Long-term prazosin therapy for COPD pulmonary hypertension

α1-adrenoceptor subtypes mediating noradrenaline-induced contraction of pulmonary artery from pulmonary hypertensive rats

The effect of monocrotaline-induced pulmonary hypertension on alpha(1)-adrenoceptor-mediated contractions of pulmonary artery segments was studied. In control and monocrotaline-treated rats, noradrenaline evoked concentration-dependent contractions of the pulmonary artery. There was no change in the potency and affinity of noradrenaline but the maximum response and receptor reserve were significantly reduced. Noradrenaline-induced contractions were competitively antagonized by prazosin, 2-(2-6dimethoxyphenoxyethyl)aminomethyl-1,4-benzodioxane hydrochloride (WB 4101) and 8-[2-[4-(2methoxyphenyl)-1-piperazinyl]ethyl]-8-azaspiro[4,5]decane-7,9 dione dihydrochloride (BMY 7378) with pA(2) values of 9.64+/-0.16, 9.45+/-0.10 and 8.30+/-0.14, respectively. These antagonists also competitively antagonized noradrenaline-induced contractions of pulmonary artery segments isolated from rats with monocrotaline-induced pulmonary hypertension. The pA(2) values were 9.66+/-0.11 (prazosin), 9.62+/-0.09 (WB 4101) and 8.47+/-0.15 (BMY 7378). Chloroethylclonidine (CEC) shifted noradrenaline concentration-response curve to the right and depressed the maximum response. There was no difference between the effects of CEC in both groups. It was therefore concluded that pulmonary hypertension significantly reduced noradrenaline-induced contractions of the rat pulmonary artery without affecting the sensitivity. Studies with receptor-selective antagonists confirmed that alpha(1)D-adrenoceptor subtype is the predominant receptor subtype in the pulmonary artery and this was maintained in this disease state.

Alpha1-adrenergic hypothesis for pulmonary hypertension

Pulmonary hypertension (PH) is a chronic and disabling condition that affects the pulmonary vasculature. Once PH is diagnosed, the prognosis is generally poor with a rapid downhill course. PH management is largely empirical because the underlying pathophysiologic mechanisms that are responsible for the excessive vasoconstrictor and vascular smooth muscle proliferative responses are poorly understood. Based on new information concerning the role of adrenergic receptors in regulating various cellular functions, a new perspective on the genesis of PH has emerged, along with a unifying hypothesis for the role of alpha1-adrenergic receptors present in the pulmonary vasculature as the major contributor to the pathophysiologic changes associated with PH. Adrenergic receptors that are present on vascular smooth muscle cells regulate vascular tone and growth. The alpha1-adrenergic receptors that are present on the small- and medium-sized pulmonary arteries have a unique and greatly enhanced affinity and activity to alpha1-adrenergic agonists. Under physiologic conditions, this helps in regulating vascular tone and maintains an adequate ventilation/perfusion matching. However, the excessive stimulation of alpha1-adrenergic receptors produces not only smooth muscle contraction but also proliferation and growth. The conditions that produce an increase in alpha1-adrenoreceptor gene synthesis, density, and activity (such as hypoxia or changes in vessel wall pressure) or increase the levels of its agonists (such as norepinephrine, appetite suppressants, or cocaine) greatly enhance pulmonary vascular smooth muscle contractile and proliferative responses and lead to the development of PH. An understanding of the role played by these receptors in the pathophysiology of PH would not only help to avoid the use of alpha1-agonists for appetite suppression and other disease states, but also would help in developing new drugs to block these receptors. A further understanding of the alpha1-adrenoreceptor subtypes present in the pulmonary vasculature, the factors that regulate their expression, and their intracellular signaling pathways would help researchers to devise newer therapeutic strategies and, hopefully, to find a cure for this crippling condition.

Recognition and management of pulmonary hypertension

Pulmonary hypertension (mean pulmonary arterial pressure > 20mm Hg at rest or > 30mm Hg during exercise) occurs (i) as primary pulmonary hypertension (no known underlying cause), (ii) as persistent pulmonary hypertension of the newborn or (iii) secondary to a variety of lung and cardiovascular diseases. In the last 10 to 15 years there have been significant advances in the medical management of this debilitating and life-threatening disorder. The main drugs in current use are anticoagulants (warfarin, heparin) and vasodilators, especially oral calcium antagonists, intravenous prostacyclin (prostaglandin I2; epoprostenol) and inhaled nitric oxide. Calcium antagonists, (e.g. nifedipine, diltiazem) are used chiefly in primary pulmonary hypertension. They are effective in patients who give a pulmonary vasodilator response to an acute challenge with a short acting vasodilator (e.g. prostacyclin, nitric oxide or adenosine), and are used in doses greater than are usual in the treatment of other cardiovascular disorders. Prostacyclin, given by continuous intravenous infusion, is effective in patients even if they do not respond to an acute vasodilator challenge. The long term benefit in these patients is thought to reflect the antiproliferative effects of the drug and/or its ability to inhibit platelet aggregation. It is used either as long term therapy or as a bridge to transplantation. Inhaled nitric oxide, which is used mainly in persistent pulmonary hypertension of the newborn, has the particular benefit of being pulmonary selective, due to its route of administration and rapid inactivation. Anticoagulants have a specific role in the treatment of pulmonary thromboembolic pulmonary hypertension and are also used routinely in patients with primary pulmonary hypertension. Nondrug treatments for pulmonary hypertension include (i) supplemental oxygen (> or = 15 h/day), which is the primary therapy in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease and (ii) heart-lung or lung transplantation, which nowadays is regarded as a last resort. Different types of pulmonary hypertension require different treatment strategies. Future advances in the treatment of pulmonary hypertension may come from the use of drug combinations, the development of new drugs, such as endothelin antagonists, nitric oxide donors and potassium channel openers, or the application of gene therapy.

Addition of nitric oxide to oxygen improves cardiopulmonary function in patients with severe COPD

STUDY OBJECTIVE

To assess the effect of nitric oxide inhalation on pulmonary hemodynamics and oxygenation in patients with COPD receiving long-term oxygen therapy (LTOT).

DESIGN

Prospective study.

SETTING

ICU of a university medical center.

PATIENTS

A total of 18 (6 female, 12 male) patients with COPD, spontaneously breathing with LTOT.

INTERVENTIONS

Oxygenation and hemodynamic variables were measured and calculated at an inspired oxygen fraction (FIO2) adjusted to mimic LTOT conditions (control), and then 1 h after each sequential addition of 5, 10, and 20 ppm nitric oxide to the gas mixture. A newly developed device (Pulmonox) provided both the delivery and continuous analysis of nitric oxide and oxidative nitric oxide products.

MEASUREMENTS AND RESULTS

There was a significant improvement in oxygenation at 5 ppm nitric oxide (PaO2/FIO2 ratio improved from 244+/-37 to 303+/-59, p<0.05), but no further improvement at higher doses (ceiling effect). There was a dose-dependent improvement in hemodynamic variables that was maximal at 20 ppm nitric oxide (mean pulmonary artery pressure decreased from 29+/-7 to 24+/-5 mm Hg, pulmonary vascular resistance index decreased from 565+/-321 to 392+/-215 dyne x s x cm(-5) x m(-2), and right ventricular ejection fraction improved from 34+/-6 to 39+/-7%, all p<0.05).

CONCLUSION

Prior studies have demonstrated that inhaled nitric oxide may improve or worsen oxygenation in patients with COPD. Our data show an unequivocal improvement in oxygenation (albeit with a ceiling effect at 5 ppm) and pulmonary hemodynamics (dose dependent) in COPD patients receiving LTOT. Further studies are warranted to examine the usefulness of inhaled nitric oxide during acute exacerbations of COPD, or even the possibility of long-term application in patients receiving LTOT.