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Liu A, Price LC, Sharma R, Wells AU, Kouranos V. Sarcoidosis Associated Pulmonary Hypertension. Biomedicines 2024; 12:177. [PMID: 38255282 PMCID: PMC10813665 DOI: 10.3390/biomedicines12010177] [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: 12/07/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
In patients with sarcoidosis, the development of pulmonary hypertension is associated with significant morbidity and mortality. The global prevalence of sarcoidosis-associated pulmonary hypertension (SAPH) reportedly ranges between 2.9% and 20% of sarcoidosis patients. Multiple factors may contribute to the development of SAPH, including advanced parenchymal lung disease, severe systolic and/or diastolic left ventricular dysfunction, veno-occlusive or thromboembolic disease, as well as extrinsic factors such as pulmonary vascular compression from enlarged lymph nodes, anemia, and liver disease. Early diagnosis of SAPH is important but rarely achieved primarily due to insufficiently accurate screening strategies, which rely entirely on non-invasive tests and clinical assessment. The definitive diagnosis of SAPH requires right heart catheterization (RHC), with transthoracic echocardiography as the recommended gatekeeper to RHC according to current guidelines. A 6-min walk test (6MWT) had the greatest prognostic value in SAPH patients based on recent registry outcomes, while advanced lung disease determined using a reduced DLCO (<35% predicted) was associated with reduced transplant-free survival in pre-capillary SAPH. Clinical management involves the identification and treatment of the underlying mechanism. Pulmonary vasodilators are useful in several scenarios, especially when a pulmonary vascular phenotype predominates. End-stage SAPH may warrant consideration for lung transplantation, which remains a high-risk option. Multi-centered randomized controlled trials are required to develop existing therapies further and improve the prognosis of SAPH patients.
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Affiliation(s)
| | | | | | | | - Vasileios Kouranos
- Royal Brompton Hospital, Part of Guy’s and St. Thomas’ NHS Foundation Trust, London SW3 6NP, UK; (A.L.); (L.C.P.); (R.S.); (A.U.W.)
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Mollace R, Scarano F, Bava I, Carresi C, Maiuolo J, Tavernese A, Gliozzi M, Musolino V, Muscoli S, Palma E, Muscoli C, Salvemini D, Federici M, Macrì R, Mollace V. Modulation of the nitric oxide/cGMP pathway in cardiac contraction and relaxation: Potential role in heart failure treatment. Pharmacol Res 2023; 196:106931. [PMID: 37722519 DOI: 10.1016/j.phrs.2023.106931] [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: 05/31/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
Evidence exists that heart failure (HF) has an overall impact of 1-2 % in the global population being often associated with comorbidities that contribute to increased disease prevalence, hospitalization, and mortality. Recent advances in pharmacological approaches have significantly improved clinical outcomes for patients with vascular injury and HF. Nevertheless, there remains an unmet need to clarify the crucial role of nitric oxide/cyclic guanosine 3',5'-monophosphate (NO/cGMP) signalling in cardiac contraction and relaxation, to better identify the key mechanisms involved in the pathophysiology of myocardial dysfunction both with reduced (HFrEF) as well as preserved ejection fraction (HFpEF). Indeed, NO signalling plays a crucial role in cardiovascular homeostasis and its dysregulation induces a significant increase in oxidative and nitrosative stress, producing anatomical and physiological cardiac alterations that can lead to heart failure. The present review aims to examine the molecular mechanisms involved in the bioavailability of NO and its modulation of downstream pathways. In particular, we focus on the main therapeutic targets and emphasize the recent evidence of preclinical and clinical studies, describing the different emerging therapeutic strategies developed to counteract NO impaired signalling and cardiovascular disease (CVD) development.
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Affiliation(s)
- Rocco Mollace
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Italy
| | - Federica Scarano
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Irene Bava
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Cristina Carresi
- Veterinary Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Jessica Maiuolo
- Pharmaceutical Biology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Annamaria Tavernese
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Micaela Gliozzi
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Vincenzo Musolino
- Pharmaceutical Biology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Saverio Muscoli
- Division of Cardiology, Foundation PTV Polyclinic Tor Vergata, Rome 00133, Italy
| | - Ernesto Palma
- Veterinary Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Carolina Muscoli
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy
| | - Daniela Salvemini
- Department of Pharmacology and Physiology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Italy
| | - Roberta Macrì
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy.
| | - Vincenzo Mollace
- Pharmacology Laboratory, Institute of Research for Food Safety and Health IRC-FSH, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro 88100, Italy; Renato Dulbecco Institute, Lamezia Terme, Catanzaro 88046, Italy.
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension associated with left heart disease (PHLHD) is common and associated with adverse prognosis. Proper diagnosis is critical to avoid inappropriate treatment. Practical approaches to noninvasive diagnosis are available, though invasive hemodynamics including volume loading or exercise are often necessary for definitive diagnosis. Treatment strategies and research in the field is rapidly evolving. RECENT FINDINGS Combined pre and post capillary pulmonary hypertension is associated with remodeling of the pulmonary vasculature that is proportional to the severity of the pulmonary hypertension. Even quite mild elevation of pulmonary vascular resistance (PVR), (greater than 2.0 Wood units (WU)) is associated with adverse outcome. Guideline-directed medical therapy (GDMT) for left heart failure has rapidly evolved, including approval of SGLT2 inhibitors for treatment of heart failure with preserved ejection fraction (HFpEF). However, full implementation of GDMT is lagging. Utilization of implanted pulmonary artery pressure monitoring can facilitate patient management in selected patient phenotypes and has been utilized to demonstrate improvement in pulmonary pressures with emerging therapies in HFpEF including SGLT2 inhibitors and sacubitril/valsartan. A variety of shunt devices to create a left-to-right shunt in order to decompress the left heart are available or undergoing clinical trials. There is concern that there could be adverse response to such devices in patients who have even mild elevation of pulmonary vascular resistance. Sleep disordered breathing is common in PHLHD and should be aggressively sought out and treated. SUMMARY Even mild elevation in pulmonary vascular resistance is associated with adverse outcome. A systematic approach to diagnosis of PHLHD is essential. Guideline-directed medical therapy for PHLHD prioritizes optimal management of the left heart disease. Pulmonary artery pressure sensors are useful in selected patients.
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Affiliation(s)
- Robert P Frantz
- Department of Cardiovascular Medicine, Rochester, Minnesota, USA
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Mendoza Zambrano EM, Gómez Rodríguez B, García Lunar I, Pereda Arnau D, Sánchez-López V, García Álvarez A, Otero Candelera R. Microvesicles and inflammatory markers in an animal model of chronic postcapillary pulmonary hypertension. Int J Med Sci 2023; 20:1336-1338. [PMID: 37786446 PMCID: PMC10542020 DOI: 10.7150/ijms.84924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/18/2023] [Indexed: 10/04/2023] Open
Affiliation(s)
- Elva Maria Mendoza Zambrano
- Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Ro cio/CSIC/Universidad de Sevilla, Seville, Spain
| | - Belén Gómez Rodríguez
- Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Ro cio/CSIC/Universidad de Sevilla, Seville, Spain
| | - Inés García Lunar
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiology Department, University Hospital, Madrid, Spain
| | - Daniel Pereda Arnau
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS). Hospital Clinic, Universidad de Barcelona, Barcelona, Spain
| | - Verónica Sánchez-López
- Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Ro cio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Ana García Álvarez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS). Hospital Clinic, Universidad de Barcelona, Barcelona, Spain
| | - Remedios Otero Candelera
- Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Ro cio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Rucker D, Joseph J. Defining the Phenotypes for Heart Failure With Preserved Ejection Fraction. Curr Heart Fail Rep 2022; 19:445-457. [PMID: 36178663 DOI: 10.1007/s11897-022-00582-x] [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] [Accepted: 08/24/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW Heart failure with preserved ejection fraction (HFpEF) imposes a significant burden on society and healthcare. The lack in efficacious therapies is likely due to the significant heterogeneity of HFpEF. In this review, we define various phenotypes based on underlying comorbidities or etiologies, discuss phenotypes arrived at by novel methods, and explore therapeutic targets. RECENT FINDINGS A few studies have used machine learning methods to uncover sub-phenotypes within HFpEF in an unbiased manner based on clinical features, echocardiographic findings, and biomarker levels. We synthesized the literature and propose three broad phenotypes: (1) young, with few comorbidities, usually obese and with low natriuretic peptide levels, (2) obese with substantive cardiometabolic burden and comorbidities and impaired ventricular relaxation, (3) old, multimorbid, with high rates of atrial fibrillation, renal and coronary artery disease, chronic obstructive pulmonary disease, and left ventricular hypertrophy. We also propose potential therapeutic strategies for these phenotypes.
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Affiliation(s)
- Dane Rucker
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jacob Joseph
- Massachusetts Veterans Epidemiology Research & Information Center, Veterans Affairs Boston Healthcare System, Cardiology Section (111), 1400 VFW Parkway, West Roxbury, Boston, MA, 02132, USA. .,Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
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Therapeutic augmentation of NO-sGC-cGMP signalling: lessons learned from pulmonary arterial hypertension and heart failure. Heart Fail Rev 2022; 27:1991-2003. [PMID: 35437713 DOI: 10.1007/s10741-022-10239-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 01/14/2023]
Abstract
The nitric oxide (NO)-guanylate cyclase (GC)-cyclic guanosine monophosphate (cGMP) pathway plays an important role in cardiovascular, pulmonary and renal function. Phosphodiesterase-5 inhibitors (PDE-5i) inhibit cGMP degradation, whereas both soluble guanylate cyclase (sGC) stimulators and sGC activators directly increase sGC. PDE-5i (e.g. sildenafil, tadalafil) and sGC stimulators (e.g. riociguat, vericiguat) have been extensively used in pulmonary artery hypertension (PAH) and heart failure (HF). PDE-5i have also been used in end-stage HF before and after left ventricular (LV) assist device (LVAD) implantation. Augmentation of NO-GC-cGMP signalling with PDE-5i causes selective pulmonary vasodilation, which is highly effective in PAH but may have controversial, potentially adverse effects in HF, including pre-LVAD implant due to device unmasking of PDE-5i-induced RV dysfunction. In contrast, retrospective analyses have demonstrated that PDE-5i have beneficial effects when initiated post LVAD implant due to the improved haemodynamics of the supported LV and the pleiotropic actions of these compounds. sGC stimulators, in turn, are effective both in PAH and in HF due to their balanced pulmonary and systemic vasodilation, and as such they are preferable to PDE-5i if the use of a pulmonary vasodilator is needed in HF patients, including those listed for LVAD implantation. Regarding the effectiveness of PDE-5i and sGC stimulators when initiated post LVAD implant, these two groups of compounds should be tested in a randomized control trial.
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