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Zamanian RT, Weatherald J, Sweatt AJ, Hemnes A, Rashid M, Psotka MA, Bogaard HJ, de Jesus Perez V. Constructing the Framework for Disease Modification in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2024; 209:1189-1195. [PMID: 38471030 PMCID: PMC11146536 DOI: 10.1164/rccm.202401-0089pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/12/2024] [Indexed: 03/14/2024] Open
Affiliation(s)
- Roham T. Zamanian
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
| | - Anna Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Moira Rashid
- Planned Parenthood of Orange and San Bernandino Counties, California
| | - Mitchell A. Psotka
- U.S. Food and Drug Administration, Silver Spring, Maryland
- Inova Schar Heart and Vascular, Falls Church, Virginia; and
| | - Harm J. Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Vinicio de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, California
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2
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Frantz RP, McLaughlin VV, Sahay S, Escribano Subías P, Zolty RL, Benza RL, Channick RN, Chin KM, Hemnes AR, Howard LS, Sitbon O, Vachiéry JL, Zamanian RT, Cravets M, Roscigno RF, Mottola D, Osterhout R, Bruey JM, Elman E, Tompkins CA, Parsley E, Aranda R, Zisman LS, Ghofrani HA. Seralutinib in adults with pulmonary arterial hypertension (TORREY): a randomised, double-blind, placebo-controlled phase 2 trial. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00072-9. [PMID: 38705167 DOI: 10.1016/s2213-2600(24)00072-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Morbidity and mortality in pulmonary arterial hypertension (PAH) remain high. Activation of platelet-derived growth factor receptor, colony stimulating factor 1 receptor, and mast or stem cell growth factor receptor kinases stimulates inflammatory, proliferative, and fibrotic pathways driving pulmonary vascular remodelling in PAH. Seralutinib, an inhaled kinase inhibitor, targets these pathways. We aimed to evaluate the efficacy and safety of seralutinib in patients with PAH receiving standard background therapy. METHODS The TORREY trial was a phase 2, randomised, multicentre, multinational, double-blind, placebo-controlled study. Patients with PAH from 40 hospital and community sites were randomly assigned 1:1 via interactive response technologies to receive seralutinib (60 mg twice daily for 2 weeks, then increased to 90 mg twice daily as tolerated) or placebo by dry powder inhaler twice daily for 24 weeks. Randomisation was stratified by baseline pulmonary vascular resistance (PVR; <800 dyne·s/cm5 and ≥800 dyne·s/cm5). Patients were eligible if classified as WHO Group 1 PH (PAH), WHO Functional Class II or III, with a PVR of 400 dyne·s/cm5 or more, and a 6 min walk distance of between 150 m and 550 m. The primary endpoint was change in PVR from baseline to 24 weeks. Analyses for efficacy endpoints were conducted in randomly assigned patients (intention-to-treat population). Safety analyses included all patients who received the study drug. TORREY was registered with ClinicalTrials.gov (NCT04456998) and EudraCT (2019-002669-37) and is completed. FINDINGS From Nov 12, 2020, to April 20, 2022, 151 patients were screened for eligibility, and following exclusions, 86 adults receiving PAH background therapy were randomly assigned to seralutinib (n=44; four male, 40 female) or placebo (n=42; four male, 38 female), and comprised the intention-to-treat population. At baseline, treatment groups were balanced except for a higher representation of WHO Functional Class II patients in the seralutinib group. The least squares mean change from baseline to week 24 in PVR was 21·2 dyne·s/cm5 (95% CI -37·4 to 79·8) for the placebo group and -74·9 dyne·s/cm5 (-139·7 to -10·2) for the seralutinib group. The least squares mean difference between the seralutinib and placebo groups for change in PVR was -96·1 dyne·s/cm5 (95% CI -183·5 to -8·8; p=0·03). The most common treatment-emergent adverse event in both treatment groups was cough: 16 (38%) of 42 patients in the placebo group; 19 (43%) of 44 patients in the seralutinib group. INTERPRETATION Treatment with inhaled seralutinib significantly decreased PVR, meeting the primary endpoint of the study among patients receiving background therapy for PAH. FUNDING Gossamer Bio.
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Affiliation(s)
- Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Vallerie V McLaughlin
- Department of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA; Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Pilar Escribano Subías
- Department of Cardiology, CIBERCV, Complutense University, Madrid, Spain; University Hospital 12 de Octubre, Madrid, Spain
| | - Ronald L Zolty
- Department of Cardiovascular Medicine, University of Nebraska College of Medicine, Omaha, NE, USA; University of Nebraska Medical Center, Omaha, NE, USA
| | - Raymond L Benza
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Mount Sinai Hospital, New York, NY, USA
| | - Richard N Channick
- Department of Clinical Medicine, University of California Los Angeles, Los Angeles, CA, USA; UCLA Medical Center, Los Angeles, CA, USA
| | - Kelly M Chin
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA; UT Southwestern Medical Center, Dallas, TX, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA; Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luke S Howard
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, London, UK; Hammersmith Hospital, London, UK
| | - Olivier Sitbon
- Department of Respiratory Medicine, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France; Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jean-Luc Vachiéry
- Department of Cardiology, Université Libre de Bruxelles, Brussels, Belgium; HUB-Hôpital Erasme, Brussels, Belgium
| | - Roham T Zamanian
- Department of Medicine-Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | - Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen and Marburg Lung Center (UGMLC), Giessen, Germany; Institute for Lung Health, Cardio-Pulmonary Institute, Giessen, Germany; German Center for Lung Research (DZL), Giessen, Germany; Department of Medicine, Imperial College, London, UK
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3
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Morales-Cano D, Barreira B, Callejo M, Olivencia MA, Ferruelo A, Milara J, Lorente JÁ, Moreno L, Cogolludo Á, Perez-Vizcaino F. Comparative analysis of antiproliferative and vasodilator effects of drugs for pulmonary hypertension: Extensive in vitro study in rats and human. Vascul Pharmacol 2024; 155:107371. [PMID: 38599357 DOI: 10.1016/j.vph.2024.107371] [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: 01/31/2024] [Revised: 03/12/2024] [Accepted: 03/16/2024] [Indexed: 04/12/2024]
Abstract
An effective pulmonary hypertension (PH) treatment should combine antiproliferative and vasodilator effects. We characterized a wide-range of drugs comparing their anti-proliferative vs vasodilator effects in human and rat pulmonary artery smooth muscle cells (PASMC). Key findings: 1) Approved PH drugs (PDE5 inhibitors, sGC stimulators and PGI2 agonists) are preferential vasodilators. 2) cGMP stimulators were more effective in cells derived from hypertensive rats. 3) Nifedipine acted equally as vasodilator and antiproliferative. 4) quercetin and imatinib were potent dual vasodilator/antiproliferative drugs. 5) Tacrolimus and levosimendan lacked antiproliferative effects. 6) Forskolin, pinacidil and hydroxyfasudil were more effective as antiproliferative in human cells.
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Affiliation(s)
- Daniel Morales-Cano
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Bianca Barreira
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - María Callejo
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Miguel A Olivencia
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Antonio Ferruelo
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Department of Critical Care, Hospital Universitario de Getafe, 28905 Madrid, Spain
| | - Javier Milara
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; Pharmacy Unit, University General Hospital Consortium, 46014 Valencia, Spain
| | - José Ángel Lorente
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Department of Critical Care, Hospital Universitario de Getafe, 28905 Madrid, Spain
| | - Laura Moreno
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Ángel Cogolludo
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Francisco Perez-Vizcaino
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, 28040 Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain.
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Novara ME, Di Martino E, Stephens B, Nayrouz M, Vitulo P, Carollo A, Provenzani A. Future Perspectives of Pulmonary Arterial Hypertension: A Review of Novel Pipeline Treatments and Indications. Drugs R D 2024; 24:13-28. [PMID: 38514585 PMCID: PMC11035521 DOI: 10.1007/s40268-024-00453-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 03/23/2024] Open
Abstract
Pulmonary arterial hypertension is characterized by elevated blood pressure and pathological changes in the pulmonary arterioles, leading to the development of right-heart failure and potentially fatal outcomes if left untreated. This review aims to provide an overview of novel drugs or formulations and new drug indications for pulmonary arterial hypertension that are currently in phases II-III of randomized controlled trials, and describe the rationale for the use of these targeted therapies, as well as their efficacy, safety profile, and impact on quality of life and survival. The literature research was conducted using data from ClinicalTrials.gov for the period between 1 January 2016 up to 31 December 2022. The population of interest includes individuals aged ≥ 18 years who have been diagnosed with pulmonary arterial hypertension. The review selection criteria included trials with recruiting, enrolling by invitation, active, terminated or completed status in 2022 and 2023. A total of 24 studies were selected for evaluation based on the inclusion and exclusion criteria. This review summarizes the updated information from randomized clinical trials involving novel therapies for pulmonary arterial hypertension. However, larger clinical trials are required to validate their clinical safety and effects. In the future, clinicians should choose therapies based on the patient's individual situation and requirements when developing treatment strategies.
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Affiliation(s)
- Maria Eugenia Novara
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Enrica Di Martino
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Brandon Stephens
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Mary Nayrouz
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Patrizio Vitulo
- Pneumology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Anna Carollo
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy.
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Khan S, Randhawa S, Patail H, Spira Y, Frishman WH, Aronow WS, Lanier GM. Pharmacological Update and Emerging Treatments of Pulmonary Hypertension. Cardiol Rev 2024:00045415-990000000-00192. [PMID: 38294225 DOI: 10.1097/crd.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Pulmonary hypertension (PH) is defined as elevated pressures in the pulmonary artery and is associated with significant morbidity and mortality. The World Health Organization classifies PH into 5 distinct groups based on underlying etiology, pathology, and modality of treatment. Therapeutic approach may be challenging due to the extensive spectrum of causes and underlying mechanisms mediating PH. The 5 groups include pulmonary arterial hypertension (group 1), PH secondary to left heart disease (group 2), PH secondary to chronic lung disease (group 3), chronic thromboembolic pulmonary hypertension (group 4), and PH due to miscellaneous causes (group 5). Although significant progress has been made in the treatment of group 1 PH, there is a continued need to develop new therapies for all types of PH. Additionally, most treatments currently available improve functional capacity and symptoms but without a significant benefit in mortality. In this review, we aim to describe the various etiologies of PH and their established pharmacotherapies, as well as expand on emerging therapeutic options for each group.
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Affiliation(s)
- Shazli Khan
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sukhbir Randhawa
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY
| | - Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Hartford, CT
| | - Yaakov Spira
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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6
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Kumar S, Biswas L, Pushkaran AC, Kumar RK. BMPR2 mutation and clinical response to imatinib in a case of heritable pulmonary arterial hypertension. Pulm Circ 2024; 14:e12335. [PMID: 38213946 PMCID: PMC10782117 DOI: 10.1002/pul2.12335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
Bone morphogenetic protein receptor 2 (BMPR2) mutation is the most common gene mutation implicated in the pathogenesis of pulmonary arterial hypertension (PAH). We describe, for the first time, an excellent clinical response to tyrosine kinase inhibitor imatinib in a patient with heritable PAH from BMPR2 mutation.
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Affiliation(s)
- Shine Kumar
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita HospitalAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Lalitha Biswas
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita HospitalAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Anju Choorakottayil Pushkaran
- Amrita Centre for Nanosciences and Molecular Medicine, Amrita HospitalAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita HospitalAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
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7
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Gillies H, Chakinala MM, Dake BT, Feldman JP, Hoeper MM, Humbert M, Jing Z, Langley J, McLaughlin VV, Niven RW, Rosenkranz S, Zhang X, Hill NS. IMPAHCT: A randomized phase 2b/3 study of inhaled imatinib for pulmonary arterial hypertension. Pulm Circ 2024; 14:e12352. [PMID: 38532768 PMCID: PMC10963589 DOI: 10.1002/pul2.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/14/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
AV-101 (imatinib) powder for inhalation, an investigational dry powder inhaled formulation of imatinib designed to target the underlying pathobiology of pulmonary arterial hypertension, was generally well tolerated in healthy adults in a phase 1 single and multiple ascending dose study. Inhaled Imatinib Pulmonary Arterial Hypertension Clinical Trial (IMPAHCT; NCT05036135) is a phase 2b/3, randomized, double-blind, placebo-controlled, dose-ranging, and confirmatory study. IMPAHCT is designed to identify an optimal AV-101 dose (phase 2b primary endpoint: pulmonary vascular resistance) and assess the efficacy (phase 3 primary endpoint: 6-min walk distance), safety, and tolerability of AV-101 dose levels in subjects with pulmonary arterial hypertension using background therapies. The study has an operationally seamless, adaptive design allowing for continuous recruitment. It includes three parts; subjects enrolled in Part 1 (phase 2b dose-response portion) or Part 2 (phase 3 intermediate portion) will be randomized 1:1:1:1 to 10, 35, 70 mg AV-101, or placebo (twice daily), respectively. Subjects enrolled in Part 3 (phase 3 optimal dose portion) will be randomized 1:1 to the optimal dose of AV-101 and placebo (twice daily), respectively. All study parts include a screening period, a 24-week treatment period, and a 30-day safety follow-up period; the total duration is ∼32 weeks. Participation is possible in only one study part. IMPAHCT has the potential to advance therapies for patients with pulmonary arterial hypertension by assessing the efficacy and safety of a novel investigational drug-device combination (AV-101) using an improved study design that has the potential to save 6-12 months of development time. ClinicalTrials.gov Identifier: NCT05036135.
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Affiliation(s)
| | - Murali M. Chakinala
- Division of Pulmonary and Critical Care MedicineWashington University in St. LouisSt. LouisMissourIUSA
| | | | | | - Marius M. Hoeper
- Department of Respiratory Medicine and Infectious DiseasesHannover Medical SchoolHannoverGermany
- German Center for Lung Research (DZL)Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH)HannoverGermany
| | - Marc Humbert
- Service de Pneumologieet Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital BicêtreUniversité Paris–Saclay, INSERMUMR_S 999Le Kremlin‐BicêtreFrance
| | - Zhi‐Cheng Jing
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesSouthern Medical UniversityGuangzhouChina
| | | | - Vallerie V. McLaughlin
- Cardiology Clinic, Frankel Cardiovascular CenterUniversity of MichiganAnn ArborMichiganUSA
| | | | - Stephan Rosenkranz
- Department of Internal Medicine III, Cologne Cardiovascular Research Center, Heart CenterUniversityof CologneCologneGermany
| | | | - Nicholas S. Hill
- Pulmonary Critical Care and Sleep DivisionTufts Medical CenterBostonMassachusettsUSA
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8
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Mahmoud AK, Abbas MT, Kamel MA, Farina JM, Pereyra M, Scalia IG, Barry T, Chao CJ, Marcotte F, Ayoub C, Scott RL, Majdalany DS, Arsanjani R. Current Management and Future Directions for Pulmonary Arterial Hypertension Associated with Congenital Heart Disease. J Pers Med 2023; 14:5. [PMID: 38276220 PMCID: PMC10817644 DOI: 10.3390/jpm14010005] [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: 11/18/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/27/2024] Open
Abstract
Current management of patients with congenital heart disease has increased their survival into adulthood. This is accompanied by potential cardiac complications, including pulmonary hypertension associated with congenital heart disease (PAH-CHD). PAH-CHD constitutes a challenging subgroup of pulmonary hypertension and requires expert management to improve quality of life and prognosis. Novel agents have shown a significant improvement in morbidity and mortality in patients with pulmonary arterial hypertension. However, the long-term effects of these medications on PAH-CHD patients remain somewhat uncertain, necessitating treatment plans largely founded on the clinical experience of the healthcare providers. The aim of this review is to summarize the current evidence and future perspectives regarding treatment strategies for PAH-CHD to help better guide management of this complex disease.
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Affiliation(s)
- Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Francois Marcotte
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Robert L. Scott
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - David S. Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
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9
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Kopeć G. Sotatercept as a next-generation therapy for pulmonary arterial hypertension: insights from the STELLAR trial. Cardiovasc Res 2023; 119:e155-e157. [PMID: 37584249 DOI: 10.1093/cvr/cvad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/20/2023] [Accepted: 05/31/2023] [Indexed: 08/17/2023] Open
Affiliation(s)
- Grzegorz Kopeć
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, John Paul II Hospital in Krakow, Prądnicka 80, 31-202 Kraków, Poland
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Montani D, Antigny F, Jutant EM, Chaumais MC, Le Ribeuz H, Grynblat J, Khouri C, Humbert M. Pulmonary hypertension associated with diazoxide: the SUR1 paradox. ERJ Open Res 2023; 9:00350-2023. [PMID: 37965230 PMCID: PMC10641583 DOI: 10.1183/23120541.00350-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/04/2023] [Indexed: 11/16/2023] Open
Abstract
The ATP-sensitive potassium channels and their regulatory subunits, sulfonylurea receptor 1 (SUR1/Kir6.2) and SUR2/Kir6.1, contribute to the pathophysiology of pulmonary hypertension (PH). Loss-of-function pathogenic variants in the ABCC8 gene, which encodes for SUR1, have been associated with heritable pulmonary arterial hypertension. Conversely, activation of SUR1 and SUR2 leads to the relaxation of pulmonary arteries and reduces cell proliferation and migration. Diazoxide, a SUR1 activator, has been shown to alleviate experimental PH, suggesting its potential as a therapeutic option. However, there are paradoxical reports of diazoxide-induced PH in infants. This review explores the role of SUR1/2 in the pathophysiology of PH and the contradictory effects of diazoxide on the pulmonary vascular bed. Additionally, we conducted a comprehensive literature review of cases of diazoxide-associated PH and analysed data from the World Health Organization pharmacovigilance database (VigiBase). Significant disproportionality signals link diazoxide to PH, while no other SUR activators have been connected with pulmonary vascular disease. Diazoxide-associated PH seems to be dose-dependent and potentially related to acute effects on the pulmonary vascular bed. Further research is required to decipher the differing pulmonary vascular consequences of diazoxide in different age populations and experimental models.
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Affiliation(s)
- David Montani
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital Bicêtre, DMU 5 Thorinno, Le Kremlin-Bicêtre, France
| | - Fabrice Antigny
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Etienne-Marie Jutant
- CHU de Poitiers, Respiratory Department, INSERM CIC 1402, IS-ALIVE Research Group, University of Poitiers, Poitiers, France
| | - Marie-Camille Chaumais
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Pharmacy, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Faculty of Pharmacy, Saclay, France
| | - Hélène Le Ribeuz
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Julien Grynblat
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Charles Khouri
- Univ. Grenoble Alpes, HP2 Laboratory, Grenoble, France
- Grenoble Alpes University Hospital, Pharmacovigilance Unit, Grenoble, France
| | - Marc Humbert
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital Bicêtre, DMU 5 Thorinno, Le Kremlin-Bicêtre, France
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11
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Eichstaedt CA, Bikou O, Sommer N, Schermuly RT, Pullamsetti SS, Weissmann N, Harbaum L, Tabeling C, Wißmüller M, Foris V, Kuebler WM, Hinderhofer K, Olschewski A, Kwapiszewska G. [Genetic diagnostics and molecular approaches in pulmonary arterial hypertension]. Pneumologie 2023; 77:862-870. [PMID: 37963476 DOI: 10.1055/a-2145-4663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The recently published new European guidelines for diagnosis and treatment of pulmonary hypertension now offer the so far most extensive description of genetic testing and counselling for pulmonary arterial hypertension patients. In addition, the importance of a clinical screening of healthy mutation carriers is highlighted as well as the genetic testing of patients with a suspicion of pulmonary veno-occlusive disease. We frame the respective parts of the guidelines on genetic testing and counselling in the context of recent data and provide comments. Finally, we give an outlook on novel molecular approaches starting from Sotatercept, addressing ion channels and novel therapeutic developments.
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Affiliation(s)
- Christina A Eichstaedt
- Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg und TLRC am Deutschen Zentrum für Lungenforschung (DZL), Heidelberg, Deutschland
- Institut für Humangenetik, Universität Heidelberg, Heidelberg, Deutschland
| | - Olympia Bikou
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Deutschland
| | - Natascha Sommer
- Pneumologie und Intensivmedizin, Medizinische Klinik II, Universitätsklinikum Gießen und Marburg und UGMLC am Deutschen Zentrum für Lungenforschung (DZL), Gießen, Deutschland
| | - Ralph T Schermuly
- Zentrum für Innere Medizin, Justus-Liebig-Universität, Gießen, UGMLC Deutsches Zentrum für Lungenforschung (DZL), Gießen, Deutschland
| | - Soni S Pullamsetti
- Medizinische Klinik II, Cardio-Pulmonary Institute (CPI), UGMLC Deutsches Zentrum für Lungenforschung (DZL), Justus-Liebig-Universität, Gießen, Deutschland
- Max-Planck-Institut für Herz- und Lungenforschung und UGMLC am Deutschen Zentrum für Lungenforschung (DZL), Bad Nauheim, Deutschland
| | - Norbert Weissmann
- Medizinische Klinik II, Cardio-Pulmonary Institute (CPI), UGMLC Deutsches Zentrum für Lungenforschung (DZL), Justus-Liebig-Universität, Gießen, Deutschland
| | - Lars Harbaum
- Abteilung für Pneumologie, II. Medizinische Klinik und Poliklinik, zzt. Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Christoph Tabeling
- Fächerverbund Infektiologie, Pneumologie und Intensivmedizin, Klinik für Pneumologie, Beatmungsmedizin und Intensivmedizin mit dem Arbeitsbereich Schlafmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Max Wißmüller
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln und Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Köln, Deutschland
| | - Vasile Foris
- Universitätsklinik für Innere Medizin, Klinische Abteilung für Pneumologie, Medizinische Universität Graz, Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Wolfgang M Kuebler
- Institut für Physiologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Katrin Hinderhofer
- Institut für Humangenetik, Universität Heidelberg, Heidelberg, Deutschland
| | - Andrea Olschewski
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
- Experimentelle Anästhesiologie, Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, Graz, Österreich
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
- Otto Loewi Research Center, Medizinische Universität Graz, Graz, Österreich
- Institute for Lung Health, Giessen, Germany
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12
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Smukowska-Gorynia A, Gościniak W, Woźniak P, Iwańczyk S, Jaxa-Kwiatkowska K, Sławek-Szmyt S, Janus M, Paluszkiewicz J, Mularek-Kubzdela T. Recent Advances in the Treatment of Pulmonary Arterial Hypertension Associated with Connective Tissue Diseases. Pharmaceuticals (Basel) 2023; 16:1252. [PMID: 37765060 PMCID: PMC10534675 DOI: 10.3390/ph16091252] [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: 08/09/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023] Open
Abstract
Pulmonary hypertension (PH) is a severe vascular complication of connective tissue diseases (CTD). Patients with CTD may develop PH belonging to diverse groups: (1) pulmonary arterial hypertension (PAH), (2) PH due to left heart disease, (3) secondary PH due to lung disease and/or hypoxia and (4) chronic thromboembolic pulmonary hypertension (CTEPH). PAH most often develops in systemic scleroderma (SSc), mostly in its limited variant. PAH-CTD is a progressive disease characterized by poor prognosis. Therefore, early diagnosis should be established. A specific treatment for PAH-CTD is currently available and recommended: prostacyclin derivative (treprostinil, epoprostenol, iloprost, selexipag), nitric oxide and natriuretic pathway: stimulators of soluble guanylate cyclase (sGC: riociguat) and phosphodiesterase-five inhibitors (PDE5i: sildenafil, tadalafil), endothelin receptor antagonists (ERA: bosentan, macitentan, ambrisentan). Moreover, novel drugs, e.g., sotatercept, have been intensively investigated in clinical trials. We aim to review the literature on recent advances in the treatment strategy and prognosis of patients with PAH-CTD. In this manuscript, we discuss the mechanism of action of PAH-specific drugs and new agents and the latest research conducted on PAH-CTD patients.
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Affiliation(s)
- Anna Smukowska-Gorynia
- 1st Department of Cardiology, Poznan University of Medical Sciences, Długa 1/2 Street, 61-848 Poznan, Poland; (W.G.); (P.W.); (S.I.); (K.J.-K.); (S.S.-S.); (M.J.); (J.P.); (T.M.-K.)
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13
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Olsson KM, Corte TJ, Kamp JC, Montani D, Nathan SD, Neubert L, Price LC, Kiely DG. Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:820-835. [PMID: 37591300 DOI: 10.1016/s2213-2600(23)00259-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/19/2023]
Abstract
Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.
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Affiliation(s)
- Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany.
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Jan C Kamp
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, INSERM Unité Mixte de Recherche 999, Université Paris-Saclay, Paris, France
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; NIHR Biomedical Research Centre, Sheffield, UK
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14
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Boucly A, Gerges C, Savale L, Jaïs X, Jevnikar M, Montani D, Sitbon O, Humbert M. Pulmonary arterial hypertension. Presse Med 2023; 52:104168. [PMID: 37516248 DOI: 10.1016/j.lpm.2023.104168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laurent Savale
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
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15
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Ahmed MS, Ghallab M, Ostrow T, Nashawi M, Alagha Z, Levine A, Aronow WS, Lanier GM. Pharmacotherapy of refractory pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:1861-1874. [PMID: 37698041 DOI: 10.1080/14656566.2023.2257134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.
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Affiliation(s)
- Mahmoud Samy Ahmed
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Muhammad Ghallab
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Talia Ostrow
- Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mouhamed Nashawi
- Department of Medicine, Baylor Scott & White Health, Dallas, TX, USA
| | - Zakaria Alagha
- Department of Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
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16
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Humbert M, Sitbon O, Guignabert C, Savale L, Boucly A, Gallant-Dewavrin M, McLaughlin V, Hoeper MM, Weatherald J. Treatment of pulmonary arterial hypertension: recent progress and a look to the future. THE LANCET. RESPIRATORY MEDICINE 2023; 11:804-819. [PMID: 37591298 DOI: 10.1016/s2213-2600(23)00264-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe but treatable form of pre-capillary pulmonary hypertension caused by pulmonary vascular remodelling. As a result of basic science discoveries, randomised controlled trials, studies of real-world data, and the development of clinical practice guidelines, considerable progress has been made in the treatment options and outcomes for patients with PAH, underscoring the importance of seamless translation of information from bench to bedside and, ultimately, to patients. However, PAH still carries a high mortality rate, which emphasises the urgent need for transformative innovations in the field. In this Series paper, written by a group of clinicians, researchers, and a patient with PAH, we review therapeutic approaches and treatment options for PAH. We summarise current knowledge of the cellular and molecular mechanisms of PAH, with an emphasis on emerging treatable pathways and optimisation of current management strategies. In considering future directions for the field, our ambition is to identify therapies with the potential to stall or reverse pulmonary vascular remodelling. We highlight novel therapeutic approaches, the important role of patients as partners in research, and innovative approaches to PAH clinical trials.
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Affiliation(s)
- Marc Humbert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France.
| | - Olivier Sitbon
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | | | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), Hannover, Germany
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
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17
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Pullamsetti SS, Sitapara R, Osterhout R, Weiss A, Carter LL, Zisman LS, Schermuly RT. Pharmacology and Rationale for Seralutinib in the Treatment of Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:12653. [PMID: 37628831 PMCID: PMC10454154 DOI: 10.3390/ijms241612653] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a complex disorder characterized by vascular remodeling and a consequent increase in pulmonary vascular resistance. The histologic hallmarks of PAH include plexiform and neointimal lesions of the pulmonary arterioles, which are composed of dysregulated, apoptosis-resistant endothelial cells and myofibroblasts. Platelet-derived growth factor receptors (PDGFR) α and β, colony stimulating factor 1 receptor (CSF1R), and mast/stem cell growth factor receptor kit (c-KIT) are closely related kinases that have been implicated in PAH progression. In addition, emerging data indicate significant crosstalk between PDGF signaling and the bone morphogenetic protein receptor type 2 (BMPR2)/transforming growth factor β (TGFβ) receptor axis. This review will discuss the importance of the PDGFR-CSF1R-c-KIT signaling network in PAH pathogenesis, present evidence that the inhibition of all three nodes in this kinase network is a potential therapeutic approach for PAH, and highlight the therapeutic potential of seralutinib, currently in development for PAH, which targets these pathways.
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Affiliation(s)
- Soni Savai Pullamsetti
- Lung Vascular Epigenetics, Center for Infection and Genomics of the Lung (CIGL), Justus-Liebig-Universität Gießen, Aulweg 132, 35392 Giessen, Germany;
| | | | | | - Astrid Weiss
- UGMLC Pulmonale Pharmakotherapie, Biomedizinisches Forschungszentrum Seltersberg (BFS), Justus-Liebig-Universität Gießen, Schubertstraße 81, 35392 Giessen, Germany;
| | | | | | - Ralph Theo Schermuly
- Department of Internal Medicine, Justus-Liebig-University Giessen, Aulweg 130, 35392 Giessen, Germany
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18
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Caputo A, Papa S, Manzi G, Laviola D, Recchioni T, Severino P, Lavalle C, Maestrini V, Mancone M, Badagliacca R, Vizza CD. Medical Management of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. Curr Heart Fail Rep 2023; 20:263-270. [PMID: 37486563 PMCID: PMC10421820 DOI: 10.1007/s11897-023-00612-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to overview the most relevant and recent knowledge regarding medical management in pulmonary arterial hypertension (PAH). RECENT FINDINGS Evidence has shown that PAH patients' quality of life and prognosis depend on the capability of the RV to adapt to increased afterload and to fully recover in response to substantially reduced pulmonary vascular resistance obtained with medical therapy. Data from recent clinical studies show that more aggressive treatment strategies, especially in higher risk categories, determine larger afterload reductions, consequentially increasing the probability of achieving right heart reverse remodeling, therefore improving the patients' survival and quality of life. Remarkable progress has been observed over the past decades in the medical treatment of PAH, related to the development of drugs that target multiple biological pathways, strategies for earlier and more aggressive treatment interventions. New hopes for treatment of patients who are unable to achieve low-risk status have been derived from the phase 2 trial PULSAR and the phase 3 trial STELLAR, which show improvement in the hemodynamic status of patients treated with sotatercept on top of background therapy. Promising results are expected from several ongoing clinical trials targeting new pathways involved in the pathophysiology of PAH.
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Affiliation(s)
- Annalisa Caputo
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy.
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Domenico Laviola
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Tommaso Recchioni
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Severino
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
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19
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Lange TJ. Refined risk stratification, current treatment, and new therapeutic approaches in pulmonary arterial hypertension. Herz 2023; 48:259-265. [PMID: 37085727 DOI: 10.1007/s00059-023-05179-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/23/2023]
Abstract
The 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines for pulmonary hypertension have introduced a refined risk stratification to guide both initial and subsequent treatment of pulmonary arterial hypertension (PAH). The risk stratification at PAH diagnosis still comprises three risk categories (low, intermediate, high) and lists some new parameters. As the estimated 1‑year mortality is more than 20% in high-risk patients after diagnosis, an initial triple-combination therapy including parenteral prostacyclin analogues is recommended for this group. All other patients should receive a dual-combination therapy with an endothelin receptor antagonist and a phosphodiesterase‑5 inhibitor. However, this approach of initial combination therapy is only recommended for classic PAH, while monotherapy followed by regular follow-up and individualized therapy should be used for patients with cardiopulmonary comorbidities. For PAH patients without cardiopulmonary comorbidities, it is recommended to assess their risk at follow-up with a new 4‑strata classification, where the intermediate-risk group is split on the basis of three noninvasive parameters. Importantly, changes from intermediate-high to intermediate-low risk have been shown to be associated with a better prognosis. In addition, the recommendations on treatment escalation became more precise with the addition of a prostacyclin receptor agonist or switching a phosphodiesterase‑5 inhibitor to a soluble guanylate cyclase stimulator for intermediate-low risk and proceeding to triple-combination therapy with parenteral prostacyclin analogues already for intermediate-high risk. With sotatercept, the first non-vasodilator PAH treatment will become available in the near future to further enrich our treatment options for this chronic and still severe disease.
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Affiliation(s)
- Tobias J Lange
- Abteilung für Innere Medizin II, Pneumologie und Beatmungsmedizin, Kreisklinik Bad Reichenhall, Riedelstr. 5, 83435, Bad Reichenhall, Germany.
- Medizinische Fakultät, Universität Regensburg, Regensburg, Germany.
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20
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Ramakrishnan P, Dahiya G, Lindstrom M, Thenappan T. Pulmonary tumor thrombotic microangiopathy: Exploration into current diagnostic aids and therapeutics. Pulm Circ 2023; 13:e12278. [PMID: 37593090 PMCID: PMC10427771 DOI: 10.1002/pul2.12278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is an under-recognized cause of pulmonary hypertension and fulminant right ventricle failure. It is associated with a high mortality due to delay in diagnosis. We present two cases of PTTM, both diagnosed postmortem, highlighting the importance of timely identification and initiation of treatment for this near-fatal condition.
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Affiliation(s)
| | - Garima Dahiya
- Cardiovascular Division, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Meghan Lindstrom
- Department of PathologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Thenappan Thenappan
- Cardiovascular Division, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
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21
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El-Kersh K, Jalil BA. Pulmonary hypertension inhaled therapies: An updated review. Am J Med Sci 2023; 366:3-15. [PMID: 36921672 DOI: 10.1016/j.amjms.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
Treatments of pulmonary hypertension (PH) continue to evolve with approval of new therapies. The currently FDA approved inhaled PH therapies include inhaled iloprost for group 1 pulmonary arterial hypertension (PAH), inhaled treprostinil solution and treprostinil dry powder inhaler for both group 1 PAH and group 3 PH associated with interstitial lung disease (PH-ILD). Inhaled treprostinil was recently approved for group 3 PH-ILD based on the results of INCREASE trial and the newer formulation of treprostinil dry powder that comes with a new inhaler was recently approved for both group 1 PAH and group 3 PH-ILD based on BREEZE study. The pipeline for inhaled PH therapies includes several promising molecules that can enrich the current PH therapeutic era and mitigate several systemic side effects by directly delivering the drug to the target organ. In this review article we summarize the evidence for the currently approved inhaled PAH/PH therapies, discuss the available inhalation devices, present a roadmap for successful treatment strategy, and present several inhaled PAH/PH therapies in the pipeline.
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Affiliation(s)
- Karim El-Kersh
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, United States.
| | - Bilal A Jalil
- Assistant Professor of Medicine, Divisions of Cardiovascular Critical Care and Advanced Heart Failure, Heart and Vascular Institute, West Virginia University, Morgantown, WV 26506, United States
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22
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Auth R, Klinger JR. Emerging pharmacotherapies for the treatment of pulmonary arterial hypertension. Expert Opin Investig Drugs 2023; 32:1025-1042. [PMID: 37881882 DOI: 10.1080/13543784.2023.2274439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a progressive and life-threatening disease. Approved treatment options currently primarily target abnormal cell signaling pathways involved in vasoconstriction and proliferation, such as those mediated by prostacyclin, cyclic guanosine monophosphate, and endothelin. AREAS COVERED Recent advancements have led to new applications and modes of delivery of currently approved PAH medications. At the same time, novel drugs targeting specific molecular pathways involved in PAH pathogenesis have been developed and are being investigated in clinical trials. This review summarizes investigational drug trials for PAH gathered from a comprehensive search using PubMed and ClinicalTrials.gov between 2003 and 2023. It includes both currently approved medications studied at different doses or new administration forms and experimental drugs that have not yet been approved. EXPERT OPINION Approved treatments for PAH target imbalances in pulmonary vasoactive pathways that work primarily on enhancing pulmonary vasodilation with less salient effects on pulmonary vascular remodeling. The advent of more locally acting inhaled medications offers additional therapeutic options that may improve the ease of drug delivery and reduce adverse systemic effects. The more recent emphasis on developing and applying therapeutics that directly impact the aberrant signaling pathways implicated in PAH appears more likely to advance the treatment of this devastating disease.
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Affiliation(s)
- Roger Auth
- Division of Pulmonary, Sleep and Critical Care Medicine, Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - James R Klinger
- Division of Pulmonary, Sleep and Critical Care Medicine, Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
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23
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Du J, Song J, Ding L, Fan X, Lin L, Li A, Liang L, Kong X. Treatment with imatinib was useful to delay the neointimal hyperplasia of aortocaval fistula in adenine-induced renal failure rats. Biochem Biophys Res Commun 2023; 672:10-16. [PMID: 37331166 DOI: 10.1016/j.bbrc.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 05/26/2023] [Accepted: 06/10/2023] [Indexed: 06/20/2023]
Abstract
PURPOSE The study was conducted to investigate the effect of the treatment with imatinib, a c-kit specific inhibitor, on the neointimal hyperplasia (NIH) of aortocaval fistula (ACF) in adenine-induced renal failure rats. MATERIALS AND METHODS All rats were randomly assigned to 4 groups: rats were fed on a normal diet (normal group); rats were fed on a 0.75% adenine-rich diet (renal failure group). The remaining rats underwent ACF after receiving a 0.75% adenine-rich diet and received daily saline gavage (model group) or imatinib gavage (imatinib group) for 7 days after surgery. Immunohistochemical method was used to detect c-kit expression, and Elastomeric Verhoeff-Van Gieson (EVG) staining was used to observe morphological changes of the ACF. The Pearson correlation analysis was used to evaluate the correlations of c-kit expression with intimal thickness and the percentage of stenosis, respectively. RESULTS The renal failure group showed positive c-kit expression on the intima of the inferior vena cava (IVC), whereas the normal group did not. Compared to the model group, intimal thickness (P = 0.001), the percentage of stenosis (P = 0.006) and c-kit expression (P = 0.04) were decreased in the imatinib group at 8 weeks postoperatively. C-kit expression was positively correlated with both intimal thickness and percentage of stenosis (intimal thickness: R = 0.650, P = 0.003; the percentage of stenosis: R = 0.581, P = 0.011) in both the model and imatinib groups. CONCLUSION Treatment with imatinib, a c-kit specific inhibitor, was useful to delay the NIH of ACF in adenine-induced renal failure rats.
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Affiliation(s)
- Jing Du
- Department of Blood Purification Center, Weifang People's Hospital, Weifang, Shandong, China
| | - Jiguang Song
- Department of Blood Purification Center, Weifang People's Hospital, Weifang, Shandong, China
| | - Lina Ding
- Department of Blood Purification Center, Weifang People's Hospital, Weifang, Shandong, China
| | - Xiaoli Fan
- Department of Blood Purification Center, Weifang People's Hospital, Weifang, Shandong, China
| | - Lin Lin
- Department of Nephrology, Weifang People's Hospital, Weifang, Shandong, China
| | - Anzhuang Li
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China; Nephrology Research Institute of Shandong Province, Jinan, Shandong, China
| | - Liming Liang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China; Nephrology Research Institute of Shandong Province, Jinan, Shandong, China.
| | - Xianglei Kong
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China; Nephrology Research Institute of Shandong Province, Jinan, Shandong, China.
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24
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Garcia MVF, Coz-Yataco A, Al-Jaghbeer MJ. Pulmonary arterial hypertension trials put to the test: Using the fragility index to assess trials robustness. Heart Lung 2023; 61:147-152. [PMID: 37271106 DOI: 10.1016/j.hrtlng.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) are considered the gold standard for evidence-based medicine. The Fragility Index (FI) is a tool to assess the robustness of RCT results. FI was validated for dichotomous outcomes and recent work expanded its use to continuous outcomes. Studying the robustness of RCTs in Pulmonary Arterial Hypertension (PAH) treatments is crucial due to the severity and mortality risks associated with this rare condition. OBJECTIVES Analyze FI and Fragility quotient (FQ) of significant primary outcomes in PAH RCTs and study FI correlation with sample size and journal impact factor. METHODS FI and FQ calculation followed by Spearman correlation to assess the correlation between FI and sample size, and FI and impact factor. RESULTS The median sample size of the 21 trials was 202 patients (IQR 106-267), with 6 trials reporting primary outcomes as dichotomous and 15 reporting continuous primary outcomes. The median FI was 10 (IQR 3-20), and the median FQ was 0.044 (0.026-0.097). A moderate correlation was found between FI and sample size, with r = 0.56; P = 0.008 and FI and journal impact factor (r=0.50; P=0.019). The FI for continuous outcomes was similar to that for dichotomous outcomes. CONCLUSIONS This study represents the first analysis of the FI and FQ of PAH treatment RCTs, and expands the use of FI to continuous outcomes in this context. The moderate correlation between FI and sample size suggests that increasing sample size alone is partially correlated to a higher FI. The similarity between FI for continuous and dichotomous outcomes supports the broader use of FI in PAH RCTs.
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Affiliation(s)
| | - Angel Coz-Yataco
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Mohammed J Al-Jaghbeer
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
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25
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Jandl K, Radic N, Zeder K, Kovacs G, Kwapiszewska G. Pulmonary vascular fibrosis in pulmonary hypertension - The role of the extracellular matrix as a therapeutic target. Pharmacol Ther 2023; 247:108438. [PMID: 37210005 DOI: 10.1016/j.pharmthera.2023.108438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/03/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
Pulmonary hypertension (PH) is a condition characterized by changes in the extracellular matrix (ECM) deposition and vascular remodeling of distal pulmonary arteries. These changes result in increased vessel wall thickness and lumen occlusion, leading to a loss of elasticity and vessel stiffening. Clinically, the mechanobiology of the pulmonary vasculature is becoming increasingly recognized for its prognostic and diagnostic value in PH. Specifically, the increased vascular fibrosis and stiffening resulting from ECM accumulation and crosslinking may be a promising target for the development of anti- or reverse-remodeling therapies. Indeed, there is a huge potential in therapeutic interference with mechano-associated pathways in vascular fibrosis and stiffening. The most direct approach is aiming to restore extracellular matrix homeostasis, by interference with its production, deposition, modification and turnover. Besides structural cells, immune cells contribute to the level of ECM maturation and degradation by direct cell-cell contact or the release of mediators and proteases, thereby opening a huge avenue to target vascular fibrosis via immunomodulation approaches. Indirectly, intracellular pathways associated with altered mechanobiology, ECM production, and fibrosis, offer a third option for therapeutic intervention. In PH, a vicious cycle of persistent activation of mechanosensing pathways such as YAP/TAZ initiates and perpetuates vascular stiffening, and is linked to key pathways disturbed in PH, such as TGF-beta/BMPR2/STAT. Together, this complexity of the regulation of vascular fibrosis and stiffening in PH allows the exploration of numerous potential therapeutic interventions. This review discusses connections and turning points of several of these interventions in detail.
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Affiliation(s)
- Katharina Jandl
- Division of Pharmacology, Otto Loewi Research Center, Medical University Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Graz, Austria.
| | - Nemanja Radic
- Division of Physiology, Otto Loewi Research Center, Medical University Graz, Graz, Austria
| | - Katarina Zeder
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Graz, Austria; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Graz, Austria; Division of Physiology, Otto Loewi Research Center, Medical University Graz, Graz, Austria; Institute for Lung Health, Member of the German Lung Center (DZL), Giessen, Germany
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26
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Alamri AK, Ma CL, Ryan JJ. Novel Drugs for the Treatment of Pulmonary Arterial Hypertension: Where Are We Going? Drugs 2023; 83:577-585. [PMID: 37017914 PMCID: PMC10074340 DOI: 10.1007/s40265-023-01862-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 04/06/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease that despite advances in therapy is associated with a 7-year survival of approximately 50%. Several risk factors are associated with developing PAH, include methamphetamine use, scleroderma, human immunodeficiency virus, portal hypertension, and genetic predisposition. PAH can also be idiopathic. There are traditional pathways underlying the pathophysiology of PAH involving nitric oxide, prostacyclin, thromboxane A2, and endothelin-1, resulting in impaired vasodilation, enhanced vasoconstriction and proliferation in the pulmonary vasculature. Established PAH medications targets these pathways; however, this paper aims to discuss novel drugs for treating PAH by targeting new and alternative pathways.
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Affiliation(s)
- Ayedh K Alamri
- Department of Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, UT, 84132, USA.
- Department of Medicine, College of Medicine, Northern Border University, Arar, 73213, Saudi Arabia.
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, UT, 84132, USA.
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, UT, 84132, USA
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27
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Benincasa G, Napoli C, Loscalzo J, Maron BA. Pursuing functional biomarkers in complex disease: Focus on pulmonary arterial hypertension. Am Heart J 2023; 258:96-113. [PMID: 36565787 DOI: 10.1016/j.ahj.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 05/11/2023]
Abstract
A major gap in diagnosis, classification, risk stratification, and prediction of therapeutic response exists in pulmonary arterial hypertension (PAH), driven in part by a lack of functional biomarkers that are also disease-specific. In this regard, leveraging big data-omics analyses using innovative approaches that integrate network medicine and machine learning correlated with clinically useful indices or risk stratification scores is an approach well-positioned to advance PAH precision medicine. For example, machine learning applied to a panel of 48 cytokines, chemokines, and growth factors could prognosticate PAH patients with immune-dominant subphenotypes at elevated or low-risk for mortality. Here, we discuss strengths and weaknesses of the most current studies evaluating omics-derived biomarkers in PAH. Progress in this field is offset by studies with small sample size, pervasive limitations in bioinformatics, and lack of standardized methods for data processing and interpretation. Future success in this field, in turn, is likely to hinge on mechanistic validation of data outputs in order to couple functional biomarker data with target-specific therapeutics in clinical practice.
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Affiliation(s)
- Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA.
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28
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Perros F, Jutant ÉM, Savale L, Dorfmüller P, Humbert M, Montani D. [Physiopathology and treatment of pulmonary arterial hypertension]. Med Sci (Paris) 2023; 39:359-369. [PMID: 37094269 DOI: 10.1051/medsci/2023053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease affecting mainly the pre-capillary pulmonary vascular bed. However, some forms of the disease have venous/capillary involvement. It is an obstructive remodelling of the pulmonary arterioles coupled with vascular pruning, increasing right ventricular afterload and leading to right heart failure. PAH has a complex pathogeny that is detailed in this review. Current specific treatments target endothelial dysfunction, and primarily aim at vasodilatation. Promising innovative treatments targeting the pulmonary artery remodelling are under development.
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Affiliation(s)
- Frédéric Perros
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Étienne-Marie Jutant
- Université de Poitiers, CHU de Poitiers, service de pneumologie, Inserm CIC 1402 Axe IS-ALIVE, Poitiers, France
| | - Laurent Savale
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Allemagne
| | - Marc Humbert
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, faculté de médecine, 94270 Le Kremlin-Bicêtre, France - Inserm UMR-S 999, groupe hospitalier Saint Joseph - Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France - Service de pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
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29
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Moriyama H, Endo J. Pathophysiological Involvement of Mast Cells and the Lipid Mediators in Pulmonary Vascular Remodeling. Int J Mol Sci 2023; 24:6619. [PMID: 37047587 PMCID: PMC10094825 DOI: 10.3390/ijms24076619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Mast cells are responsible for IgE-dependent allergic responses, but they also produce various bioactive mediators and contribute to the pathogenesis of various cardiovascular diseases, including pulmonary hypertension (PH). The importance of lipid mediators in the pathogenesis of PH has become evident in recent years, as exemplified by prostaglandin I2, the most central therapeutic target in pulmonary arterial hypertension. New bioactive lipids other than eicosanoids have also been identified that are associated with the pathogenesis of PH. However, it remains largely unknown how mast cell-derived lipid mediators are involved in pulmonary vascular remodeling. Recently, it has been demonstrated that mast cells produce epoxidized n-3 fatty acid (n-3 epoxides) in a degranulation-independent manner, and that n-3 epoxides produced by mast cells regulate the abnormal activation of pulmonary fibroblasts and suppress the progression of pulmonary vascular remodeling. This review summarizes the role of mast cells and bioactive lipids in the pathogenesis of PH. In addition, we introduce the pathophysiological role and therapeutic potential of n-3 epoxides, a mast cell-derived novel lipid mediator, in the pulmonary vascular remodeling in PH. Further knowledge of mast cells and lipid mediators is expected to lead to the development of innovative therapies targeting pulmonary vascular remodeling.
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Affiliation(s)
- Hidenori Moriyama
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku 160-8582, Tokyo, Japan
- Department of Cardiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa 272-8513, Chiba, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku 160-8582, Tokyo, Japan
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30
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Aziz R, Khan A, Yousefi M, Khetani S, Choudhry H. Spontaneous Non-Traumatic Mediastinal Hematoma in a Patient on Imatinib Therapy for a Gastrointestinal Stromal Tumor (GIST). Cureus 2023; 15:e37701. [PMID: 37206503 PMCID: PMC10191238 DOI: 10.7759/cureus.37701] [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] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Mediastinal hematomas are thoracic complications often resulting from direct trauma or aortic dissections. Spontaneous non-traumatic mediastinal hematomas are rare. We present a case of spontaneous non-traumatic mediastinal hematoma in a patient on Imatinib therapy for a gastrointestinal stromal tumor (GIST). A 67-year-old female presented to the ER with the chief complaint of constant sharp right shoulder pain that progressed to her chest. The patient was not on any anticoagulants and had not complained of shortness of breath. Under suspicion of a pulmonary embolism, a CT chest scan was performed, and a diagnosis of non-traumatic anterior mediastinal hematoma was confirmed. This case may warrant further investigation into the links between Imatinib use and the formation of mediastinal hematomas.
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Affiliation(s)
- Rida Aziz
- Internal Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Azeem Khan
- Internal Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Maryam Yousefi
- Internal Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
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31
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Nakamura J, Tsujino I, Shima H, Nakaya T, Sugimoto A, Sato T, Watanabe T, Ohira H, Suzuki M, Tsuneta S, Hisada R, Kato M, Konno S. Clinical and Hemodynamic Responses to Imatinib in Pulmonary Veno-Occlusive Disease/Pulmonary Capillary Hemangiomatosis: A Retrospective Pilot Study of Five Cases and Review of the Literature. Am J Cardiovasc Drugs 2023; 23:329-338. [PMID: 36995544 DOI: 10.1007/s40256-023-00577-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Pulmonary veno-occlusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) are rare types of pulmonary arterial hypertension with dismal prognoses; there is no established medical treatment for these conditions. Possible efficacy of imatinib against these conditions has been reported in 15 cases; however, how and in whom imatinib is effective remain unknown. METHODS We retrospectively evaluated clinical data from consecutive patients with PVOD/PCH treated with imatinib at our institution. The diagnosis of PVOD/PCH was established using the following criteria: pre-capillary pulmonary hypertension; diffusion capacity of the lung for carbon monoxide < 60%; and two or more high-resolution computed tomography findings of interlobular septal thickening, centrilobular opacities, and mediastinal lymphadenopathy. The dose of pulmonary vasodilators remained unchanged during the assessment of imatinib. RESULTS The medical records of five patients with PVOD/PCH were reviewed. The patients were aged 67 ± 13 years, their diffusion capacity of the lung for carbon monoxide was 29 ± 8%, and their mean pulmonary artery pressure was 40 ± 7 mmHg. Imatinib was administered at 50-100 mg/day; consequently, the World Health Organization functional class improved in one patient. In addition, imatinib improved the arterial oxygen partial pressure in this and another patient (these two also experienced a decreased mean pulmonary artery pressure and pulmonary vascular resistance after imatinib usage). CONCLUSIONS This study indicated that imatinib improves the clinical condition, including pulmonary hemodynamics, of some patients with PVOD/PCH. In addition, patients with a certain high-resolution computed tomography pattern or PCH-dominant vasculopathy may respond favorably to imatinib.
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Affiliation(s)
- Junichi Nakamura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan.
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Hideki Shima
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshitaka Nakaya
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Ayako Sugimoto
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takahiro Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Taku Watanabe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Ohira
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Satonori Tsuneta
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Ryo Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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Garrison AT, Bignold RE, Wu X, Johnson JR. Pericytes: The lung-forgotten cell type. Front Physiol 2023; 14:1150028. [PMID: 37035669 PMCID: PMC10076600 DOI: 10.3389/fphys.2023.1150028] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
Pericytes are a heterogeneous population of mesenchymal cells located on the abluminal surface of microvessels, where they provide structural and biochemical support. Pericytes have been implicated in numerous lung diseases including pulmonary arterial hypertension (PAH) and allergic asthma due to their ability to differentiate into scar-forming myofibroblasts, leading to collagen deposition and matrix remodelling and thus driving tissue fibrosis. Pericyte-extracellular matrix interactions as well as other biochemical cues play crucial roles in these processes. In this review, we give an overview of lung pericytes, the key pro-fibrotic mediators they interact with, and detail recent advances in preclinical studies on how pericytes are disrupted and contribute to lung diseases including PAH, allergic asthma, and chronic obstructive pulmonary disease (COPD). Several recent studies using mouse models of PAH have demonstrated that pericytes contribute to these pathological events; efforts are currently underway to mitigate pericyte dysfunction in PAH by targeting the TGF-β, CXCR7, and CXCR4 signalling pathways. In allergic asthma, the dissociation of pericytes from the endothelium of blood vessels and their migration towards inflamed areas of the airway contribute to the characteristic airway remodelling observed in allergic asthma. Although several factors have been suggested to influence this migration such as TGF-β, IL-4, IL-13, and periostin, recent evidence points to the CXCL12/CXCR4 pathway as a potential therapeutic target. Pericytes might also play an essential role in lung dysfunction in response to ageing, as they are responsive to environmental risk factors such as cigarette smoke and air pollutants, which are the main drivers of COPD. However, there is currently no direct evidence delineating the contribution of pericytes to COPD pathology. Although there is a lack of human clinical data, the recent available evidence derived from in vitro and animal-based models shows that pericytes play important roles in the initiation and maintenance of chronic lung diseases and are amenable to pharmacological interventions. Therefore, further studies in this field are required to elucidate if targeting pericytes can treat lung diseases.
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Affiliation(s)
- Annelise T. Garrison
- School of Biosciences, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Rebecca E. Bignold
- School of Biosciences, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Xinhui Wu
- School of Biosciences, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
- Department of Molecular Pharmacology, Faculty of Science and Engineering, University of Groningen, Groningen, Netherlands
- Groningen Research Institute for Asthma and COPD, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jill R. Johnson
- School of Biosciences, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
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Gillies H, Niven R, Dake BT, Chakinala MM, Feldman JP, Hill NS, Hoeper MM, Humbert M, McLaughlin VV, Kankam M. AV-101, a novel inhaled dry-powder formulation of imatinib, in healthy adult participants: a phase 1 single and multiple ascending dose study. ERJ Open Res 2023; 9:00433-2022. [PMID: 36923571 PMCID: PMC10009698 DOI: 10.1183/23120541.00433-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/16/2022] [Indexed: 11/12/2022] Open
Abstract
Background Oral imatinib has been shown to be effective, but poorly tolerated, in patients with advanced pulmonary arterial hypertension (PAH). To maintain efficacy while improving tolerability, AV-101, a dry powder inhaled formulation of imatinib, was developed to deliver imatinib directly to the lungs. Methods This phase 1, placebo-controlled, randomised single ascending dose (SAD) and multiple ascending dose (MAD) study evaluated the safety/tolerability and pharmacokinetics of AV-101 in healthy adults. The SAD study included five AV-101 cohorts (1 mg, 3 mg, 10 mg, 30 mg, 90 mg) and placebo, and a single-dose oral imatinib 400-mg cohort. The MAD study included three AV-101 cohorts (10 mg, 30 mg, 90 mg) and placebo; dosing occurred twice daily for 7 days. Results 82 participants (SAD n=48, MAD n=34) were enrolled. For the SAD study, peak plasma concentrations of imatinib occurred within 3 h of dosing with lower systemic exposure compared to oral imatinib (p<0.001). For the MAD study, systemic exposure of imatinib was higher after multiple doses of AV-101 compared to a single dose, but steady-state plasma concentrations were lower for the highest AV-101 cohort (90 mg) compared to simulated steady-state oral imatinib at day 7 (p=0.0002). Across AV-101 MAD dose cohorts, the most common treatment-emergent adverse events were cough (n=7, 27%) and headache (n=4, 15%). Conclusions AV-101 was well tolerated in healthy adults, and targeted doses of AV-101 significantly reduced the systemic exposure of imatinib compared with oral imatinib. An ongoing phase 2b/phase 3 study (IMPAHCT; clinicaltrials.gov identifier NCT05036135) will evaluate the safety/tolerability and clinical benefit of AV-101 for PAH.
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Affiliation(s)
| | | | | | | | | | - Nicholas S Hill
- Pulmonary Critical Care and Sleep Division, Tufts Medical Center, Boston, MA, USA
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School and German Centre of Lung Research, Hannover, Germany
| | - Marc Humbert
- Université Paris-Saclay, INSERM, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | - Martin Kankam
- Altasciences Clinical Kansas, Inc., Overland Park, KS, USA
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Cullivan S, Gaine S, Sitbon O. New trends in pulmonary hypertension. Eur Respir Rev 2023; 32:32/167/220211. [PMID: 36813291 PMCID: PMC9949382 DOI: 10.1183/16000617.0211-2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/12/2022] [Indexed: 02/24/2023] Open
Abstract
Pulmonary hypertension (PH) is a prevalent disease of the pulmonary vasculature that is characterised by considerable morbidity and mortality. Substantial efforts have been made in recent years to improve disease recognition, diagnosis and management, and this is reflected in current guidelines. The haemodynamic definition of PH has been revised and a definition for exercise PH has been provided. Risk stratification has been refined and the importance of comorbidities and phenotyping have been highlighted. These changes provide an opportunity to potentially identify pulmonary vascular disease at an earlier stage and to enhance patient-centred, goal-orientated treatment decisions. A promising fourth treatment pathway for pulmonary arterial hypertension and potential targeted therapies for group 3 PH are on the horizon, concepts which seemed inconceivable only a few years ago. Beyond medication, there is a greater appreciation for the importance of supervised training in stable PH and the possible role of interventional therapies in select cases. The landscape of PH is changing and it is characterised by progress, innovation and opportunities. In this article, we highlight some of the new trends in PH, with a specific focus on the revised European Society of Cardiology/European Respiratory Society 2022 guidelines for the diagnosis and management of PH.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Olivier Sitbon
- Department of Respiratory and Intensive Care Medicine, CHU Bicêtre, Paris-Saclay University, INSERM URM_S999, Le Kremlin-Bicêtre, France
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Novel Molecular Mechanisms Involved in the Medical Treatment of Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24044147. [PMID: 36835558 PMCID: PMC9965798 DOI: 10.3390/ijms24044147] [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: 01/16/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe condition with a high mortality rate despite advances in diagnostic and therapeutic strategies. In recent years, significant scientific progress has been made in the understanding of the underlying pathobiological mechanisms. Since current available treatments mainly target pulmonary vasodilation, but lack an effect on the pathological changes that develop in the pulmonary vasculature, there is need to develop novel therapeutic compounds aimed at antagonizing the pulmonary vascular remodeling. This review presents the main molecular mechanisms involved in the pathobiology of PAH, discusses the new molecular compounds currently being developed for the medical treatment of PAH and assesses their potential future role in the therapeutic algorithms of PAH.
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36
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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.
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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
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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Galkin A, Sitapara R, Clemons B, Garcia E, Kennedy M, Guimond D, Carter LL, Douthitt A, Osterhout R, Gandjeva A, Slee D, Salter-Cid L, Tuder RM, Zisman LS. Inhaled seralutinib exhibits potent efficacy in models of pulmonary arterial hypertension. Eur Respir J 2022; 60:2102356. [PMID: 35680144 PMCID: PMC9724289 DOI: 10.1183/13993003.02356-2021] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Signalling through platelet-derived growth factor receptor (PDGFR), colony-stimulating factor 1 receptor (CSF1R) and mast/stem cell growth factor receptor kit (c-KIT) plays a critical role in pulmonary arterial hypertension (PAH). We examined the preclinical efficacy of inhaled seralutinib, a unique small-molecule PDGFR/CSF1R/c-KIT kinase inhibitor in clinical development for PAH, in comparison to a proof-of-concept kinase inhibitor, imatinib. METHODS Seralutinib and imatinib potency and selectivity were compared. Inhaled seralutinib pharmacokinetics/pharmacodynamics were studied in healthy rats. Efficacy was evaluated in two rat models of PAH: SU5416/Hypoxia (SU5416/H) and monocrotaline pneumonectomy (MCTPN). Effects on inflammatory/cytokine signalling were examined. PDGFR, CSF1R and c-KIT immunohistochemistry in rat and human PAH lung samples and microRNA (miRNA) analysis in the SU5416/H model were performed. RESULTS Seralutinib potently inhibited PDGFRα/β, CSF1R and c-KIT. Inhaled seralutinib demonstrated dose-dependent inhibition of lung PDGFR and c-KIT signalling and increased bone morphogenetic protein receptor type 2 (BMPR2). Seralutinib improved cardiopulmonary haemodynamic parameters and reduced small pulmonary artery muscularisation and right ventricle hypertrophy in both models. In the SU5416/H model, seralutinib improved cardiopulmonary haemodynamic parameters, restored lung BMPR2 protein levels and decreased N-terminal pro-brain natriuretic peptide (NT-proBNP), more than imatinib. Quantitative immunohistochemistry in human lung PAH samples demonstrated increased PDGFR, CSF1R and c-KIT. miRNA analysis revealed candidates that could mediate seralutinib effects on BMPR2. CONCLUSIONS Inhaled seralutinib was an effective treatment of severe PAH in two animal models, with improved cardiopulmonary haemodynamic parameters, a reduction in NT-proBNP, reverse remodelling of pulmonary vascular pathology and improvement in inflammatory biomarkers. Seralutinib showed greater efficacy compared to imatinib in a preclinical study.
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Affiliation(s)
- Anna Galkin
- Gossamer Bio, Inc., San Diego, CA, USA
- A. Galkin and R. Sitapara contributed equally as first authors
| | - Ravikumar Sitapara
- Gossamer Bio, Inc., San Diego, CA, USA
- The Rensselaer Center for Translational Research Inc., Rensselaer, NY, USA
- A. Galkin and R. Sitapara contributed equally as first authors
| | | | | | | | | | | | | | | | - Aneta Gandjeva
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Rubin M Tuder
- University of Colorado School of Medicine, Aurora, CO, USA
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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40
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Ainscough AJ, Smith TJ, Haensel M, Rhodes CJ, Fellows A, Whitwell HJ, Vasilaki E, Gray K, Freeman A, Howard LS, Wharton J, Dunmore B, Upton PD, Wilkins MR, Edel JB, Wojciak-Stothard B. An organ-on-chip model of pulmonary arterial hypertension identifies a BMPR2-SOX17-prostacyclin signalling axis. Commun Biol 2022; 5:1192. [PMID: 36344664 PMCID: PMC9640600 DOI: 10.1038/s42003-022-04169-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is an unmet clinical need. The lack of models of human disease is a key obstacle to drug development. We present a biomimetic model of pulmonary arterial endothelial-smooth muscle cell interactions in PAH, combining natural and induced bone morphogenetic protein receptor 2 (BMPR2) dysfunction with hypoxia to induce smooth muscle activation and proliferation, which is responsive to drug treatment. BMPR2- and oxygenation-specific changes in endothelial and smooth muscle gene expression, consistent with observations made in genomic and biochemical studies of PAH, enable insights into underlying disease pathways and mechanisms of drug response. The model captures key changes in the pulmonary endothelial phenotype that are essential for the induction of SMC remodelling, including a BMPR2-SOX17-prostacyclin signalling axis and offers an easily accessible approach for researchers to study pulmonary vascular remodelling and advance drug development in PAH.
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Affiliation(s)
- Alexander J Ainscough
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Chemistry, Imperial College London, London, UK
| | - Timothy J Smith
- Department of Chemistry, Imperial College London, London, UK
| | - Maike Haensel
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Adam Fellows
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Harry J Whitwell
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Eleni Vasilaki
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Kelly Gray
- Emerging Innovations Unit, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Adrian Freeman
- Emerging Innovations Unit, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Luke S Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John Wharton
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Benjamin Dunmore
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Paul D Upton
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Joshua B Edel
- Department of Chemistry, Imperial College London, London, UK
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Zhao J, Wang Q, Deng X, Qian J, Tian Z, Liu Y, Li M, Zeng X. The treatment strategy of connective tissue disease associated pulmonary arterial hypertension: Evolving into the future. Pharmacol Ther 2022; 239:108192. [DOI: 10.1016/j.pharmthera.2022.108192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
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Otani N, Tomoe T, Kawabe A, Sugiyama T, Horie Y, Sugimura H, Yasu T, Nakamoto T. Recent Advances in the Treatment of Pulmonary Arterial Hypertension. Pharmaceuticals (Basel) 2022; 15:1277. [PMID: 36297387 PMCID: PMC9609229 DOI: 10.3390/ph15101277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 09/29/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease in which stenosis or obstruction of the pulmonary arteries (PAs) causes an increase in PA pressure, leading to right-sided heart failure and death. Basic research has revealed a decrease in the levels of endogenous vasodilators, such as prostacyclin, and an increase in the levels of endogenous vasoconstrictors, such as endothelin, in patients with PAH, leading to the development of therapeutic agents. Currently, therapeutic agents for PAH target three pathways that are selective for PAs: the prostacyclin, endothelin, and nitric oxide pathways. These treatments improve the prognosis of PAH patients. In this review, we introduce new drug therapies and provide an overview of the current therapeutic agents.
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Affiliation(s)
| | | | | | | | | | | | | | - Takaaki Nakamoto
- Department of Cardiology, Dokkyo Medical University Nikkyo Medical Center, 632 Takatoku, Nikko 321-2593, Japan
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Strategizing Drug Therapies in Pulmonary Hypertension for Improved Outcomes. Pharmaceuticals (Basel) 2022; 15:ph15101242. [PMID: 36297354 PMCID: PMC9609426 DOI: 10.3390/ph15101242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 01/19/2023] Open
Abstract
Pulmonary hypertension (PH) is characterized by a resting mean pulmonary artery pressure (PAP) of 20 mmHg or more and is a disease of multiple etiologies. Of the various types of PH, pulmonary arterial hypertension (PAH) is characterized by elevated resistance in the pulmonary arterial tree. It is a rare but deadly disease characterized by vascular remodeling of the distal pulmonary arteries. This paper focuses on PAH diagnosis and management including current and future treatment options. Over the last 15 years, our understanding of this progressive disease has expanded from the concept of vasoconstrictive/vasodilatory mismatch in the pulmonary arterioles to now a better appreciation of the role of genetic determinants, numerous cell signaling pathways, cell proliferation and apoptosis, fibrosis, thrombosis, and metabolic abnormalities. While knowledge of its pathophysiology has expanded, the majority of the treatments available today still modulate the same three vasodilatory pathways that have been targeted for over 30 years (endothelin, nitric oxide, and prostacyclin). While modifying these pathways may help improve symptoms and quality of life, none of these directly modify the underlying disease pathogenesis. However, there are now studies ongoing with new drugs that can prevent or reverse these underlying causes of PAH. This review discusses the evidence base for the current treatment algorithms for PAH, as well as discusses novel therapies in development.
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Yaku A, Inagaki T, Asano R, Okazawa M, Mori H, Sato A, Hia F, Masaki T, Manabe Y, Ishibashi T, Vandenbon A, Nakatsuka Y, Akaki K, Yoshinaga M, Uehata T, Mino T, Morita S, Ishibashi-Ueda H, Morinobu A, Tsujimura T, Ogo T, Nakaoka Y, Takeuchi O. Regnase-1 Prevents Pulmonary Arterial Hypertension Through mRNA Degradation of Interleukin-6 and Platelet-Derived Growth Factor in Alveolar Macrophages. Circulation 2022; 146:1006-1022. [PMID: 35997026 DOI: 10.1161/circulationaha.122.059435] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a type of pulmonary hypertension (PH) characterized by obliterative pulmonary vascular remodeling, resulting in right-sided heart failure. Although the pathogenesis of PAH is not fully understood, inflammatory responses and cytokines have been shown to be associated with PAH, in particular, with connective tissue disease-PAH. In this sense, Regnase-1, an RNase that regulates mRNAs encoding genes related to immune reactions, was investigated in relation to the pathogenesis of PH. METHODS We first examined the expression levels of ZC3H12A (encoding Regnase-1) in peripheral blood mononuclear cells from patients with PH classified under various types of PH, searching for an association between the ZC3H12A expression and clinical features. We then generated mice lacking Regnase-1 in myeloid cells, including alveolar macrophages, and examined right ventricular systolic pressures and histological changes in the lung. We further performed a comprehensive analysis of the transcriptome of alveolar macrophages and pulmonary arteries to identify genes regulated by Regnase-1 in alveolar macrophages. RESULTS ZC3H12A expression in peripheral blood mononuclear cells was inversely correlated with the prognosis and severity of disease in patients with PH, in particular, in connective tissue disease-PAH. The critical role of Regnase-1 in controlling PAH was also reinforced by the analysis of mice lacking Regnase-1 in alveolar macrophages. These mice spontaneously developed severe PAH, characterized by the elevated right ventricular systolic pressures and irreversible pulmonary vascular remodeling, which recapitulated the pathology of patients with PAH. Transcriptomic analysis of alveolar macrophages and pulmonary arteries of these PAH mice revealed that Il6, Il1b, and Pdgfa/b are potential targets of Regnase-1 in alveolar macrophages in the regulation of PAH. The inhibition of IL-6 (interleukin-6) by an anti-IL-6 receptor antibody or platelet-derived growth factor by imatinib but not IL-1β (interleukin-1β) by anakinra, ameliorated the pathogenesis of PAH. CONCLUSIONS Regnase-1 maintains lung innate immune homeostasis through the control of IL-6 and platelet-derived growth factor in alveolar macrophages, thereby suppressing the development of PAH in mice. Furthermore, the decreased expression of Regnase-1 in various types of PH implies its involvement in PH pathogenesis and may serve as a disease biomarker, and a therapeutic target for PH as well.
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Affiliation(s)
- Ai Yaku
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
- Department of Rheumatology and Clinical Immunology (A.Y., A.M.), Graduate School of Medicine, Kyoto University, Japan
| | - Tadakatsu Inagaki
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
| | - Ryotaro Asano
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
- Department of Advanced Medical Research for Pulmonary Hypertension (R.A., T.O.), National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cardiovascular Medicine (R.A., T.O.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Okazawa
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
| | - Hiroyoshi Mori
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
| | - Ayuko Sato
- Department of Pathology, Hyogo College of Medicine, Nishinomiya, Japan (A.S., T.T.)
| | - Fabian Hia
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Takeshi Masaki
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
| | - Yusuke Manabe
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan (Y.M.)
| | - Tomohiko Ishibashi
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
| | - Alexis Vandenbon
- Laboratory of Systems Virology, Department of Biosystems Science, Institute for Frontier Life and Medical Sciences (A.V.), Kyoto University, Japan
| | - Yoshinari Nakatsuka
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Kotaro Akaki
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Masanori Yoshinaga
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Takuya Uehata
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Takashi Mino
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine (S.M.), Kyoto University, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology (H.I.-U.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology (A.Y., A.M.), Graduate School of Medicine, Kyoto University, Japan
| | - Tohru Tsujimura
- Department of Pathology, Hyogo College of Medicine, Nishinomiya, Japan (A.S., T.T.)
| | - Takeshi Ogo
- Department of Advanced Medical Research for Pulmonary Hypertension (R.A., T.O.), National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cardiovascular Medicine (R.A., T.O.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshikazu Nakaoka
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan (T. Inagaki, R.A., M.O., H.M., T. Masaki, Y.M., T. Ishibashi, Y. Nakaoka)
- Department of Cardiovascular Medicine (Y. Nakaoka), Osaka University Graduate School of Medicine, Suita, Japan
- Department of Molecular Imaging in Cardiovascular Medicine (Y. Nakaoka), Osaka University Graduate School of Medicine, Suita, Japan
| | - Osamu Takeuchi
- Department of Medical Chemistry (A.Y., F.H., Y. Nakatsuka, K.A., M.Y., T.U., T. Mino, O.T.), Graduate School of Medicine, Kyoto University, Japan
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Medrek S, Melendres-Groves L. Evolving nonvasodilator treatment options for pulmonary arterial hypertension. Curr Opin Pulm Med 2022; 28:361-368. [PMID: 35838352 DOI: 10.1097/mcp.0000000000000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With the establishment of vasodilator therapy as a mainstay of treatment for pulmonary arterial hypertension (PAH), new therapeutic approaches are needed to prevent the development of the vasculopathy associated with this disease. Many studies are currently underway to investigate nonvasodilator treatment options. RECENT FINDINGS Modulation of bone morphogenic protein receptor type 2 (BMPR2) signaling with sotatercept showed promising results in phase 2 studies. Rituximab, an anti-CD20 monoclonal antibody, showed some signal for beneficial effect in patients with scleroderma-associated PAH. Studies evaluating agents including tocilizumab, selonsertib, bardoxolone, 10-nitro-9(E)-enoic acid (CXA-10) and intravenous iron have not shown acceptable efficacy in treating PAH. SUMMARY Pharmacologic approaches for the treatment of PAH include altering of transforming growth factor β/BMPR2 signaling, proliferation via growth factors, immune response, oxidative stress, estrogen signaling, metabolism, and neurohormonal modulation. Other treatment modalities including pulmonary artery nerve denervation, stem cell therapy, and inter-atrial shunt formation are also being explored.
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Affiliation(s)
- Sarah Medrek
- Division of Pulmonary Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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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.
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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.)
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Langleben D, Orfanos SE, Fox BD, Messas N, Giovinazzo M, Catravas JD. The Paradox of Pulmonary Vascular Resistance: Restoration of Pulmonary Capillary Recruitment as a Sine Qua Non for True Therapeutic Success in Pulmonary Arterial Hypertension. J Clin Med 2022; 11:jcm11154568. [PMID: 35956182 PMCID: PMC9369805 DOI: 10.3390/jcm11154568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Exercise-induced increases in pulmonary blood flow normally increase pulmonary arterial pressure only minimally, largely due to a reserve of pulmonary capillaries that are available for recruitment to carry the flow. In pulmonary arterial hypertension, due to precapillary arteriolar obstruction, such recruitment is greatly reduced. In exercising pulmonary arterial hypertension patients, pulmonary arterial pressure remains high and may even increase further. Current pulmonary arterial hypertension therapies, acting principally as vasodilators, decrease calculated pulmonary vascular resistance by increasing pulmonary blood flow but have a minimal effect in lowering pulmonary arterial pressure and do not restore significant capillary recruitment. Novel pulmonary arterial hypertension therapies that have mainly antiproliferative properties are being developed to try and diminish proliferative cellular obstruction in precapillary arterioles. If effective, those agents should restore capillary recruitment and, during exercise testing, pulmonary arterial pressure should remain low despite increasing pulmonary blood flow. The effectiveness of every novel therapy for pulmonary arterial hypertension should be evaluated not only at rest, but with measurement of exercise pulmonary hemodynamics during clinical trials.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-514-340-7531
| | - Stylianos E. Orfanos
- 1st Department of Critical Care and Pulmonary Services, Pulmonary Hypertension Center, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 10676 Athens, Greece
| | - Benjamin D. Fox
- Pulmonary Division, Yitzchak Shamir Hospital, Tel Aviv University, Tzrifin 69978, Israel
| | - Nathan Messas
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Michele Giovinazzo
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - John D. Catravas
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23529, USA
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Qin C, Zan Y, Xie L, Liu H. Ataxia telangiectasia mutated: The potential negative regulator in platelet-derived growth factor-BB promoted proliferation of pulmonary arterial smooth muscle cells. Front Cardiovasc Med 2022; 9:942251. [PMID: 35990964 PMCID: PMC9382100 DOI: 10.3389/fcvm.2022.942251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To study the role of ataxia telangiectasia mutated (ATM) in the platelet-derived growth factor (PDGF)-BB-induced proliferation of pulmonary arterial smooth muscle cells (PASMCs) through reactive oxygen species (ROS) formation. Methods Primary cultures of PASMCs were treated with different concentrations of PDGF-BB or exogenous hydrogen peroxide (H2O2). The activation level of ATM and the proliferation level of PASMCs were measured by immunofluorescence staining and Cell Counting Kit-8, respectively. Moreover, NADPH oxidase 2 (NOX2) and intracellular H2O2 were detected under the stimulation of different levels of PDGF-BB by Western blot and dihydroethidium staining. Results Both the control group and 50 ng/ml of the PDGF-BB group showed significantly higher levels of phosphorylation ATM compared to other groups (P < 0.05). With the ATM inhibitor, 50 ng/ml of the PDGF-BB group showed further increased proliferative level compared to the 10 ng/ml (P < 0.05). Both the levels of NOX2 and H2O2 showed dose-dependent manners under PDGF-BB stimulation (P < 0.05). ATM could be activated by H2O2 upon a dose-dependent way, except for the 500 μM H2O2 group. Under 200 μM H2O2 stimulation, proliferation level decreased significantly (P < 0.05), while no significant difference was shown with the addition of ATM inhibitor (P > 0.05). Conclusion Our study first established ROS-induced ATM activation in PDGF-BB-stimulated proliferation of PASMCs. Inhibition of ATM had promoted effects on the proliferation of PASMCs under the excessive levels of PDGF-BB and H2O2. Our study might provide a novel promising target for the treatment of pulmonary arterial hypertension (PAH).
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Affiliation(s)
- Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yiheng Zan
- Pulmonary Vascular Remodeling Research Unit, West China Institute of Women's and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Disease, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liang Xie
- Pulmonary Vascular Remodeling Research Unit, West China Institute of Women's and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Disease, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hanmin Liu
- Pulmonary Vascular Remodeling Research Unit, West China Institute of Women's and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Disease, Chengdu, China
- Department of Burns and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Hanmin Liu
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Zhu HR, Kuang HY, Li Q, Ji XJ. Effects of oral targeted treatments in pulmonary arterial hypertension: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:915470. [PMID: 35983180 PMCID: PMC9378982 DOI: 10.3389/fcvm.2022.915470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background Although pulmonary arterial hypertension (PAH) is a fatal disease, specific drugs have been used to treat PAH. These drugs predominantly target these three pathobiological pathways: Endothelin receptor antagonist (ERA), nitric oxide (NO), and prostanoids pathways. In this review, we aimed to analyze the efficacy and safety of oral targeted treatments for PAH. Methods The national library of medicine (MEDLINE), excerpta medica database (EMBASE), and Cochrane Central Register of Controlled Trials databases were searched. Randomized controlled trials that compared the oral targeted drugs with placebos were selected. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for variables with dichotomous outcomes, and standardized mean differences with continuous outcomes variables. Additionally, the mean of the differences for the 6-min walk distance (6MWD) was analyzed. Results In total, 23 studies involving 7,121 patients were included in this study. These studies show that orally PAH-specific drugs could decrease the risk of clinical worsening events, with an OR of 0.55 (p < 0.001). Furthermore, these drugs could improve exercise capacity, showing a 21.74-m increase in 6MWD (95% CI: 17.53–25.95 m) and cause a greater amelioration of functional class (OR = 0.60, 95% CI: 0.47–0.76). Additionally, subgroup analysis indicated that compared with placebo, ERAs, and drugs in the NO pathway were most effective and safe, which are associated with an improvement in exercise capacity, 6MWD, and worsening events-free survival rate. Conclusion Nitric oxide exhibited the most prominent clinical effect on exercise tolerance. However, in the subgroup analysis, oral targeted drugs of different pathways show applicability to different populations, which highlights the need for precise treatment in the clinical setting. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=297946], identifier [CRD 42022297946].
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Affiliation(s)
- Hui-ru Zhu
- National Clinical Research Center for Child Health and Disorders, Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Hong-yu Kuang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Li
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-juan Ji
- Department of Ultrasound, Chongqing General Hospital, Chongqing, China
- *Correspondence: Xiao-juan Ji,
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Tamura Y, Tamura Y. Dasatinib-induced Pulmonary Hypertension. Intern Med 2022; 61:2245-2246. [PMID: 35110497 PMCID: PMC9424095 DOI: 10.2169/internalmedicine.9107-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yudai Tamura
- Cardiovascular Center, International University of Health and Welfare Mita Hospital, Japan
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Japan
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