era of PAH care, 1-year survival rates have increased to 86%–90% from 65% in the 1980s, and average long-term survival has increased to 6 years from 2.8 years. The heterogeneity in the etiology and disease course has opened doors to focusing research in phenotyping the disease and understanding the pathophysiology at a cellular and genetic level. This may eventually lead to precision medicine and the development of medications that may prevent or reverse pulmonary vascular remodeling. With more insight, clinical trial designs and primary end-points may change to identify the true survival benefit of pharmacotherapy. Identifying responders from non-responders to therapy may help provide individualized patient-centered care rather than an algorithm-based approach. The purpose of this review is to highlight the latest advances in screening, diagnosis, and management of PAH.
Collapse
Affiliation(s)
- Himanshu Deshwal
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Tatiana Weinstein
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Roxana Sulica
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
22
|
Diaz-Rodriguez N, Nyhan SM, Kolb TM, Steppan J. How We Would Treat Our Own Pulmonary Hypertension if We Needed to Undergo Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:1540-1548. [PMID: 34649806 DOI: 10.1053/j.jvca.2021.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/13/2021] [Accepted: 09/19/2021] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension (PH) is a disease that has many etiologies and is particularly prevalent in patients presenting for cardiac surgery, with which it is linked to poor outcomes. This manuscript is intended to provide a comprehensive review of the impact of PH on the perioperative management of patients who are undergoing cardiac surgery. The diagnosis of PH often involves a combination of noninvasive and invasive testing, whereas preoperative optimization frequently necessitates the use of specific medications that affect anesthetic management of these patients. The authors postulate that a thoughtful, multidisciplinary approach is required to deliver excellent perioperative care. Furthermore, they use an index case to illustrate the implications of managing a patient with pulmonary hypertension who presents for cardiac surgery with cardiopulmonary bypass.
Collapse
Affiliation(s)
- Natalia Diaz-Rodriguez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Sinead M Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
23
|
Torres Crigna A, Link B, Samec M, Giordano FA, Kubatka P, Golubnitschaja O. Endothelin-1 axes in the framework of predictive, preventive and personalised (3P) medicine. EPMA J 2021; 12:265-305. [PMID: 34367381 PMCID: PMC8334338 DOI: 10.1007/s13167-021-00248-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
Endothelin-1 (ET-1) is involved in the regulation of a myriad of processes highly relevant for physical and mental well-being; female and male health; in the modulation of senses, pain, stress reactions and drug sensitivity as well as healing processes, amongst others. Shifted ET-1 homeostasis may influence and predict the development and progression of suboptimal health conditions, metabolic impairments with cascading complications, ageing and related pathologies, cardiovascular diseases, neurodegenerative pathologies, aggressive malignancies, modulating, therefore, individual outcomes of both non-communicable and infectious diseases such as COVID-19. This article provides an in-depth analysis of the involvement of ET-1 and related regulatory pathways in physiological and pathophysiological processes and estimates its capacity as a predictor of ageing and related pathologies,a sensor of lifestyle quality and progression of suboptimal health conditions to diseases for their targeted preventionand as a potent target for cost-effective treatments tailored to the person.
Collapse
Affiliation(s)
- Adriana Torres Crigna
- Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Barbara Link
- Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Marek Samec
- Clinic of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 036 01 Martin, Slovakia
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 036 01 Martin, Slovakia
| | - Olga Golubnitschaja
- Predictive, Preventive and Personalised (3P) Medicine, Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| |
Collapse
|
24
|
Zhao Q, Guo N, Chen J, Parks D, Tian Z. Comparative assessment of efficacy and safety of ambrisentan and bosentan in patients with pulmonary arterial hypertension: A meta-analysis. J Clin Pharm Ther 2021; 47:146-156. [PMID: 34319626 DOI: 10.1111/jcpt.13481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 02/04/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Two endothelin receptor antagonists, ambrisentan and bosentan, have been demonstrated to be effective individually compared with placebo in the treatment of patients with pulmonary arterial hypertension (PAH). This network meta-analysis compared the efficacy and safety of ambrisentan and bosentan in patients with PAH. METHODS Clinical trials were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), EMBASE and PubMed databases. Weighted mean differences (MD) with 95% confidence intervals (CI) were calculated for continuous outcomes (6-min walk distance [6MWD] and Borg dyspnoea index [BDI]). Hazard ratio (HR) was calculated for binary outcomes, including clinical worsening, discontinuation due to adverse events (AEs) and liver dysfunction. Surface under cumulative ranking curve (SUCRA) was used to rank the treatments in each index. RESULTS Five clinical trials from four published studies (total patients: n = 920) were included. Ambrisentan and bosentan showed no significant difference in 6MWD (MD: -1.32; 95% CI: -27.87, 25.31, SUCRA score: ambrisentan 0.73, bosentan 0.77), BDI (MD: -0.16; 95% CI: -0.98, 0.65, SUCRA score: ambrisentan 0.83, bosentan 0.66), clinical worsening (HR: 0.99; 95% CI: 0.33, 2.94, SUCRA score: ambrisentan 0.75, bosentan 0.74) and discontinuation due to AEs (HR: 0.84; 95% CI: 0.11, 5.86, SUCRA score: ambrisentan 0.47, bosentan 0.57). However, ambrisentan was significantly better than bosentan with respect to abnormal liver function (HR: 23.18; 95% CI: 2.24, 377.20, SUCRA score: ambrisentan 0.99, bosentan 0.02). WHAT IS NEW AND CONCLUSION The results of this network meta-analysis suggest that ambrisentan was similar to bosentan in efficacy, while it exhibited better tolerability with respect to abnormal liver function in comparison with bosentan, in patients with PAH.
Collapse
Affiliation(s)
- Qinhua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Na Guo
- GlaxoSmithKline, Beijing, China
| | | | | | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
25
|
Boucly A, Savale L, Jaïs X, Bauer F, Bergot E, Bertoletti L, Beurnier A, Bourdin A, Bouvaist H, Bulifon S, Chabanne C, Chaouat A, Cottin V, Dauphin C, Degano B, De Groote P, Favrolt N, Feng Y, Horeau-Langlard D, Jevnikar M, Jutant EM, Liang Z, Magro P, Mauran P, Moceri P, Mornex JF, Palat S, Parent F, Picard F, Pichon J, Poubeau P, Prévot G, Renard S, Reynaud-Gaubert M, Riou M, Roblot P, Sanchez O, Seferian A, Tromeur C, Weatherald J, Simonneau G, Montani D, Humbert M, Sitbon O. Association Between Initial Treatment Strategy and Long-term Survival in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 204:842-854. [PMID: 34185620 DOI: 10.1164/rccm.202009-3698oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The relationship between initial treatment strategy and survival in pulmonary arterial hypertension (PAH) remains uncertain. Objectives: To evaluate long-term survival in PAH according to initial treatment strategy. Methods: Retrospective analysis of incident patients with idiopathic, heritable or anorexigen-induced PAH enrolled in the French Registry (01/2006 to 12/2018). Survival was assessed according to initial strategy: monotherapy, dual or triple combination (two oral medications and a parenteral prostacyclin). Results: Among 1611 enrolled patients, 984 were initiated with monotherapy, 551 with dual and 76 with triple therapy. The triple combination group was younger with fewer comorbidities but higher mortality risk. Survival was better with triple therapy (91% at 5 years) as compared to dual or monotherapy (both 61% at 5 years), p<0.001. A propensity score matching on age, sex and pulmonary vascular resistance also showed significant differences between triple and dual therapy (10-year survival 85% vs 65%). In high-risk patients (n=243), survival was better with triple therapy vs monotherapy or dual therapy, while there was no difference between monotherapy and double therapy. In intermediate-risk patients (n=1134), survival improved with increasing number of therapies. In multivariable Cox regression, triple therapy was independently associated with a lower risk of death (hazard ratio 0.29, 95% confidence interval 0.11-0.80, p=0.017). Among the 148 patients initiated with a parenteral prostacyclin, those on triple therapy had better survival than those on monotherapy or dual therapy. Conclusions: Initial triple combination therapy including parenteral prostacyclin seems to be associated with better survival in PAH, particularly in the youngest high-risk patients.
Collapse
Affiliation(s)
- Athénaïs Boucly
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Laurent Savale
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Xavier Jaïs
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Fabrice Bauer
- INSERM U1096, Heart Failure Clinic and Pulmonary Hypertension Center, Service de chirurgie cardiaque, Hôpital Charles Nicole, Rouen, France
| | | | - Laurent Bertoletti
- Université de Saint-Etienne, Jean Monnet; INSERM, Thrombosis Research Group, EA3065; CIC-CIE3, Saint-Etienne, France.,Centre Hospitalier Universitaire, Service de Médecine Interne et Thérapeutique, Saint-Etienne, France
| | - Antoine Beurnier
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Physiologie, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Arnaud Bourdin
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, Pneumonology, Montpellier, France
| | - Hélène Bouvaist
- CHU Grenoble Alpes Service de Cardiologie, 568151, Grenoble, France
| | - Sophie Bulifon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Céline Chabanne
- CHU de Rennes, Hôpital Pontchaillou, Cardiology, Rennes, France
| | - Ari Chaouat
- Centre hospitalier régional universitaire de Nancy, 26920, Département de Pneumologie Hôpital de Brabois, Nancy, France.,Université de Lorraine, 137665, Inserm UMR_S 1116, Défaillance Cardiovasculaire Aigüe et Chronique, Faculté de Médecine de Nancy, Nancy, France
| | - Vincent Cottin
- Louis Pradel University Hospital, Respiratory Medicine, Lyon, France
| | - Claire Dauphin
- Hôpital Gabriel Montpied, 55448, Service de Cardiologie et Maladies Vasculaires, Clermont-Ferrand, France
| | - Bruno Degano
- Centre Hospitalier Universitaire Grenoble Alpes, 36724, Pneumologie-Physiologie, Grenoble, France
| | - Pascal De Groote
- CHR Lille - Hôpital cardiologique, Clinique de cardiologie, Lille, France
| | - Nicolas Favrolt
- CHU François Mitterrand, Service de Pneumologie et Soins Intensifs Respiratoires, Dijon, France
| | - Yuanchao Feng
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | | | - Mitja Jevnikar
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Etienne-Marie Jutant
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Zhiying Liang
- Libin Cardiovascular Institute of Alberta, 157745, Calgary, Alberta, Canada
| | - Pascal Magro
- CHU de Tours, service de pneumologie, Tours, France
| | - Pierre Mauran
- Paediatric and Congenital Cardiology Unit, American Memorial Hospital, CHU Reims, Reims, France
| | | | | | | | - Florence Parent
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | | | - Jérémie Pichon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Patrice Poubeau
- CHU de La Réunion Sites Sud Saint-Pierre, 56577, Saint-Pierre, Réunion
| | | | - Sébastien Renard
- Hopital de la Timone - Deparment de Cardiologie, 375330, Marseille, France
| | | | | | - Pascal Roblot
- Department of Internal Medicine, Infectious and Tropical Diseases, Poitiers University Hospital, Poitiers, France
| | - Olivier Sanchez
- Hopital Europeen Georges Pompidou, 55647, Respiratory Unit, Paris, France
| | - Andrei Seferian
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Cécile Tromeur
- CHRU de Brest, 26990, Internal Medicine and Chest Disease, Brest, France
| | | | - Gérald Simonneau
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - David Montani
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Marc Humbert
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France
| | - Olivier Sitbon
- Centre Hospitalier Universitaire de Bicêtre, 41664, Service de Pneumologie et Soins Intensifs Respiratoires, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, 89691, Le Kremlin-Bicetre, France.,INSERM U999, 130034, Le Plessis Robinson, France;
| |
Collapse
|
26
|
Vitry G, Paulin R, Grobs Y, Lampron MC, Shimauchi T, Lemay SE, Tremblay E, Habbout K, Awada C, Bourgeois A, Nadeau V, Paradis R, Breuils-Bonnet S, Roux-Dalvai F, Orcholski M, Potus F, Provencher S, Boucherat O, Bonnet S. Oxidized DNA Precursors Cleanup by NUDT1 Contributes to Vascular Remodeling in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 203:614-627. [PMID: 33021405 DOI: 10.1164/rccm.202003-0627oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Pulmonary arterial hypertension (PAH) is a life-threatening condition characterized by abnormally elevated pulmonary pressures and right ventricular failure. Excessive proliferation and resistance to apoptosis of pulmonary artery smooth muscle cells (PASMCs) is one of the most important drivers of vascular remodeling in PAH, for which available treatments have limited effectiveness.Objectives: To gain insights into the mechanisms leading to the development of the disease and identify new actionable targets.Methods: Protein expression profiling was conducted by two-dimensional liquid chromatography coupled to tandem mass spectrometry in isolated PASMCs from controls and patients with PAH. Multiple molecular, biochemical, and pharmacologic approaches were used to decipher the role of NUDT1 (nudrix hyrolase 1) in PAH.Measurements and Main Results: Increased expression of the detoxifying DNA enzyme NUDT1 was detected in cells and tissues from patients with PAH and animal models. In vitro, molecular or pharmacological inhibition of NUDT1 in PAH-PASMCs induced accumulation of oxidized nucleotides in the DNA, irresolvable DNA damage (comet assay), disruption of cellular bioenergetics (Seahorse), and cell death (terminal deoxynucleotidyl transferase dUTP nick end labeling assay). In two animal models with established PAH (i.e., monocrotaline and Sugen/hypoxia-treated rats), pharmacological inhibition of NUDT1 using (S)-Crizotinib significantly decreased pulmonary vascular remodeling and improved hemodynamics and cardiac function.Conclusions: Our results indicate that, by overexpressing NUDT1, PAH-PASMCs hijack persistent oxidative stress in preventing incorporation of oxidized nucleotides into DNA, thus allowing the cell to escape apoptosis and proliferate. Given that NUDT1 inhibitors are under clinical investigation for cancer, they may represent a new therapeutic option for PAH.
Collapse
Affiliation(s)
- Géraldine Vitry
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Roxane Paulin
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and.,Department of Medicine and
| | - Yann Grobs
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Marie-Claude Lampron
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Sarah-Eve Lemay
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Eve Tremblay
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Karima Habbout
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Charifa Awada
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Alice Bourgeois
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Valérie Nadeau
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Renée Paradis
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Sandra Breuils-Bonnet
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | | | - Mark Orcholski
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - François Potus
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and.,Department of Medicine and
| | - Olivier Boucherat
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and.,Department of Medicine and
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Quebec Heart and Lung Institute Research Centre, Québec City, Quebec, Canada; and.,Department of Medicine and
| |
Collapse
|
27
|
Escribano Subías P, Aurtenetxe Pérez A, Pérez Olivares C, Gómez Climent L, Diago Cabezudo JI, Perelló MF. Recent advances in the management of pulmonary arterial hypertension: lessons from the upfront combination of ambrisentan and tadalafil. Expert Rev Respir Med 2021; 15:493-504. [PMID: 33472458 DOI: 10.1080/17476348.2021.1878027] [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: 10/22/2022]
Abstract
INTRODUCTION The sixth World Symposium of Pulmonary Hypertension (sixth WSPH) brought to the forefront for the first time the value of earlier, aggressive management with an upfront oral combination in patients with pulmonary arterial hypertension (PAH) of low or intermediate risk. This was prompted by results from the AMBITION study (ambrisentan + tadalafil). A literature search was conducted to collect all evidence provided by upfront treatment with this combination, as well as other combinations under investigation at the time the manuscript was prepared. AREAS COVERED The value of an upfront oral combination with ambrisentan and tadalafil is reviewed on the basis of topics discussed at the sixth WSPH, such as evidence in different PAH etiologies, according to risk stratification and in so-called 'atypical' patients where monotherapy is still recommended. Evidence in clinical practice is also reviewed. New evidence about the value of the upfront oral combination is also commented. Finally, tendencies in primary endpoints to assess the effect of PAH-targeted therapies (time to clinical worsening and hemodynamics) and their value are also reviewed. EXPERT OPINION All above-mentioned aspects are put into perspective with regard to the impact of new advances on improving PAH management in clinical practice.
Collapse
Affiliation(s)
- Pilar Escribano Subías
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Agueda Aurtenetxe Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Servicio de Neumología, Hospital Universitario Basurto, Bilbao, Spain
| | - Carmen Pérez Olivares
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain.,Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | | | | |
Collapse
|
28
|
Xiao Y, Chen PP, Zhou RL, Zhang Y, Tian Z, Zhang SY. Pathological Mechanisms and Potential Therapeutic Targets of Pulmonary Arterial Hypertension: A Review. Aging Dis 2020; 11:1623-1639. [PMID: 33269111 PMCID: PMC7673851 DOI: 10.14336/ad.2020.0111] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive cardiovascular disease characterized by pulmonary vasculature reconstruction and right ventricular dysfunction. The mortality rate of PAH remains high, although multiple therapeutic strategies have been implemented in clinical practice. These drugs mainly target the endothelin-1, prostacyclin and nitric oxide pathways. Management for PAH treatment includes improving symptoms, enhancing quality of life, and extending survival rate. Existing drugs developed to treat the disease have resulted in enormous economic and healthcare liabilities. The estimated cost for advanced PAH has exceeded $200,000 per year. The pathogenesis of PAH is associated with numerous molecular processes. It mainly includes germline mutation, inflammation, dysfunction of pulmonary arterial endothelial cells, epigenetic modifications, DNA damage, metabolic dysfunction, sex hormone imbalance, and oxidative stress, among others. Findings based on the pathobiology of PAH may have promising therapeutic outcomes. Hence, faced with the challenges of increasing healthcare demands, in this review, we attempted to explore the pathological mechanisms and alternative therapeutic targets, including other auxiliary devices or interventional therapies, in PAH. The article will discuss the potential therapies of PAH in detail, which may require further investigation before implementation.
Collapse
Affiliation(s)
- Ying Xiao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pei-Pei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui-Lin Zhou
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
29
|
White RJ, Jerjes-Sanchez C, Bohns Meyer GM, Pulido T, Sepulveda P, Wang KY, Grünig E, Hiremath S, Yu Z, Gangcheng Z, Yip WLJ, Zhang S, Khan A, Deng CQ, Grover R, Tapson VF. Combination Therapy with Oral Treprostinil for Pulmonary Arterial Hypertension. A Double-Blind Placebo-controlled Clinical Trial. Am J Respir Crit Care Med 2020; 201:707-717. [PMID: 31765604 PMCID: PMC7068822 DOI: 10.1164/rccm.201908-1640oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown. Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy. Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response. Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting. Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening. Clinical trial registered with www.clinicaltrials.gov (NCT01560624).
Collapse
Affiliation(s)
- R James White
- Division of Pulmonary and Critical Care Medicine and the Mary M. Parkes Center, University of Rochester Medical Center, Rochester, New York
| | | | | | - Tomas Pulido
- Departamento de Cardioneumología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Kuo Yang Wang
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ekkehard Grünig
- Thoraxclinic at University Hospital Heidelberg, Heidelberg, Germany
| | | | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital of Central South University, Changsha, China
| | | | - Wei Luen James Yip
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Shuyang Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Akram Khan
- Oregon Health and Science University, Portland, Oregon
| | - C Q Deng
- United Therapeutics, Research Triangle Park, North Carolina; and
| | - Rob Grover
- United Therapeutics, Research Triangle Park, North Carolina; and
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | | |
Collapse
|
30
|
Kuwana M, Blair C, Takahashi T, Langley J, Coghlan JG. Initial combination therapy of ambrisentan and tadalafil in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) in the modified intention-to-treat population of the AMBITION study: post hoc analysis. Ann Rheum Dis 2020; 79:626-634. [PMID: 32161055 PMCID: PMC7213337 DOI: 10.1136/annrheumdis-2019-216274] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate initial combination therapy with ambrisentan plus tadalafil (COMB) compared with monotherapy of either agent (MONO), and the utility of baseline characteristics and risk stratification in predicting outcomes, in patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) and the systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) subpopulation. METHODS This post hoc analysis of the Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) study included patients with CTD-PAH from the modified intention-to-treat population. Time to clinical failure (TtCF) was assessed by baseline characteristics, treatment assignment and risk group (low, intermediate and high) at baseline and week 16. TtCF was compared between groups using Kaplan-Meier curves and Cox proportional hazards regression modelling. RESULTS The analysis included 216 patients (COMB, n=117; MONO, n=99). The risk of clinical failure was lower with COMB versus MONO (risk reduction: CTD-PAH 51.7%, SSc-PAH 53.7%), particularly in patients with haemodynamic parameters characteristic of typical PAH without features of left heart disease and/or restrictive lung disease at baseline. The risk of clinical failure was lower with COMB versus MONO in the baseline low-risk group (HR not calculated due to no events in COMB), baseline intermediate-risk group (HR 0.519, 95% CI 0.297 to 0.905) and in the week 16 low-risk group (HR 0.069, 95% CI 0.009 to 0.548). CONCLUSIONS The benefit of COMB over MONO was demonstrated in patients with CTD-PAH, particularly in those with typical PAH haemodynamic characteristics at baseline. COMB is appropriate for patients categorised as low risk and intermediate risk at baseline and low risk at follow-up. TRIAL REGISTRATION NUMBER NCT01178073.
Collapse
Affiliation(s)
- Masataka Kuwana
- Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Christiana Blair
- Research and Development, Gilead Sciences, Inc, Foster City, California, USA
| | | | | | | |
Collapse
|
31
|
Hachulla E, Launay D, Boucly A, Mouthon L, de Groote P, Cottin V, Pugnet G, Prévôt G, Bourlier D, Dauphin C, Chaouat A, Weatherald J, Simonneau G, Montani D, Humbert M, Sitbon O, Giovannelli J. Survival Improved in Patients Aged ≤ 70 Years With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension During the Period 2006 to 2017 in France. Chest 2019; 157:945-954. [PMID: 31756332 DOI: 10.1016/j.chest.2019.10.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/06/2019] [Accepted: 10/19/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND To date, nothing is known about the evolution of survival in systemic sclerosis-associated pulmonary arterial hypertension (PAH) over the last decade. METHODS This study used a multivariate Cox regression model adjusted for clinically relevant baseline confounders to assess the association between the occurrence of death and date of PAH diagnosis comparing two periods of the same duration (2006-2011 vs 2012-2017). Interactions between the two diagnosis periods and baseline variables were tested. RESULTS A total of 306 incident patients were included, 167 (54.6%) with a PAH diagnosis occurring in 2006 to 2011 and 139 (45.4%) in 2012 to 2017. No significant difference in survival was observed between patients diagnosed with PAH in 2012 to 2017 compared with those diagnosed in 2006 to 2011 (hazard ratio [HR], 0.76 [0.46-1.26]; P = .29). A significant interaction was observed between PAH diagnosis periods and age (P = .05). When stratifying according to age (based on the median age of 70 years), a significant increase was observed in survival in patients aged ≤ 70 years between the 2006 to 2011 period and the 2012 to 2017 period (HR, 0.40 [0.17-0.99]; P = .046) but not in older patients (HR, 1.29 [0.67-2.51]; P = .44). A significantly higher proportion of initial (ie, within the first 4 months) endothelin receptor antagonist/phosphodiesterase type 5 inhibitor combination therapy was observed in younger patients diagnosed from 2012 to 2017 vs those diagnosed from 2006 to 2011 (42.9% vs 19.5%; P = .002) but not in older patients. CONCLUSIONS Over the period 2006 to 2017, survival in systemic sclerosis-associated PAH improved over time in patients aged ≤ 70 years but not in older patients. Further investigations are needed to confirm this relation, as general improvement in medical care and management may also be a possible explanation.
Collapse
Affiliation(s)
- Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, Referral Center for Rare Systemic Autoimmune Diseases North and Northwest of France, Lille, France; Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France.
| | - David Launay
- Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, Referral Center for Rare Systemic Autoimmune Diseases North and Northwest of France, Lille, France; Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France
| | - Athénaïs Boucly
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Luc Mouthon
- APHP, Hôpital Cochin, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes Systémiques Rares Ile de France, Université Paris Descartes, Paris, France
| | - Pascal de Groote
- CHU de Lille, Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Department of Respiratory Medicine, Louis Pradel Hospital, University Claude Bernard Lyon 1, University of Lyon, UMR 754, Lyon, France
| | | | - Grégoire Prévôt
- CHU de Toulouse, Hôpital Larrey, Service de Pneumologie, Toulouse, France
| | - Delphine Bourlier
- Université de Bordeaux, CHU de Bordeaux, Hôpital du Haut Lévêque, Service de Maladies Respiratoires, Pessac, France
| | - Claire Dauphin
- University of Auvergne, CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France
| | - Ari Chaouat
- CHU Nancy, Pôle des Spécialités Médicales, Département de Pneumologie, Université de Lorraine, INGRES, EA 7298, Vandoeuvre-lès-Nancy, France
| | - Jason Weatherald
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France; Department of Medicine, Section of Respiratory Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Gérald Simonneau
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - David Montani
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Marc Humbert
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Olivier Sitbon
- APHP, Hôpital Bicêtre, Service de Pneumologie, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, INSERM UMR_S 999, France
| | - Jonathan Giovannelli
- Université de Lille, Inserm, CHU Lille, U995-LIRIC-Lille Inflammation Research International Center, F-59000 Lille, France
| |
Collapse
|
32
|
Beghetti M, Gorenflo M, Ivy DD, Moledina S, Bonnet D. Treatment of pediatric pulmonary arterial hypertension: A focus on the NO-sGC-cGMP pathway. Pediatr Pulmonol 2019; 54:1516-1526. [PMID: 31313530 PMCID: PMC6771736 DOI: 10.1002/ppul.24442] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While pulmonary arterial hypertension (PAH) is rare in infants and children, it results in substantial morbidity and mortality. In recent years, prognosis has improved, coinciding with the introduction of new PAH-targeted therapies, although much of their use in children is off-label. Evidence to guide the treatment of children with PAH is less extensive than for adults. The goal of this review is to discuss the treatment recommendations for children with PAH, as well as the evidence supporting the use of prostanoids, endothelin receptor antagonists (ERAs), and phosphodiesterase type 5 inhibitors (PDE5i) in this setting. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected concentrating on the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway in PAH. The methodology of an ongoing study evaluating the sGC stimulator riociguat in children with PAH is also described. RESULTS Despite recent medical advances, improved therapeutic strategies for pediatric PAH are needed. The efficacy and tolerability of riociguat in adults with PAH have been well trialed. CONCLUSION The pooling of data across trials, supplemented by registry data, will help to confirm the safety and tolerability of prostanoids, ERAs, and PDE5i in children. Ongoing studies will clarify the place of sGC stimulators in the treatment strategy for pediatric PAH.
Collapse
Affiliation(s)
- Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque PédiatriqueChildren's University HospitalGenevaSwitzerland
| | - Matthias Gorenflo
- Department of Pediatrics II, Pediatric Cardiology and Congenital Heart Defects, Center for PediatricsUniversity Hospital HeidelbergGermany
| | - D. Dunbar Ivy
- Children's Hospital Colorado, Heart InstituteUniversity of Colorado School of MedicineDenverColorado
| | - Shahin Moledina
- Cardiology DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Damien Bonnet
- M3C‐Paediatric Cardiology, Necker Enfants Malades, AP‐HPUniversité Paris DescartesParisFrance
| |
Collapse
|
33
|
Heresi GA, Love TE, Tonelli AR, Highland KB, Dweik RA. Choice of Initial Oral Therapy for Pulmonary Arterial Hypertension: Age and Long-Term Survival. Am J Respir Crit Care Med 2019; 198:1090-1093. [PMID: 29949380 DOI: 10.1164/rccm.201801-0059le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Thomas E Love
- 2 Case Western Reserve University School of Medicine Cleveland, Ohio
| | | | | | | |
Collapse
|
34
|
Weatherald J, Boucly A, Sahay S, Humbert M, Sitbon O. The Low-Risk Profile in Pulmonary Arterial Hypertension. Time for a Paradigm Shift to Goal-oriented Clinical Trial Endpoints? Am J Respir Crit Care Med 2019; 197:860-868. [PMID: 29256625 DOI: 10.1164/rccm.201709-1840pp] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Jason Weatherald
- 1 Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,2 Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Athénaïs Boucly
- 3 Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,4 Service de Pneumologie, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,5 INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; and
| | - Sandeep Sahay
- 6 Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Marc Humbert
- 3 Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,4 Service de Pneumologie, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,5 INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; and
| | - Olivier Sitbon
- 3 Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,4 Service de Pneumologie, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,5 INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; and
| |
Collapse
|
35
|
Coghlan JG, Picken C, Clapp LH. Selexipag in the management of pulmonary arterial hypertension: an update. DRUG HEALTHCARE AND PATIENT SAFETY 2019; 11:55-64. [PMID: 31496830 PMCID: PMC6689562 DOI: 10.2147/dhps.s181313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/02/2019] [Indexed: 12/27/2022]
Abstract
Selexipag is a compound that was designed to overcome the issues associated with oral administration of prostanoid compounds, beraprost and treprostinil in the treatment of pulmonary hypertension (PAH). As a selective IP agonist, it was designed to avoid the off-target prostanoid effects especially in the gastrointestinal system. To place this compound in context, this paper briefly reviews the efficacy, tolerability, and safety of subcutaneous, inhaled, and oral prostanoid preparations and comparesthemto selexipag. Selexipag is the first agent targeting a prostanoid receptor where a reduction in the primary efficacy morbidity/mortality composite end-point has been demonstrated. While safety outcomes favor selexipag over placebo, tolerability issues remain. Efficacy in terms of improvement in effort tolerance, hemodynamic and mortality benefit is less than seen with IV therapy. This is the first prostanoid demonstrated in a clinical trial to have added benefit in those on background double combination therapy and the first non IV prostanoid to demonstrate outcome benefit in the connective tissue disease (CTD) population in a randomized controlled trial.
Collapse
Affiliation(s)
- J Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London NW3 2QG, UK
| | - Christina Picken
- Institute of Cardiovascular Sciences, University College London, London WC1E 6JF, UK
| | - Lucie H Clapp
- Institute of Cardiovascular Sciences, University College London, London WC1E 6JF, UK
| |
Collapse
|
36
|
Affiliation(s)
- Lai-Ming Yung
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Paul B Yu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
37
|
Kataoka M, Satoh T, Matsubara H, Yamamoto K, Inada T, Umezawa K, Takahashi T, Nakano A, Fukuda K. Safety and Efficacy of Ambrisentan-Phosphodiesterase Type 5 (PDE5) Inhibitor Combination Therapy for Japanese Pulmonary Arterial Hypertension Patients in Real-World Clinical Practice. Circ Rep 2019; 1:268-275. [PMID: 33693149 PMCID: PMC7889478 DOI: 10.1253/circrep.cr-19-0029] [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] [Indexed: 11/09/2022] Open
Abstract
Background:
This retrospective study was conducted to evaluate the safety and efficacy of ambrisentan combination therapy with phosphodiesterase type 5 (PDE5) inhibitors in Japanese patients with pulmonary arterial hypertension (PAH). Methods and Results:
PAH patients who received ambrisentan for the first time in combination with a PDE5 inhibitor between January 2013 and the end of August 2015 were included in this study. Adverse drug reaction (ADR) safety analysis, as well as the efficacy analysis focusing on changes in clinical parameters, were investigated for overall cases and cases stratified by patient background. Forty-eight consecutive patients (n=21, 43.8% with idiopathic PAH; male/female, 18/30; average age, 43.3±17.4 years; World Health Organization functional class III/IV, n=22, 45.8%) who were treated with ambrisentan and a PDE5 inhibitor in Japan underwent the safety analysis. A total of 14 ADR occurred in 10 patients (20.8%). ADR included headache (8.3%), face edema (4.2%), angina pectoris (2.1%), hyperemia (2.1%), dyspnea (2.1%), pulmonary hypertension (i.e., worsening of PAH, 2.1%), nausea (2.1%), hepatic function abnormal (2.1%), edema (2.1%), and sudden death (2.1%). On analysis of hemodynamics parameters, there was a significant improvement in the mean pulmonary arterial pressure (−13.5 mmHg, P=0.0001) and pulmonary vascular resistance (−563.53 dyn·s·cm−5, P=0.0033). Conclusions:
Ambrisentan combination therapy is safe and effective in hemodynamics improvement.
Collapse
Affiliation(s)
- Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine Tokyo Japan
| | - Toru Satoh
- Department of Cardiology, Kyorin University School of Medicine Tokyo Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center Okayama Japan
| | - Koji Yamamoto
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences Aichi Japan
| | - Tsukasa Inada
- Department of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital Osaka Japan
| | | | | | | | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine Tokyo Japan
| |
Collapse
|
38
|
A Phase I Study to Show the Relative Bioavailability and Bioequivalence of Fixed-Dose Combinations of Ambrisentan and Tadalafil in Healthy Subjects. Clin Ther 2019; 41:1110-1127. [PMID: 31060740 DOI: 10.1016/j.clinthera.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/28/2019] [Accepted: 04/04/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Pulmonary arterial hypertension (PAH) is a life-threatening disease that typically causes shortness of breath and exercise intolerance. Combination therapy with ambrisentan and tadalafil has proven to be more effective at preventing clinical failure events in patients with PAH than either drug alone. The aim of this study was to evaluate the bioequivalence of an ambrisentan/tadalafil fixed-dose combination (FDC) compared with co-administration of the 2 monotherapies. METHODS This 3-part, randomized, single-dose, open-label crossover study was conducted in healthy volunteers. The first part of the study consisted of a 5-way crossover that compared the relative bioavailability of 4 FDC formulations (10-mg ambrisentan + 40-mg tadalafil) with co-administered reference monotherapies. One formulation was selected and its relative bioavailability was assessed when produced in 3 different granulation sizes during the second part of the study. In the third part of the study, the bioequivalence of the candidate FDC with the reference monotherapies was evaluated for the 10-mg/40-mg dose strength, in addition to 2 other dose strengths (5 mg/20 mg and 5 mg/40 mg). For all parts of the study, blood samples were taken at regular intervals after each dose, ambrisentan and tadalafil concentrations determined, and pharmacokinetic (PK) parameters (Cmax, AUC0-∞, and AUC0-t) obtained. Test/reference ratios of the geometric means of PK parameters were used to evaluate bioequivalence. Safety and tolerability were assessed by recording adverse events and monitoring vital signs, ECGs, and clinical laboratory data. FINDINGS Of the 174 subjects screened for eligibility, 112 were allocated to a randomized treatment sequence across all study parts, and 100 completed their full assigned treatments. All 4 FDC formulations tested during part 1 of the study yielded PK parameters similar those of the reference treatments. In part 2, granulation size was found to not affect the relative bioavailability of the selected formulation. In part 3, the selected FDC was found to be bioequivalent to co-administration of the monotherapies in both the fasted and fed states. The FDC was also found to be bioequivalent to the reference treatments at the 2 additional dose strengths. All but one of the adverse events was mild to moderate in intensity, and no serious adverse events were reported. IMPLICATIONS An ambrisentan/tadalafil FDC was bioequivalent to concurrently administered monotherapies and therefore represents a viable alternative treatment to co-administration. Use of an FDC is likely to be associated with reduced costs and improved patient compliance. ClinicalTrials.gov identifier: NCT02688387.
Collapse
|
39
|
Improving Survival in Patients with Pulmonary Arterial Hypertension: Focus on Intravenous Epoprostenol. Am J Cardiovasc Drugs 2019; 19:99-105. [PMID: 30671881 DOI: 10.1007/s40256-018-00319-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pulmonary arterial hypertension represents a devastating disease, causing progressive increase of pulmonary vascular resistance leading to right ventricular dysfunction and death. Therapeutic management has rapidly advanced in recent years due to improved understanding of pathophysiology and new drugs have been developed; however, survival remains poor. Oral agents as phosphodiesterase type V inhibitors, the soluble guanylyl cyclase stimulator riociguat, the prostacyclin receptor agonist selexipag and the endothelin receptor antagonists have each achieved evidence-based validation and are recommended for pulmonary arterial hypertension. Initial oral monotherapy or combination therapy is recommended for patients with low or intermediate risk according to each patient's risk stratification. Intravenous epoprostenol is a synthetic prostacyclin and the first drug approved for the disease. Although it represents the only treatment shown to reduce mortality, it is underused. Survival rates for patients treated with oral combination drug therapies are lower than those for patients treated with initial combination therapies including intravenous epoprostenol. This raises the interesting question of whether intermediate risk pulmonary arterial hypertension patients should be routinely introduced to therapies including intravenous epoprostenol rather than combination oral therapies.
Collapse
|
40
|
Giordano N, Corallo C, Chirico C, Brazzi A, Marinetti A, Fioravanti A, Valenti R, Nuti R, Pecetti G. Pulmonary arterial hypertension in systemic sclerosis: Diagnosis and treatment according to the European Society of Cardiology and European Respiratory Society 2015 guidelines. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:35-42. [PMID: 35382146 PMCID: PMC8922580 DOI: 10.1177/2397198318808998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/30/2018] [Indexed: 09/29/2023]
Abstract
Scleroderma (systemic sclerosis) is an autoimmune connective tissue disease which presents endothelial dysfunction and fibroblast dysregulation, resulting in vascular and fibrotic disorders. Pulmonary hypertension is frequent in patients with systemic sclerosis: the natural evolution of the disease can induce the development of different forms of pulmonary hypertension, representing one of the main causes of death. Among the different forms of pulmonary hypertension in systemic sclerosis, pulmonary arterial hypertension is the most frequent one (rate of occurrence is estimated between 7% and 12%). This pulmonary vascular complication should be treated with a combination of drugs that is able to counteract endothelial dysfunction, antagonizing the endothelin-1 system and replacing prostaglandin I2 and nitric oxide activity. A correct diagnosis is mandatory, because it is possible only for pulmonary arterial hypertension to use specific drugs that are able to control the symptomatic condition and the evolution of the disease. According to the most recent guidelines, for the patients with systemic sclerosis, also without pulmonary hypertension symptoms, echocardiography screening for the detection of pulmonary hypertension is recommended. Pulmonary arterial hypertension screening programs in systemic sclerosis patients is able to identify milder forms of the disease, allowing earlier management and better long-term outcome.
Collapse
Affiliation(s)
- Nicola Giordano
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Claudio Corallo
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Chiara Chirico
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Angelica Brazzi
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Adriana Marinetti
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Roberto Valenti
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Ranuccio Nuti
- Scleroderma Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Gianluca Pecetti
- Medical and Scientific Direction, Actelion Pharmaceuticals Italia s.r.l., Imola, Italy
| |
Collapse
|
41
|
Akagi S, Matsubara H, Nakamura K, Ito H. Modern treatment to reduce pulmonary arterial pressure in pulmonary arterial hypertension. J Cardiol 2018; 72:466-472. [DOI: 10.1016/j.jjcc.2018.04.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 11/30/2022]
|
42
|
Strange G, Lau EM, Giannoulatou E, Corrigan C, Kotlyar E, Kermeen F, Williams T, Celermajer DS, Dwyer N, Whitford H, Wrobel JP, Feenstra J, Lavender M, Whyte K, Collins N, Steele P, Proudman S, Thakkar V, Keating D, Keogh A. Survival of Idiopathic Pulmonary Arterial Hypertension Patients in the Modern Era in Australia and New Zealand. Heart Lung Circ 2018; 27:1368-1375. [DOI: 10.1016/j.hlc.2017.08.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/20/2017] [Indexed: 11/28/2022]
|
43
|
Davenport AP, Kuc RE, Southan C, Maguire JJ. New drugs and emerging therapeutic targets in the endothelin signaling pathway and prospects for personalized precision medicine. Physiol Res 2018; 67:S37-S54. [PMID: 29947527 DOI: 10.33549/physiolres.933872] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
During the last thirty years since the discovery of endothelin-1, the therapeutic strategy that has evolved in the clinic, mainly in the treatment of pulmonary arterial hypertension, is to block the action of the peptide either at the ET(A) subtype or both receptors using orally active small molecule antagonists. Recently, there has been a rapid expansion in research targeting ET receptors using chemical entities other than small molecules, particularly monoclonal antibody antagonists and selective peptide agonists and antagonists. While usually sacrificing oral bio-availability, these compounds have other therapeutic advantages with the potential to considerably expand drug targets in the endothelin pathway and extend treatment to other pathophysiological conditions. Where the small molecule approach has been retained, a novel strategy to combine two vasoconstrictor targets, the angiotensin AT(1) receptor as well as the ET(A) receptor in the dual antagonist sparsentan has been developed. A second emerging strategy is to combine drugs that have two different targets, the ET(A) antagonist ambrisentan with the phosphodiesterase inhibitor tadalafil, to improve the treatment of pulmonary arterial hypertension. The solving of the crystal structure of the ET(B) receptor has the potential to identify allosteric binding sites for novel ligands. A further key advance is the experimental validation of a single nucleotide polymorphism that has genome wide significance in five vascular diseases and that significantly increases the amount of big endothelin-1 precursor in the plasma. This observation provides a rationale for testing this single nucleotide polymorphism to stratify patients for allocation to treatment with endothelin agents and highlights the potential to use personalized precision medicine in the endothelin field.
Collapse
Affiliation(s)
- A P Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom.
| | | | | | | |
Collapse
|
44
|
Correale M, Ferraretti A, Monaco I, Grazioli D, Di Biase M, Brunetti ND. Endothelin-receptor antagonists in the management of pulmonary arterial hypertension: where do we stand? Vasc Health Risk Manag 2018; 14:253-264. [PMID: 30323613 PMCID: PMC6174907 DOI: 10.2147/vhrm.s133921] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pulmonary arterial hypertension, a disease largely neglected until a few decades ago, is presently the object of intense studies by several research teams. Despite considerable progress, pulmonary arterial hypertension remains a major clinical problem, because it is not always easy to diagnose, treat, and prevent. The disease was considered incurable until the late 1990s, when Epoprostenol was introduced as the first tool against this illness. More recently, therapy for pulmonary arterial hypertension gained momentum after publication of the SERAPHIN and AMBITION trials, which also highlighted the importance of upfront therapy. This review also focuses on recent substudies from these trials and progress in drugs targeting the endothelin pathway. Future perspectives with regard to endothelin-receptor antagonists are also discussed.
Collapse
Affiliation(s)
- Michele Correale
- Department of Cardiology, Ospedali Riuniti University Hospital, Foggia
| | | | | | - Davide Grazioli
- Department of Cardiology, Ospedali Riuniti University Hospital, Foggia
| | | | | |
Collapse
|
45
|
Hoeper MM, Apitz C, Grünig E, Halank M, Ewert R, Kaemmerer H, Kabitz HJ, Kähler C, Klose H, Leuchte H, Ulrich S, Olsson KM, Distler O, Rosenkranz S, Ghofrani HA. Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:37-45. [PMID: 30190158 DOI: 10.1016/j.ijcard.2018.08.082] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 01/09/2023]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available. The treatment algorithm for PAH was modified based on the observation that there are now many patients diagnosed with IPAH who are at an advanced age and have significant cardiopulmonary comorbidities. For patients newly diagnosed with classic forms of PAH, i.e. younger patients without significant cardiopulmonary comorbidities, the consensus-based recommendation was to use initial combination therapy as the standard approach. The use of monotherapies was no longer considered appropriate in such patients. The choice of treatment strategies should be based on the risk assessment as proposed in the European guidelines. In patients presenting with a low or intermediate risk, oral combination therapy with endothelin receptor antagonists and phosphodiesterase-5 inhibitors or soluble guanylate cyclase stimulators, respectively, should be used. In high-risk patients, triple combination therapy including a subcutaneous or intravenous prostacyclin analogue should be considered. For patients who suffer from PAH and significant cardiopulmonary comorbidities, initial monotherapy is recommended and the use of combination therapies should be considered on an individual basis. The latter recommendations are based on the scarcity of evidence supporting the use of combination therapy and the higher risk of drug-related adverse events in such patients.
Collapse
Affiliation(s)
- Marius M Hoeper
- Department of Pneumology, Hannover Medical School, Hanover, Germany; German Centre for Lung Research (DZL), Germany.
| | - Christian Apitz
- Department of Pediatric Cardiology, University Hospital for Pediatric and Adolescent Medicine, Ulm, Germany
| | - Ekkehard Grünig
- German Centre for Lung Research (DZL), Germany; Centre for Pulmonary Hypertension, Chest Clinic at Heidelberg University Hospital, Germany
| | - Michael Halank
- Medical Department I, Carl Gustav Carus University Hospital at the TU Dresden, Dresden, Germany
| | - Ralf Ewert
- University Medicine Greifswald, Department and Outpatient Department for Internal Medicine, Pneumology/Infectiology, Greifswald, Germany
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Hospital at the Technical University of Munich, Germany
| | - Hans-Joachim Kabitz
- Medical Department II, Pneumology, Cardiology and Internal Intensive Medicine, Constance Hospital, Germany
| | - Christian Kähler
- Department of Pneumology, Critical Care and Allergology, Lung Centre South-West, Wangen im Allgäu, Germany
| | - Hans Klose
- Centre for Pulmonary Hypertension Hamburg, Pneumology Department, Hamburg-Eppendorf University Hospital, Germany
| | - Hanno Leuchte
- Neuwittelsbach, Hospital of the Compassionate Sisters and Academic Teaching Hospital at the LMU, Munich, Germany
| | - Silvia Ulrich
- Clinic for Pneumology, Zurich University Hospital, Switzerland
| | - Karen M Olsson
- Department of Pneumology, Hannover Medical School, Hanover, Germany; German Centre for Lung Research (DZL), Germany
| | - Oliver Distler
- Clinic for Rheumatology, Zurich University Hospital, Switzerland
| | - Stephan Rosenkranz
- Department of Internal Medicine III, Cardiovascular Research Centre (CCRC), Heart Centre of the University of Cologne, Germany
| | - H Ardeschir Ghofrani
- German Centre for Lung Research (DZL), Germany; Universities of Giessen and Marburg Lung Center (UGMLC), Gießen, Germany; Department for Pneumology, Kerckhoff Hospital Bad Nauheim, Germany; Department of Medicine, Imperial College, London, UK
| |
Collapse
|
46
|
Lyseng-Williamson KA, Behr J. Ambrisentan ± tadalafil in WHO functional class II/III pulmonary arterial hypertension: a guide to its use in the EU. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
47
|
McLaughlin V, Bacchetta M, Badesch D, Benza R, Burger C, Chin K, Frantz R, Frost A, Hemnes A, Kim NH, Rosenzweig EB, Rubin L. Update on pulmonary arterial hypertension research: proceedings from a meeting of experts. Curr Med Res Opin 2018; 34:263-273. [PMID: 29132217 DOI: 10.1080/03007995.2017.1404974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND While pulmonary arterial hypertension (PAH) remains a progressive, symptomatic condition characterized by increased pulmonary vascular resistance, ultimately leading to right heart failure, great strides have been made in its understanding and treatment over the past two decades. REVIEW Continued research in pre-clinical, clinical, and health economic areas of research, in addition to registry analyses and technology advances, is critical for understanding the pathophysiology of the disease and devising the best ways to monitor and manage patients. On December 3, 2016, the latest pre-clinical, clinical, health economic outcome, and registry data on PAH was presented in a symposium sponsored by Actelion. This paper reviews the published research and insight into upcoming research that was presented at this interactive meeting.
Collapse
Affiliation(s)
- Vallerie McLaughlin
- a Division of Cardiovascular Medicine, Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Matthew Bacchetta
- b Department of Surgery , New York Presbyterian Hospital-Columbia University Medical Center , New York , NY , USA
| | - David Badesch
- c Division of Pulmonary Sciences and Critical Care Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Raymond Benza
- d Allegheny General Hospital, Cardiovascular Diseases , Pittsburgh , PA , USA
| | - Charles Burger
- e Department of Internal Medicine, Division of Pulmonary , Critical Care, and Sleep Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Kelly Chin
- f Internal Medicine, UT Southwestern Medical Center , Dallas , TX , USA
| | - Robert Frantz
- g Division of Cardiovascular Diseases , Mayo Clinic , Rochester , MN , USA
| | - Adaani Frost
- h The Lung Center, Houston Methodist Hospital , Houston , TX , USA
| | - Anna Hemnes
- i Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine or Division of Cardiovascular Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Nick H Kim
- j Division of Pulmonary and Critical Care Medicine , University of California San Diego , La Jolla , CA , USA
| | - Erika B Rosenzweig
- k Department of Pediatrics, Division of Cardiology , Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital , New York , NY , USA
| | - Lewis Rubin
- l Division of Pulmonary and Critical Care Medicine , University of California, San Diego Medical School , San Diego , CA , USA
| |
Collapse
|
48
|
Burger CD, Ghandour M, Padmanabhan Menon D, Helmi H, Benza RL. Early intervention in the management of pulmonary arterial hypertension: clinical and economic outcomes. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:731-739. [PMID: 29200882 PMCID: PMC5703162 DOI: 10.2147/ceor.s119117] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) has a high morbidity rate and is fatal if left untreated. Increasing evidence supports early intervention, possibly with initial combination therapy. PAH-specific pharmaceuticals, however, are expensive and may have serious adverse effects, particularly when used in combination. The currently dynamic health care economy reinforces the need for a review of early intervention from both outcomes and economic perspectives. We aimed to review the clinical and economic impact of PAH therapy, particularly examining drug cost, hospitalization burden, and health care economics impact, and the effect of early intervention on clinical outcomes. We searched PubMed, Scopus, Ovid, and MEDLINE databases from 2005 to 2017 for studies comparing drug cost, clinical outcomes, and hospitalization burden associated with therapy for PAH. Emerging data indicate that early therapy is effective, but drug therapy is expensive, particularly with combination therapy. Efficacy studies also generally show benefit of combination therapy for patients in World Health Organization functional class II, with a consistent decrease in hospitalization. Pharmacoeconomic studies are limited but indicate that increased pharmacy costs are at least partially offset by decreased health care utilization, particularly inpatient care. Modeling also shows a cost benefit with combination therapy at 2 years. Nonetheless, more rigorously collected health care economic data should be incorporated into future drug efficacy trials to provide a clearer understanding of the impact and the associated cost benefit of early PAH therapy. Increasing evidence in support of early intervention and combination therapy for PAH is associated with rising medication costs that are largely offset by reduced hospitalization, on the basis of the currently available literature. Nonetheless, the studies performed to date have methodologic limitations that highlight the need for prospective studies using more robust economic modeling.
Collapse
Affiliation(s)
| | | | | | - Haytham Helmi
- Division of Transplant Medicine and Research Administration, Mayo Clinic, Jacksonville, FL, USA
| | - Raymond L Benza
- Advanced Heart Failure, Transplant, Mechanical Circulatory Support and Pulmonary Hypertension, Allegheny Health Network, Pittsburg, PA, USA
| |
Collapse
|
49
|
Rosenkranz S, Dumitrescu D. Hipertensión pulmonar. Regreso al futuro. Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
50
|
Moonen A, Garsia R, Youssef P, Torzillo P, Corte T, Boehm C, Cordina R, Celermajer D, Lau E. Outcomes of pulmonary arterial hypertension therapy in Australia: is monotherapy adequate? Intern Med J 2017; 47:1124-1128. [DOI: 10.1111/imj.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/12/2017] [Accepted: 05/22/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Avalon Moonen
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Roger Garsia
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Peter Youssef
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Paul Torzillo
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Tamera Corte
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Christiane Boehm
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Rachael Cordina
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - David Celermajer
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Edmund Lau
- Pulmonary Hypertension Clinic Royal Prince Alfred Hospital Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| |
Collapse
|