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Huang J, An Q, Shi H, Li C, Zhang W, Wang L. Retrospective cohort study of pulmonary arterial hypertension associated with connective tissue disease effect on patients' prognosis. Clin Rheumatol 2023; 42:3131-3142. [PMID: 37382842 DOI: 10.1007/s10067-023-06667-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE The objectives of this study are to clarify clinical characteristics and recognize prognostic factors of CTD-PAH patients. METHODS A retrospective cohort study of consecutive patients with documented CTD-PAH diagnosis from Jan 2014 to Dec 2019 was conducted, the ones who have other comorbid conditions that cause PH were excluded. Survival functions were plotted using the Kaplan-Meier method. Univariable and multivariable Cox regression analysis was applied to determine the survival-related factors. RESULTS In 144 patients with CTD-PAH analyzed, the median sPAP value was 52.5 (44.0, 71.0) mmHg, the overall targeted drug usage rate was 55.6%, and only 27.5% patients were given combination. Twenty-four non-PAH-CTD patients with sPAP value were included as the control group. Compared with non-PAH-CTD groups, CTD-PAH patients had worse cardiac function, higher NT-pro BNP and γ-globulin level, and lower PaCO2 level. Compared with the mild PAH group, the moderate-severe PAH group had worse cardiac function; increased Hb, HCT, and NP-pro BNP level; and decreased PaO2. Kaplan-Meier analysis showed significant difference for survival among non-PAH-CTD, mild CTD-PAH, and moderate-severe CTD-PAH groups. The univariate analyses showed that Hb, pH, and Ln (NT-pro BNP) were identified as factors significantly associated with survival, and Hb and pH showed significant association with risk of death in the multivariate model. Kaplan-Meier analysis also showed that Hb > 109.0 g/L and pH > 7.457 affected CTD-PAH patients' survival significantly. CONCLUSIONS PAH is not rare in CTDs patients; PAH affects CTD patients' prognosis significantly. Higher Hb and pH were associated with an increased risk of death. Key Points • Pulmonary arterial hypertension affects connective tissue disease patients' prognosis significantly. • The significantly factors associated with survival is hemoglobin, pH, and Ln (NT-pro BNP).
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Affiliation(s)
- Jing Huang
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Qi An
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Hongyang Shi
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Xibei Hospital), No.157, Xiwu Road, Xincheng District, Xi'an, 710004, People's Republic of China
| | - Cong Li
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Xibei Hospital), No.157, Xiwu Road, Xincheng District, Xi'an, 710004, People's Republic of China
| | - Wei Zhang
- Department of Emergency, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Lei Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Xibei Hospital), No.157, Xiwu Road, Xincheng District, Xi'an, 710004, People's Republic of China.
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Kularatne M, Boucly A, Savale L, Solinas S, Cheron C, Roche A, Jevnikar M, Jaïs X, Montani D, Humbert M, Sitbon O. Pharmacological management of connective tissue disease-associated pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:2101-2115. [PMID: 37869785 DOI: 10.1080/14656566.2023.2273395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, progressive pulmonary vasculopathy (Group 1 Pulmonary Hypertension (PH)) that complicates the course of many connective tissue diseases (CTD). Detailed testing is required to differentiate PAH from other types of PH caused by CTD such as left heart disease (Group 2 PH), pulmonary parenchymal disease (Group 3 PH), and chronic thromboembolic pulmonary hypertension (Group 4 PH). PAH is most frequently seen in systemic sclerosis but can also be seen with systemic lupus erythematosus, mixed CTD, and primary Sjogren's syndrome. AREAS COVERED This review discusses the epidemiology of CTD-associated PAH, outlines the complex diagnosis approach, and finishes with an in-depth discussion on the current treatment paradigm. Focus is placed on challenges faced in the treatment of CTD-associated PAH, (decreased efficacy and poorer tolerance of pharmacological therapies) and includes a discussion on the future investigational treatments. EXPERT OPINION Despite significant advances over the past decades with more aggressive treatment algorithms, CTD-associated PAH patients continue to have poorer survival compared to those with idiopathic PAH. This review highlights factors leading to disparate outcomes compared to other forms of PAH, and discusses on further improvements that may increase quality of life and survival for CTD-associated PAH patients.
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Affiliation(s)
- Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Céline Cheron
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Li M, Tian Z, Qian J, Huang C, Zhao J, Wang Q, Song Y, Tian X, Li M, Liu J, Zeng X. Impact of pregnancy in patients with systemic lupus erythematosus-associated pulmonary arterial hypertension: case series and literature review. Lupus Sci Med 2022; 9:9/1/e000636. [PMID: 35256456 PMCID: PMC8905977 DOI: 10.1136/lupus-2021-000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 11/22/2022]
Abstract
Objective This study aimed to investigate the clinical characteristics and outcomes of pregnancy complicated by SLE-associated pulmonary arterial hypertension (SLE-PAH) in a case series and literature review. Methods This single-centre retrospective study included 10 consecutive pregnancies complicated by SLE-PAH confirmed by right heart catheterisation (RHC) at Peking Union Medical College Hospital between 2009 and 2020. A literature search was conducted and 14 pregnancy cases complicated by SLE-PAH were reviewed. Results At the time of 10 patients’ initial visits, the average age was 30.00±5.72 years and the median disease duration of SLE and PAH was 34.5 (range 1–164) months and 2 (1–51) months. Two patients carried planned pregnancy, seven patients developed PAH during pregnancy and one pregnancy was unplanned. Further, nine patients had low disease activity, with Systemic Lupus Erythematosus Disease Activity Index between 0 and 4, and 30%, 30% and 40% of patients were of WHO functional class II, III and IV, respectively. All patients were evaluated by RHC and echocardiography. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were elevated in 70% of patients, with a median level of 776 (56–18 023) pg/mL. The median time of completed pregnancies in all patients was 31 (15–38) weeks and six patients delivered live infants. SLE activity and PAH severity improved in 70% of patients within 6 months after delivery. One patient died on the 15th day after induction of labour. In the remaining patients, all achieved a lupus low disease activity state; according to the European Society of Cardiology/European Respiratory Society risk stratification, seven were categorised at a lower risk state compared with their risk stratification during pregnancy, and two remained at intermediate risk. Additionally, 80% of patients exhibited mild impairments with WHO functional class I or II. The median NT-proBNP level was 184 (32–4003) pg/mL within 6 months after delivery. In the reviewed literature, the average age of patients was 30.09±5.37 years. The median time of completed pregnancies was 36 (28–40) weeks. More cases were planned and successful, and the survival rates of mothers and neonates were 85.71% and 92.86%, respectively. Conclusions Successful pregnancy could be possible in women with SLE-PAH if SLE-PAH treatment goals are achieved under proper therapies, careful monitoring and thorough evaluations.
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Affiliation(s)
- Mucong Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Junyan Qian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Can Huang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yijun Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Abstract
Contraindications to liver transplantation are gradually narrowing. Cardiac illness and chronic liver disease may manifest independently or may be superimposed on each other due to shared pathophysiology. Cardiac surgery involving the cardiopulmonary bypass in patients with Child-Pugh Class C liver disease is associated with a high risk of perioperative morbidity and mortality. Liver transplantation involves hemodynamic perturbations, volume shifts, coagulation abnormalities, electrolyte disturbances, and hypothermia, which may prove fatal in patients with cardiac illness depending upon the severity. Additionally, cardiovascular complications are the major cause of adverse postoperative outcomes after liver transplantation even in the absence of cardiac pathologies. Clinical decision-making has remained an unsettled issue in these clinical scenarios. The absence of randomized clinical studies has further crippled our endeavours for a consensus on the management of patients with end-stage liver disease with cardiac illness. This review seeks to address this complex clinical setting by gathering information from published literature. The management algorithm in this review may facilitate clinical decision making and augur future research.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Kirtania L, Maiti R, Srinivasan A, Mishra A. Effect of Combination Therapy of Endothelin Receptor Antagonist and Phosphodiesterase-5 Inhibitor on Clinical Outcome and Pulmonary Haemodynamics in Patients with Pulmonary Arterial Hypertension: A Meta-Analysis. Clin Drug Investig 2019; 39:1031-44. [PMID: 31420854 DOI: 10.1007/s40261-019-00841-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The combination of an endothelin receptor antagonist and a phosphodiesterase-5 inhibitor having different biological targets has become an integral part of the treatment of pulmonary arterial hypertension; however, several clinical studies have reported conflicting results. OBJECTIVE The objective of this meta-analysis was to evaluate the effect of an endothelin receptor antagonist and phosphodiesterase-5 inhibitor combination in pulmonary arterial hypertension. METHODS After performing a comprehensive literature search in MEDLINE, Cochrane and the International Clinical Trial Registry Platform, reviewers assessed eligibility and extracted data from seven relevant articles (publications till December 2018). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in the selection, analysis and reporting of findings. The odds ratio and mean difference were calculated to estimate the difference in clinical worsening, 6-minute walking distance, pulmonary vascular resistance and N-terminal pro-brain natriuretic peptide between the groups. Quality assessment was performed using the risk of bias assessment tool and a meta-regression for probable variables affecting effect size. RESULTS The random-effect model analysis revealed an odds ratio of 0.56 [95% confidence interval (CI) 0.41-0.76; p = 0.0002] for clinical worsening, mean difference of 15.64 (95% CI 2.67-28.61; p = 0.02) for 6-minute walking distance, - 1.66 (95% CI - 3.82 to 0.50; p = 0.13) for pulmonary vascular resistance and - 21.04 (95% CI - 26.87 to - 15.22; p < 0.00001) for N-terminal pro-brain natriuretic peptide. The meta-regression showed no statistically significant association between the dose and duration of treatment and outcomes (odds ratio of clinical worsening and mean difference of 6-minute walking distance). CONCLUSIONS In pulmonary arterial hypertension, endothelin receptor antagonist and phosphodiesterase-5 inhibitor combination therapy significantly improved 6-minute walking distance, clinical worsening and N-terminal pro-brain natriuretic peptide compared with the monotherapy but did not offer any advantage in improving pulmonary vascular resistance. PROSPERO REGISTRATION NO CRD42018091133.
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Lei Y, Zhang X, Lin H, Feng Y, Wang J, Luo R. The effects of oral treatment for systemic sclerosis related pulmonary arterial hypertension: A systematic review and meta-analysis. Mod Rheumatol 2020; 31:151-161. [PMID: 31829087 DOI: 10.1080/14397595.2019.1704125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The usage of oral therapies, endothelin receptor antagonists (ERAs), phosphodiesterase type-5 (PDE-5) inhibitors and prostaglandin analogs has resulted in improved outcomes in patients with pulmonary arterial hypertension related to systemic sclerosis (SSc-PAH). However, the optimal therapeutics have not been determined. METHODS A systematic searching in the databases of Medline (PubMed), Embase, the Cochrane Library (Central) and unpublished clinical trials (clinicaltrials.gov) was conducted to identify the clinical studies with oral treatment for SSc-PAH patients published before 1 June 2019. The data were extracted and the quality was assessed. The main outcomes are exercise capacity and hemodynamic parameters, which were synthesized and analyzed. RESULTS In total, 27 clinical trials were enrolled for further analysis. It was demonstrated that bosentan treatment, the widely used drug for PAH, might improve the exercise capacity and pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) in this clinical setting, although without significant difference. Meanwhile, the usage of prostaglandin analogs could improve the parameters mentioned above. Furthermore, combined therapy with ambrisentan and tadalafil significantly increased the treatment efficacy of key parameters in SSc-PAH patients compared with basic treatment. CONCLUSION This meta-analysis reveals that combination therapy might provide more benefits to exercise capacity and hemodynamic parameters in SSc-PAH patients. Still more RCTs are needed to provide more solid evidence.
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Affiliation(s)
- Yunxia Lei
- Southern Medical University, Guangzhou, China.,Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiao Zhang
- Southern Medical University, Guangzhou, China.,Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haobo Lin
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuan Feng
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jieying Wang
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Riqiang Luo
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
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Saygin D, Domsic RT. Pulmonary Arterial Hypertension In Systemic Sclerosis: Challenges In Diagnosis, Screening And Treatment. Open Access Rheumatol 2019; 11:323-333. [PMID: 31920409 PMCID: PMC6939800 DOI: 10.2147/oarrr.s228234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/15/2019] [Indexed: 12/31/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem autoimmune disease characterized by vasculopathy, fibrosis and immune system activation. Pulmonary hypertension and interstitial lung disease account for majority of SSc-related deaths. Diagnosis of SSc-PAH can be challenging due to nonspecific clinical presentation which can lead to delayed diagnosis. Many screening algorithms have been developed to detect SSc-associated pulmonary arterial hypertension (SSc-PAH) in early stages. Currently used PAH-specific medications are largely extrapolated from IPAH studies due to smaller number of patients with SSc-PAH. In this review, we discuss the current state of knowledge in epidemiology and risk factors for development of SSc-PAH, and challenges and potential solutions in the diagnosis, screening and management of SSc-PAH.
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Affiliation(s)
- Didem Saygin
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Abstract
Pulmonary hypertension is a life-threatening illness with debilitating physical and emotional consequences. The progression of this devastating disease is characterized by a continuous increase in pulmonary vascular resistance, which results in elevated pulmonary artery pressure and leads to right heart failure. Treatment is focused on targeting the underlying complex etiology via the endothelin, prostacyclin, and nitric oxide (NO) pathways. Emergence of new treatments over the past 2 decades has led to improvement in the functional status and time to clinical worsening. Even with recent advances, outcomes remain suboptimal. Phosphodiesterase-5 (PDE-5) inhibitors, such as sildenafil, were approved for treatment of pulmonary arterial hypertension (PAH) by the Food and Drug Administration (FDA) in 2005, which holds promise in improving quality of life and therefore making this class of medications effective palliative therapy agents. In this review, we summarize the emergence of sildenafil as a treatment for PAH and its role as palliative therapy.
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Huang WC, Hsu CH, Sung SH, Ho WJ, Chu CY, Chang CP, Chiu YW, Wu CH, Chang WT, Lin L, Lin SL, Cheng CC, Wu YJ, Wu SH, Hsieh TY, Hsu HH, Fu M, Dai ZK, Kuo PH, Hwang JJ, Cheng SM. 2018 TSOC guideline focused update on diagnosis and treatment of pulmonary arterial hypertension. J Formos Med Assoc 2019; 118:1584-1609. [PMID: 30926248 DOI: 10.1016/j.jfma.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsin Hsu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shih-Hsien Sung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Jing Ho
- Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Ping Chang
- Division of Cardiology, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Wei Chiu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chun-Hsien Wu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ting Chang
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan City, Taiwan
| | - Lin Lin
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Shoa-Lin Lin
- Department of Internal Medicine, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan; Pulmonary Hypertension Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Shu-Hao Wu
- Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Tsu-Yi Hsieh
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Morgan Fu
- Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Zen-Kong Dai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan.
| | - Shu-Meng Cheng
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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10
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Al Otair HA, Idrees MM, Saleemi SA, Eltoukhy AM, Alhijji AA, Al Habeeb WA, Omair MA. Pulmonary arterial hypertension in Saudi patients with systemic sclerosis: Clinical and hemodynamic characteristics and mortality. Ann Thorac Med 2019; 14:83-89. [PMID: 30745940 PMCID: PMC6341865 DOI: 10.4103/atm.atm_33_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a major cause of morbidity and mortality in patients with systemic sclerosis (SSc). The objective of this study is to describe the clinical characteristics, mortality, and predictors of SSc-PAH in Saudi patients. METHODS Retrospective chart review study of SSc patients who were followed for at least 1 year in three tertiary care centers in Saudi Arabia was conducted. Clinical information, echocardiographic findings, and right heart catheterization (RHC) results were collected. Descriptive statistics were used for demographic and disease characteristics. RESULTS Fifty-seven patients with SSc were reviewed. PAH was confirmed by RHC in 40 patients (87.5%, females). Their mean age was 45.43 ± 13.48 years. The mean pulmonary artery pressure was 42.9 ± 12.7 mmHg, the pulmonary vascular resistance index was 19.4 ± 7.7 woods unit, and cardiac index was 2.43 ± 0.68 min/m2. The median time from symptoms to first assessment was 42.8 ± 115.62 months. Most patients (77.5%) presented with functional Class III or IV and more than half (22.55%) were on dual combination therapy. Ten patients (25%) SSc PAH died over a follow up period of 37 ± 7 months. Compared to SSc patients without PAH, SSc-PAH patients had shorter 6-min walk distance (6MWD) (296.1 ± 116.5 vs. 399.59 ± 40.60 m, P < 0.0001), higher pro-brain natriuretic peptide (1755.8 ± 2123.4 vs. 69.8 ± 44.3 pg/ml P = 0.004), and more frequent Raynaud's phenomenon (RP) (90% vs. 35%, P < 0.0001). Logistic regression showed RP (odds ratio [OR] =48.58, 95% confidence interval [CI]; 3.73-633.10) and 6MWD (OR 1.02: 95% CI; 1.01-1.03) were associated with the development of PAH. CONCLUSION Our cohort of Saudi SSc-PAH patients has a younger disease onset and a lower mortality than what is described worldwide despite late presentation and requirement of combination therapy. The presence of RP and lower were associated with the development of SSc-PAH.
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Affiliation(s)
- Hadil Ak Al Otair
- Department of Critical Care, King Saud University, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Department of Medicine, Division of Pulmonology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sarfraz A Saleemi
- Department of Medicine, Division of Pulmonology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed M Eltoukhy
- Department of Critical Care, King Saud University, Riyadh, Saudi Arabia
| | - Ali A Alhijji
- Department of Medicine, Division of Rheumatology, King Saud University, Riyadh, Saudi Arabia
| | | | - Mohammed A Omair
- Department of Medicine, Division of Rheumatology, King Saud University, Riyadh, Saudi Arabia
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11
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Abstract
Definition and classification: Pulmonary hypertension (PH) is a group of life-threatening progressive diseases of various genesis, characterized by a progressive increase in arterial pressure (AP) in the pulmonary artery (PA), the remodeling of pulmonary vessels, which leads to an increase in pulmonary vascular resistance and pulmonary arterial pressure and more often leads to right ventricular heart failure and premature death. Pulmonary hypertension is clinically divided into five groups: patients in the first group have idiopathic pulmonary arterial hypertension (IPAH), whereas in patients of other groups secondary PH associated with cardiopulmonary or other systemic diseases is observed. The development of secondary LH is caused by congenital heart defects, collagenoses, presence of thrombus in the pulmonary artery, prolonged high pressure in the left atrium, hypoxemia, chronic obstructive pulmonary diseases (COPDs). In case of secondary PH, thrombosis and other changes in the pulmonary veins occur.
Ways of pharmacological correction of pulmonary hypertension: Over the last decade pharmacotherapy of PH has been developing rapidly, and the introduction of modern methods of treatment, especially for primary PAH, has led to positive results. However, despite the progress in treatment, the functional limitations and survival of patients remain unsatisfactory. Currently, there are two levels of treatment for pulmonary hypertension: primary and specific pathogenetic therapies. Primary therapy is aimed at the main cause of PH. It also includes supportive therapy. Pathogenetic therapy includes prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors. Tactics of therapy can be established on the basis of either clinical classification, or functional class. Prostanoids are a promising group of drugs for the treatment of pulmonary arterial hypertension (PAH), since they possess not only vasodilating, but also antiplatelet and antiproliferative actions. Therefore, it seems logical to use prostacyclin and its analogs to treat patients with various forms of PAH.
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12
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Miklashevich IM, Shkolnikova МA, Gorbachevsky SV, Shmalts AA, Groznova ОS, Sadykova DI, Yakovleva LV, Degtyarev DN, Burov AA, Ovsyannikov DY, Volkov AV. CONTEMPORARY STRATEGY OF PULMONARY HYPERTENSION MANAGEMENT IN PEDIATRICS. Cardiovasc Ther Prev 2018. [DOI: 10.15829/1728-8800-2018-2-101-124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pulmonary hypertension (PH) in pediatrics is a polygenic multifactorial condition with extremely adverse prognosis. Selection of optimal management is a severe task. In absence of treatment the mean life duration in children is not higher one year. Last two decades, revolution in approaches to treatment improved the survival of this patients group. Recently, pediatricians and pediatric cardiologists have three drugs groups that act on the main pathogenetic chains of PH: endothelin pathway, nitric oxide pathway and prostacyclin pathway. At the moment, approaches to pediatric PH are based on the data obtained in the trials on adult patients. However, not long ago there were first randomized trials on children performed. The group of authors of current article presents a modern view on the problem of PH in children, and expert recommendations on children management. Class of recommendations and evidence level were set by the data obtained in pediatric population or on adult population with at least 10% of children included. To the strategy, developed by the Russian clinicians, laid the analysis of experience of the pathology treatment in Russian Federation, as the current practics and clinical guidelines on pediatric PH in Europe, and the recent trials published.
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Affiliation(s)
- I. M. Miklashevich
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | - М. A. Shkolnikova
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | | | | | - О. S. Groznova
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | | | | | - D. N. Degtyarev
- Kulakov Scientific Center of Obstetrics, Gynecology and Perinatology
| | - A. A. Burov
- Kulakov Scientific Center of Obstetrics, Gynecology and Perinatology
| | | | - A. V. Volkov
- Nasonova ScientificResearch Center of Rheumatology
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13
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Valieva ZS, Martynyuk TV, Chazova IE. [Bosentan use in pulmonary arterial hypertension: Russian and foreign experience]. TERAPEVT ARKH 2017; 89:95-103. [PMID: 28914858 DOI: 10.17116/terarkh201789895-103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The results of evaluating the efficacy and safety of bosentan in patients with pulmonary arterial hypertension (PAH), as shown by the data of foreign randomized controlled trials and the authors' own experience, convincingly demonstrate that the introduction of the drug into clinical practice has led to a significant improvement of the possibilities of drug therapy in patients with this serious illness. Bosentan substantially improves physical activity in patients, reduces the severity of clinical symptoms, slows down the rates of disease progression, and prolongs survival in patients with different forms of PAH.
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Affiliation(s)
- Z S Valieva
- Russian Cardiology Research and Production Complex, Ministry of Health of Russia, Moscow
| | - T V Martynyuk
- Russian Cardiology Research and Production Complex, Ministry of Health of Russia, Moscow
| | - I E Chazova
- Russian Cardiology Research and Production Complex, Ministry of Health of Russia, Moscow
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14
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Vizza CD, Jansa P, Teal S, Dombi T, Zhou D. Sildenafil dosed concomitantly with bosentan for adult pulmonary arterial hypertension in a randomized controlled trial. BMC Cardiovasc Disord 2017; 17:239. [PMID: 28874133 DOI: 10.1186/s12872-017-0674-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 08/29/2017] [Indexed: 01/24/2023] Open
Abstract
Background Few controlled clinical trials exist to support oral combination therapy in pulmonary arterial hypertension (PAH). Methods Patients with PAH (idiopathic [IPAH] or associated with connective tissue disease [APAH-CTD]) taking bosentan (62.5 or 125 mg twice daily at a stable dose for ≥3 months) were randomized (1:1) to sildenafil (20 mg, 3 times daily; n = 50) or placebo (n = 53). The primary endpoint was change from baseline in 6-min walk distance (6MWD) at week 12, assessed using analysis of covariance. Patients could continue in a 52-week extension study. An analysis of covariance main-effects model was used, which included categorical terms for treatment, baseline 6MWD (<325 m; ≥325 m), and baseline aetiology; sensitivity analyses were subsequently performed. Results In sildenafil versus placebo arms, week-12 6MWD increases were similar (least squares mean difference [sildenafil–placebo], −2.4 m [90% CI: –21.8 to 17.1 m]; P = 0.6); mean ± SD changes from baseline were 26.4 ± 45.7 versus 11.8 ± 57.4 m, respectively, in IPAH (65% of population) and −18.3 ± 82.0 versus 17.5 ± 59.1 m in APAH-CTD (35% of population). One-year survival was 96%; patients maintained modest 6MWD improvements. Changes in WHO functional class and Borg dyspnoea score and incidence of clinical worsening did not differ. Headache, diarrhoea, and flushing were more common with sildenafil. Conclusions Sildenafil, in addition to stable (≥3 months) bosentan therapy, had no benefit over placebo for 12-week change from baseline in 6MWD. The influence of PAH aetiology warrants future study. Trial registration ClinicalTrials.gov NCT00323297 (registration date: May 5, 2006). Electronic supplementary material The online version of this article (10.1186/s12872-017-0674-3) contains supplementary material, which is available to authorized users.
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15
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Gaine S, Chin K, Coghlan G, Channick R, Di Scala L, Galiè N, Ghofrani HA, Lang IM, McLaughlin V, Preiss R, Rubin LJ, Simonneau G, Sitbon O, Tapson VF, Hoeper MM. Selexipag for the treatment of connective tissue disease-associated pulmonary arterial hypertension. Eur Respir J 2017; 50:50/2/1602493. [PMID: 28818881 PMCID: PMC5593379 DOI: 10.1183/13993003.02493-2016] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 05/10/2017] [Indexed: 12/03/2022]
Abstract
Patients with connective tissue disease-associated pulmonary arterial hypertension (PAH-CTD) have a poor prognosis compared with other aetiologies. The underlying CTD can influence treatment response and outcomes. We characterised the GRIPHON study PAH-CTD subgroup and evaluated response to selexipag. Of 334 patients with PAH-CTD, PAH was associated with systemic sclerosis (PAH-SSc) in 170, systemic lupus erythematosus (PAH-SLE) in 82 and mixed CTD/CTD-other in 82. For the primary composite endpoint of morbidity/mortality, hazard ratios (HR) and 95% CI were calculated using Cox proportional hazard models. Compared with the overall GRIPHON population, the CTD subgroup was slightly older with a greater proportion of females and shorter time since diagnosis. Patients with PAH-SSc appeared to be more impaired at baseline, with a more progressive disease course. The converse was observed for PAH-SLE. Selexipag reduced the risk of composite morbidity/mortality events in patients with PAH-CTD by 41% (HR 0.59; 95% CI 0.41–0.85). Treatment effect was consistent irrespective of baseline PAH therapy or CTD subtype (interaction p=0.87 and 0.89, respectively). Adverse events were predominately prostacyclin-related and known for selexipag treatment. GRIPHON has allowed the comprehensive characterisation of patients with PAH-CTD. Selexipag delayed progression of PAH and was well-tolerated among PAH-CTD patients, including those with PAH-SSc and PAH-SLE. Selexipag delays disease progression and is well tolerated in PAH-CTD, irrespective of subtype or other PAH therapyhttp://ow.ly/SvIV30cqo9J
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Affiliation(s)
- Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kelly Chin
- University of Texas Southwestern, Medical Centre, Dallas, TX, USA
| | | | - Richard Channick
- Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nazzareno Galiè
- Dept of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University Hospital, Bologna, Italy
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany.,German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Irene M Lang
- Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | - Vallerie McLaughlin
- Dept of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ralph Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Lewis J Rubin
- Dept of Medicine, University of California, San Diego, CA, USA
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin-Bicêtre, France.,INSERM U-999, Centre chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin-Bicêtre, France.,INSERM U-999, Centre chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | | | - Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research, Hannover, Germany
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16
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Rivera-Lebron BN, Risbano MG. Ambrisentan: a review of its use in pulmonary arterial hypertension. Ther Adv Respir Dis 2017; 11:233-244. [PMID: 28425346 PMCID: PMC5933647 DOI: 10.1177/1753465817696040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease defined by an elevation in pulmonary arterial pressure that can lead to right heart failure and death. Ambrisentan is a selective endothelin receptor antagonist approved for the treatment of idiopathic, heritable PAH and connective tissue disease-associated PAH. Ambrisentan has been shown to improve exercise capacity and hemodynamics with an acceptable side-effect profile. It has also proven to be safely used in combination with other PAH-specific medications, especially with phosphodiesterase-5 inhibitors. In the recent randomized trial, AMBITION, it was shown that upfront combination therapy of ambrisentan and tadalafil significantly decreased the risk of clinical failure compared with monotherapy. This review describes the drug profile of ambrisentan and its safety and efficacy in the treatment of PAH.
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Affiliation(s)
- Belinda N. Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael G. Risbano
- Division of Pulmonary, Allergy and Critical Care Medicine, Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh Medical Center, 3459 Fifth Avenue, Montefiore Hospital, NW 628, Pittsburgh, PA 15213, USA
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17
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Nowicka D. Thermography Improves Clinical Assessment in Patients with Systemic Sclerosis Treated with Ozone Therapy. Biomed Res Int 2017; 2017:5842723. [PMID: 28349063 PMCID: PMC5352863 DOI: 10.1155/2017/5842723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/05/2016] [Accepted: 01/16/2017] [Indexed: 12/02/2022]
Abstract
Objective. Treatment of scleroderma is challenging and limited. The aim of our study was to evaluate the usefulness of thermography in assessment of the clinical condition (joints movability and skin thickness) in clinically advanced patients with systemic sclerosis before and after ozone therapy. Method. The study included 42 patients aged 32 to 73 years with advanced systemic sclerosis hospitalized in the university clinic between 2003 and 2006. Thermography and clinical examinations were conducted at baseline and after two series of bath in water with ozone. Results. The comparison of results showed significant increase in skin temperature by 2.5°C, significant increase in interphalangeal joints movability by 18 degrees, and significant decrease in skin score by 14.7 points. The skin temperature was correlated with skin score (r = -0.59) and joints movability (r = +0.8). Conclusions. Ozone therapy shows positive effect on clinical parameters and skin temperature as measured with thermography. The study indicated possibility of introducing ozonotherapy as an independent therapy in cases with low level of progression or during remission periods and as additional treatment in patients with advanced disease requiring immunosuppressive treatment. Thermography is useful in assessment of skin condition showing strong correlation between skin temperature and clinical parameters.
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Affiliation(s)
- Danuta Nowicka
- Department of Dermatology, Venereology and Allergology, Wrocław Medical University, Wrocław, Poland
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18
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Abstract
Pulmonary arterial hypertension (PAH) is an uncommon, progressive and life
threatening disease characterized by a proliferative vasculopathy of the small
muscular pulmonary arterioles resulting in elevated pulmonary vascular
resistance and eventually right ventricular failure. An increasing understanding
of the pathobiology of PAH and its natural history has led to the development of
numerous targeted therapies. Despite these advances there is significant
progression of disease and the survival rate remains low. This article reviews
the agents currently available for the medical management of PAH.
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Affiliation(s)
- Stella S Hahn
- Northwell Health Division of Pulmonary Critical Care and Sleep Medicine, 410 Lakeville Road, Suite 107, New Hyde Park, NY 11042, USA
| | - Mina Makaryus
- Northwell Health Division of Pulmonary Critical Care and Sleep Medicine, 410 Lakeville Road, Suite 107, New Hyde Park, NY 11042, USA
| | - Arunabh Talwar
- Northwell Health Division of Pulmonary Critical Care and Sleep Medicine, 410 Lakeville Road, Suite 107, New Hyde Park, NY 11042, USA
| | - Mangala Narasimhan
- Northwell Health Division of Pulmonary Critical Care and Sleep Medicine, 410 Lakeville Road, Suite 107, New Hyde Park, NY 11042, USA
| | - Gulrukh Zaidi
- Northwell Health Division of Pulmonary Critical Care and Sleep Medicine, 410 Lakeville Road, Suite 107, New Hyde Park, NY 11042, USA
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19
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Tang CP, Lee KL, Ying KY. Review of the diagnosis and pharmacological management of pulmonary arterial hypertension in connective tissue disease. Hong Kong Bulletin on Rheumatic Diseases 2016. [DOI: 10.1515/hkbrd-2016-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Connective-tissue-disease-associated pulmonary arterial hypertension (CTD-PAH) is a well-recognised pulmonary complication most commonly seen in patients with systemic sclerosis, followed by systemic lupus erythematosus and mixed connective tissue disease. In systemic-sclerosis-associated-pulmonary arterial hypertension (SSc-PAH), patients usually present late and the progression can be rapid with poor prognosis and survival. Early detection and prompt intervention of SSc-PAH is an important cornerstone to halt the disease progression. Various pulmonary vasodilatory agents were developed over the past two decades. They were shown to improve patients’ symptoms, functional status, exercise capacity, haemodynamics and long-term survival. Other immunosuppressive therapies also demonstrated to improve symptoms and functional status in certain group of patients. This article is to review the diagnosis and pharmacological management of patient with CTD-PAH.
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Affiliation(s)
- Chun-Pong Tang
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Ka-Lai Lee
- Consultant, Department of Medicine, Princess Margaret Hospital, Hong Kong
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20
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Vandecasteele E, De Pauw M, De Keyser F, Decuman S, Deschepper E, Piette Y, Brusselle G, Smith V. Six-minute walk test in systemic sclerosis: A systematic review and meta-analysis. Int J Cardiol 2016; 212:265-73. [DOI: 10.1016/j.ijcard.2016.03.084] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/19/2016] [Indexed: 01/17/2023]
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21
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Hakamata A, Odagiri K, Miyakawa S, Irisawa H, Takeuchi K, Inui N, Tanaka S, Uchida S, Watanabe H. Pharmacokinetic and Pharmacodynamic Comparison of Sildenafil-Bosentan and Sildenafil-Ambrisentan Combination Therapies for Pulmonary Hypertension. Clin Transl Sci 2016; 9:29-35. [PMID: 26756977 PMCID: PMC5351320 DOI: 10.1111/cts.12382] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/20/2015] [Indexed: 11/30/2022] Open
Abstract
To elucidate whether the pharmacokinetics (PK) and pharmacodynamics (PD) of sildenafil are influenced differently when it is coadministered with bosentan (S+B) or with ambrisentan (S+A), we evaluated the PK and PD profiles of sildenafil before and after 4-5 weeks of S+A or S+B treatment in patients with pulmonary arterial hypertension. The area under the plasma concentration-time curve of sildenafil was significantly higher in S+A treatment than in S+B treatment (165.8 ng•h/mL vs. 396.8 ng•h/mL, P = 0.018) and the oral clearance of sildenafil was significantly lower after S+A treatment than after S+B treatment (120.6 L/h/kg vs. 50.4 L/h/kg, P = 0.018). In the PD study, incremental shuttle walking distance was superior during treatment with S+A than during treatment with S+B (S+B; 280 m vs. S+A; 340 m, P = 0.042). There were no concerns about safety with either combination therapy regime.
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Affiliation(s)
- A Hakamata
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - K Odagiri
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - S Miyakawa
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - H Irisawa
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - K Takeuchi
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - N Inui
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
| | - S Tanaka
- Department of Pharmacy Practice and ScienceSchool of Pharmaceutical ScienceUniversity of ShizuokaShizuokaJapan
| | - S Uchida
- Department of Pharmacy Practice and ScienceSchool of Pharmaceutical ScienceUniversity of ShizuokaShizuokaJapan
| | - H Watanabe
- Department of Clinical Pharmacology and TherapeuticsHamamatsu University School of MedicineHamamatsuJapan
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22
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Gall H, Sommer N, Milger K, Richter MJ, Voswinckel R, Bandorski D, Seeger W, Grimminger F, Ghofrani HA. Survival with sildenafil and inhaled iloprost in a cohort with pulmonary hypertension: an observational study. BMC Pulm Med 2016; 16:5. [PMID: 26753921 PMCID: PMC4709958 DOI: 10.1186/s12890-015-0164-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/22/2015] [Indexed: 11/18/2022] Open
Abstract
Background Combination therapy is frequently used to treat patients with pulmonary hypertension but few studies have compared treatment regimens. This study examined the long-term effect of different combination regimens of inhaled iloprost and oral sildenafil on survival and disease progression. Methods This was a retrospective study of patients in the Giessen Pulmonary Hypertension Registry who received iloprost monotherapy followed by addition of sildenafil (iloprost/sildenafil), sildenafil monotherapy followed by addition of iloprost (sildenafil/iloprost), or upfront combination therapy (iloprost + sildenafil). The primary outcome was transplant-free survival (Kaplan–Meier analysis). When available, haemodynamic parameters and 6-minute-walk distance were evaluated. Results Overall, 148 patients were included. Baseline characteristics were similar across treatment groups; however, the iloprost + sildenafil cohort had higher mean pulmonary vascular resistance and pulmonary arterial pressure than the others. Transplant-free survival differed significantly between groups (P = 0.007, log-rank test). Cumulative transplant-free survival was highest for patients who received iloprost/sildenafil (1 year survival: iloprost/sildenafil, 95.1 %; sildenafil/iloprost, 91.8 %; iloprost + sildenafil, 62.9 %); this group also remained on monotherapy significantly longer than the sildenafil/iloprost group (median 17.0 months vs 7.0 months, respectively; P = 0.004). Compared with pre-treatment values, mean 6-minute-walk distance increased significantly for all groups 3 months after beginning combination therapy. Conclusions In this observational study of patients with pulmonary hypertension receiving combination therapy with iloprost and sildenafil, cumulative transplant-free survival was highest in those who received iloprost monotherapy initially. However, owing to the size and retrospective design of this study, further research is needed before making firm treatment recommendations. Electronic supplementary material The online version of this article (doi:10.1186/s12890-015-0164-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henning Gall
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany.
| | - Natascha Sommer
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany.
| | - Katrin Milger
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany. .,Medical Clinic V, University of Munich, Comprehensive Pneumology Center, Munich, Germany.
| | - Manuel J Richter
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany.
| | - Robert Voswinckel
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany. .,Department of Internal Medicine, Friedberg Hospital, Friedberg, Germany.
| | - Dirk Bandorski
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany.
| | - Werner Seeger
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany. .,Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany.
| | - Friedrich Grimminger
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany.
| | - Hossein-Ardeschir Ghofrani
- Universities of Giessen & Marburg Lung Center, Medizinische Klinik II, Klinikstraße 33, 35392, Giessen, Germany. .,Faculty of Medicine, Imperial College London, London, UK.
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Abstract
Pulmonary arterial hypertension (PAH) is a rare medical condition that significantly shortens life expectancy. The lack of understanding and complexity of treatments frequently lead to delays in diagnosis and treatment of patients. This is worsened by the gap in medical education related to the rarity of disease and the subspecialty nature of management. Advancements in diagnostics and treatment in recent years makes a review of this nature important and timely. Understanding the specialty nature of drug therapy, the complexities of managing prostacyclin analogs, and treatment algorithms are essential for pharmacists caring for these patients in both acute and ambulatory settings. This review article will provide an overview of published guidelines as well as discuss new therapies, clinical controversies, and the pharmacist’s role in the management of these patients.
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Affiliation(s)
- Tracy E. Macaulay
- UK HealthCare Pharmacy Services, Lexington, KY, USA
- Gill Heart Institute, UKHealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington, KY, USA
| | | | - Kristen T. Pogue
- Department of Pharmacy, University of Michigan Health System, Victor Vaughan Bldg, Ann Arbor, MI, USA
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24
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Thom HH, Capkun G, Cerulli A, Nixon RM, Howard LS. Network meta-analysis combining individual patient and aggregate data from a mixture of study designs with an application to pulmonary arterial hypertension. BMC Med Res Methodol 2015; 15:34. [PMID: 25887646 DOI: 10.1186/s12874-015-0007-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 05/27/2014] [Accepted: 02/16/2015] [Indexed: 11/10/2022] Open
Abstract
Background Network meta-analysis (NMA) is a methodology for indirectly comparing, and strengthening direct comparisons of two or more treatments for the management of disease by combining evidence from multiple studies. It is sometimes not possible to perform treatment comparisons as evidence networks restricted to randomized controlled trials (RCTs) may be disconnected. We propose a Bayesian NMA model that allows to include single-arm, before-and-after, observational studies to complete these disconnected networks. We illustrate the method with an indirect comparison of treatments for pulmonary arterial hypertension (PAH). Methods Our method uses a random effects model for placebo improvements to include single-arm observational studies into a general NMA. Building on recent research for binary outcomes, we develop a covariate-adjusted continuous-outcome NMA model that combines individual patient data (IPD) and aggregate data from two-arm RCTs with the single-arm observational studies. We apply this model to a complex comparison of therapies for PAH combining IPD from a phase-III RCT of imatinib as add-on therapy for PAH and aggregate data from RCTs and single-arm observational studies, both identified by a systematic review. Results Through the inclusion of observational studies, our method allowed the comparison of imatinib as add-on therapy for PAH with other treatments. This comparison had not been previously possible due to the limited RCT evidence available. However, the credible intervals of our posterior estimates were wide so the overall results were inconclusive. The comparison should be treated as exploratory and should not be used to guide clinical practice. Conclusions Our method for the inclusion of single-arm observational studies allows the performance of indirect comparisons that had previously not been possible due to incomplete networks composed solely of available RCTs. We also built on many recent innovations to enable researchers to use both aggregate data and IPD. This method could be used in similar situations where treatment comparisons have not been possible due to restrictions to RCT evidence and where a mixture of aggregate data and IPD are available. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0007-0) contains supplementary material, which is available to authorized users.
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25
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Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease with high rates of morbidity and mortality. Current therapies improve symptoms, functional capacity, and, in select cases, survival. Little is known about patient factors that may predict the likelihood of patient-important, clinically relevant responses to therapy such as the 6-min walk distance (6MWD) and health-related quality of life (HRQoL). METHODS Data from the randomized clinical trial of tadalafil in PAH were used. Adjusted logistic regression models were created to examine the relationship between baseline characteristics and odds of achieving the minimal important difference (MID) in three parameters, defined as either a > 33-m increase in 6MWD, a > 5-unit increase in physical component summary score of the Medical Outcomes Study Short Form-36 (SF-36), or a > 5-unit increase in mental component summary score of the SF-36. RESULTS The study included 405 subjects. Younger age, male sex, lower baseline 6MWD, and disease etiology were associated with greater odds of achieving the MID for the 6-min walk test. Active treatment, younger age, and male sex were associated with greater odds of achieving the MID for the physical component summary score. Male sex was associated with greater odds of achieving the MID for the mental component summary score. CONCLUSIONS Age, sex, baseline functional capacity, and disease etiology are variably associated with the likelihood of achieving clinically relevant responses in patient-important outcomes to PAH-specific therapy such as 6MWD and HRQoL. The increased likelihood of response in men compared with women is a novel finding and may reflect pathophysiologic differences between sexes.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine (Drs Mathai, Hassoun, and Wise), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine (Drs Mathai, Hassoun, and Wise), Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Milo A Puhan
- Division of Pulmonary and Critical Care Medicine (Drs Mathai, Hassoun, and Wise), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yi Zhou
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Robert A Wise
- Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and United Therapeutics Corporation, Research Triangle Park, NC
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26
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Butrous G. The role of phosphodiesterase inhibitors in the management of pulmonary vascular diseases. Glob Cardiol Sci Pract 2014; 2014:257-90. [PMID: 25780785 PMCID: PMC4352681 DOI: 10.5339/gcsp.2014.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 09/11/2014] [Indexed: 01/07/2023] Open
Abstract
Phosphodiesterase inhibitors (PDE) can be used as therapeutic agents for various diseases such as dementia, depression, schizophrenia and erectile dysfunction in men, as well as congestive heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, other inflammatory diseases, diabetes and various other conditions. In this review we will concentrate on one type of PDE, mainly PDE5 and its role in pulmonary vascular diseases.
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27
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Gashouta MA, Humbert M, Hassoun PM. Update in systemic sclerosis-associated pulmonary arterial hypertension. Presse Med 2014; 43:e293-304. [DOI: 10.1016/j.lpm.2014.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 01/08/2023] Open
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Boueiz A, Hassoun PM. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pulmonary arterial hypertension associated with connective tissue diseases. Ann Thorac Med 2014; 9:S26-37. [PMID: 25076994 PMCID: PMC4114266 DOI: 10.4103/1817-1737.134016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 12/22/2022] Open
Abstract
The explosive growth of medical literature on pulmonary hypertension (PH) has led to a steady increase in awareness of this disease within the medical community during the past decade. The recent revision of the classification of PH is presented in in the main guidelines. Group 1 PH or pulmonary arterial hypertension (PAH) is a heterogeneous group and includes PH due to inheritable, drug-induced, and toxin-induced causes and to such underlying systemic causes as connective tissue diseases, human immunodeficiency viral infection, portal hypertension, congenital heart disease, and schistosomiasis. Systemic sclerosis (SSc) is an autoimmune multisystem disorder, which affects over 240 persons per million in the United States.[1] Its manifestations are not confined to the skin but may also involve the lungs, kidneys, peripheral circulation, musculoskeletal system, gastrointestinal tract, and heart. The outcome of PAH associated with SSc is worse when compared to other subtypes of PAH. In this review, we summarize available information about the pulmonary vascular and cardiac manifestations of SSc with special emphasis on their prognostic implications as well as the peculiarity of their detection.
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Affiliation(s)
- Adel Boueiz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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29
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Idrees MM, Swiston J, Nizami I, Al Dalaan A, Levy RD. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Medical and surgical management for pulmonary arterial hypertension. Ann Thorac Med 2014; 9:S79-91. [PMID: 25077002 PMCID: PMC4114282 DOI: 10.4103/1817-1737.134043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 01/14/2023] Open
Abstract
Prior to the availability of the pulmonary arterial hypertension (PAH)-specific therapy, PAH was a dreadful disease with a very poor prognosis. Better understanding of the complex pathobiology of PAH has led to a major therapeutic evolution. International regulatory agencies have approved many specific drugs with different pharmacologic pathways and routes of administration. In the year 2013, two new drugs with great potentials in managing PAH have been added to the treatment options, macitentan and riociguat. Additional drugs are expected to come in the near future. A substantial body of evidence has confirmed the effectiveness of pulmonary arterial hypertension (PAH)-specific therapies in improving the patients’ symptomatic status and slowing down the rate of clinical deterioration. Although the newer modern medications have significantly improved the survival of patients with PAH, it remains a non-curable and fatal disease. Lung transplantation (LT) remains the only therapeutic option for selected patients with advanced disease who continue to deteriorate despite optimal therapy.
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Affiliation(s)
- Majdy M Idrees
- Pulmonary Medicine, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - John Swiston
- Pulmonary Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Imran Nizami
- Department of Organs Transplant, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Abdullah Al Dalaan
- Pulmonary Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert D Levy
- Pulmonary Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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30
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Abstract
Pulmonary arterial hypertension (PAH) is a severe and progressive intrinsic disease of the precapillary lung vasculature. Since the introduction of PAH-targeted drugs, survival of PAH patients seems to have improved. Randomized controlled trials have led to evidence-based guidelines to direct treatment in adults. However, since disease characteristics differ between adults and children, it is hazardous to simply extrapolate these guidelines to children. Moreover, pediatric data on treatment strategies and how to assess treatment response remain virtually absent. Optimal treatment strategies are highly needed to guide therapy and improve survival in children with PAH. This review provides an overview of currently available treatments for PAH and the limited efficacy and safety data in children (with the exclusion of perinatal pulmonary vascular diseases, as persistent pulmonary hypertension of the newborn). We also discuss potential treatment goals and how the available data can be translated into treatment strategies in pediatric PAH.
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Affiliation(s)
- Willemijn M H Zijlstra
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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31
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Rosanio S, Pelliccia F, Gaudio C, Greco C, Keylani AM, D'Agostino DC. Pulmonary arterial hypertension in adults: novel drugs and catheter ablation techniques show promise? Systematic review on pharmacotherapy and interventional strategies. Biomed Res Int 2014; 2014:743868. [PMID: 25013799 PMCID: PMC4072027 DOI: 10.1155/2014/743868] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/18/2014] [Indexed: 11/25/2022]
Abstract
This systematic review aims to provide an update on pharmacological and interventional strategies for the treatment of pulmonary arterial hypertension in adults. Currently US Food and Drug Administration approved drugs including prostanoids, endothelin-receptor antagonists, phosphodiesterase type-5 inhibitors, and soluble guanylate-cyclase stimulators. These agents have transformed the prognosis for pulmonary arterial hypertension patients from symptomatic improvements in exercise tolerance ten years ago to delayed disease progression today. On the other hand, percutaneous balloon atrioseptostomy by using radiofrequency perforation, cutting balloon dilatation, or insertion of butterfly stents and pulmonary artery catheter-based denervation, both associated with very low rate of major complications and death, should be considered in combination with specific drugs at an earlier stage rather than late in the progression of pulmonary arterial hypertension and before the occurrence of overt right-sided heart failure.
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Affiliation(s)
- Salvatore Rosanio
- Division of Cardiology, Department of Internal Medicine, University of North Texas Health Science Center, 855 Montgomery Street, PCC Room 315, Fort Worth, TX 76107, USA
| | - Francesco Pelliccia
- Department of Heart and Great Vessels “Attilio Reale”, La Sapienza University, Rome, Italy
| | - Carlo Gaudio
- Department of Heart and Great Vessels “Attilio Reale”, La Sapienza University, Rome, Italy
| | - Cesare Greco
- Department of Heart and Great Vessels “Attilio Reale”, La Sapienza University, Rome, Italy
| | - Abdul M. Keylani
- Division of Cardiology, Department of Internal Medicine, University of North Texas Health Science Center, 855 Montgomery Street, PCC Room 315, Fort Worth, TX 76107, USA
| | - Darrin C. D'Agostino
- Division of Cardiology, Department of Internal Medicine, University of North Texas Health Science Center, 855 Montgomery Street, PCC Room 315, Fort Worth, TX 76107, USA
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32
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Strange G, Williams T, Kermeen F, Whyte K, Keogh A. Pulmonary hypertension and breathlessness: is it a combination we can ignore? Intern Med J 2014; 44:114-23. [DOI: 10.1111/imj.12321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/29/2013] [Indexed: 11/27/2022]
Affiliation(s)
- G. Strange
- University of Notre Dame; Fremantle Western Australia
- Pulmonary Research; Pulmonary Hypertension Society ANZ, Inc.; Sydney New South Wales Australia
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - T. Williams
- Allergy, Immunology and Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - F. Kermeen
- Pulmonary Hypertension and Lung Transplantation Unit; The Prince Charles Hospital; Brisbane Queensland Australia
| | - K. Whyte
- Auckland City Hospital; Auckland New Zealand
| | - A. Keogh
- St Vincent's Hospital; Sydney New South Wales Australia
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33
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Abstract
Pulmonary arterial hypertension (PAH), a common complication of systemic sclerosis, carries a very severe prognosis and is one of the leading causes of death in patients who suffer from it. Indeed, response to modern medical therapy has been disappointing in scleroderma-related PAH compared with other forms of PAH from the WHO group 1 classification of diseases, despite similar histological changes involving the pulmonary vasculature. This review discusses specific features of scleroderma-related PAH, currently available and US FDA-approved therapy for this syndrome, as well as potential future therapeutic developments based on newly acquired knowledge of this disorder.
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Affiliation(s)
- Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA, Tel.: +1 410 614 5158, ,
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34
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Mukherjee B, Howard L. Combination therapy in pulmonary arterial hypertension: do we have the right strategy? Expert Rev Respir Med 2014; 5:191-205. [DOI: 10.1586/ers.11.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rubenfire M, Huffman MD, Krishnan S, Seibold JR, Schiopu E, McLaughlin VV. Survival in systemic sclerosis with pulmonary arterial hypertension has not improved in the modern era. Chest 2014; 144:1282-1290. [PMID: 23744060 DOI: 10.1378/chest.12-0653] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The impact of modern therapy on survival in pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc) is not clear. We sought to determine associations among commonly used clinical and hemodynamic variables, treatment, and long-term survival in PAH associated with SSc compared with PAH defined as idiopathic, familial, or associated with anorexigens. METHODS The observation period (1996-2010) included the option for epoprostenol and the availability of oral agents in 2002 (modern era of endothelin antagonists and phosphodiesterase-5 inhibitors). Primary outcome was all-cause mortality. RESULTS Eighty-three patients had SSc (mean age, 59 years), and 120 had PAH (mean age, 51 years) (P < .0001, > 80% were functional class III or IV in both groups). Compared with PAH, SSc had a lower mean pulmonary artery pressure (48 mm Hg vs 58 mm Hg, P < .0001) and pulmonary vascular resistance (10 resistance units vs 15 resistance units, P < .0001), and a higher cardiac index (2.3 L/min/m2 vs 1.8 L/min/m2, P < .0001). PAH was more often treated with prostacyclin (71% vs 44%, P < .0001), but there were no differences in the use of monotherapy or combination oral therapy. SSc had a twofold-higher mortality over the 14 years. The 5-year survival in the modern era for PAH was 87%, compared with 51% for SSc (P < .001). CONCLUSIONS Despite an improvement in clinical status, unlike in PAH, mortality in SSc has not improved since the introduction of epoprostenol.
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Affiliation(s)
- Melvyn Rubenfire
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI.
| | - Mark D Huffman
- Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sangeetha Krishnan
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | | | - Elena Schiopu
- Division of Rheumatology, University of Michigan, Ann Arbor, MI
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36
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Douwes JM, Roofthooft MTR, Van Loon RLE, Ploegstra MJ, Bartelds B, Hillege HL, Berger RMF. Sildenafil add-on therapy in paediatric pulmonary arterial hypertension, experiences of a national referral centre. Heart 2014; 100:224-30. [DOI: 10.1136/heartjnl-2013-304895] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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37
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Abstract
Despite major advances in understanding the mechanisms of disease and development of specific drug therapy, pulmonary arterial hypertension (PAH) remains a progressive, fatal disease. At present there are 3 classes of drug therapy for PAH: prostaglandins, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors. To maximize therapeutic benefit, and according to national and international guidelines, many patients are treated with combinations of these medications. This review presents a detailed account of the published data on the use of combination therapy in PAH. There are few randomized, placebo-controlled trial data to strongly support efficacy of most combination therapy, particularly oral combination therapy.
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Affiliation(s)
- Meredith E Pugh
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232, USA
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Montani D, Günther S, Dorfmüller P, Perros F, Girerd B, Garcia G, Jaïs X, Savale L, Artaud-Macari E, Price LC, Humbert M, Simonneau G, Sitbon O. Pulmonary arterial hypertension. Orphanet J Rare Dis 2013; 8:97. [PMID: 23829793 PMCID: PMC3750932 DOI: 10.1186/1750-1172-8-97] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic and progressive disease leading to right heart failure and ultimately death if untreated. The first classification of PH was proposed in 1973. In 2008, the fourth World Symposium on PH held in Dana Point (California, USA) revised previous classifications. Currently, PH is devided into five subgroups. Group 1 includes patients suffering from idiopathic or familial PAH with or without germline mutations. Patients with a diagnosis of PAH should systematically been screened regarding to underlying mutations of BMPR2 gene (bone morphogenetic protein receptor type 2) or more rarely of ACVRL1 (activine receptor-like kinase type 1), ENG (endogline) or Smad8 genes. Pulmonary veno occusive disease and pulmonary capillary hemagiomatosis are individualized and designated as clinical group 1'. Group 2 'Pulmonary hypertension due to left heart diseases' is divided into three sub-groups: systolic dysfonction, diastolic dysfonction and valvular dysfonction. Group 3 'Pulmonary hypertension due to respiratory diseases' includes a heterogenous subgroup of respiratory diseases like PH due to pulmonary fibrosis, COPD, lung emphysema or interstitial lung disease for exemple. Group 4 includes chronic thromboembolic pulmonary hypertension without any distinction of proximal or distal forms. Group 5 regroup PH patients with unclear multifactorial mechanisms. Invasive hemodynamic assessment with right heart catheterization is requested to confirm the definite diagnosis of PH showing a resting mean pulmonary artery pressure (mPAP) of ≥ 25 mmHg and a normal pulmonary capillary wedge pressure (PCWP) of ≤ 15 mmHg. The assessment of PCWP may allow the distinction between pre-capillary and post-capillary PH (PCWP > 15 mmHg). Echocardiography is an important tool in the management of patients with underlying suspicion of PH. The European Society of Cardiology and the European Respiratory Society (ESC-ERS) guidelines specify its role, essentially in the screening proposing criteria for estimating the presence of PH mainly based on tricuspid regurgitation peak velocity and systolic artery pressure (sPAP). The therapy of PAH consists of non-specific drugs including oral anticoagulation and diuretics as well as PAH specific therapy. Diuretics are one of the most important treatment in the setting of PH because right heart failure leads to fluid retention, hepatic congestion, ascites and peripheral edema. Current recommendations propose oral anticoagulation aiming for targeting an International Normalized Ratio (INR) between 1.5-2.5. Target INR for patients displaying chronic thromboembolic PH is between 2–3. Better understanding in pathophysiological mechanisms of PH over the past quarter of a century has led to the development of medical therapeutics, even though no cure for PAH exists. Several specific therapeutic agents were developed for the medical management of PAH including prostanoids (epoprostenol, trepoprostenil, iloprost), endothelin receptor antagonists (bosentan, ambrisentan) and phosphodiesterase type 5 inhibitors (sildenafil, tadalafil). This review discusses the current state of art regarding to epidemiologic aspects of PH, diagnostic approaches and the current classification of PH. In addition, currently available specific PAH therapy is discussed as well as future treatments.
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Affiliation(s)
| | - Jason Yuan
- Department of Medicine and Pharmacology, University of Illinois, Chicago, Illinois
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40
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Gruenig E, Michelakis E, Vachiéry JL, Vizza CD, Meyer FJ, Doelberg M, Bach D, Dingemanse J, Galiè N. Acute Hemodynamic Effects of Single-Dose Sildenafil When Added to Established Bosentan Therapy in Patients With Pulmonary Arterial Hypertension: Results of the COMPASS-1 Study. J Clin Pharmacol 2013; 49:1343-52. [DOI: 10.1177/0091270009341182] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Waxman AB, Zamanian RT. Pulmonary arterial hypertension: new insights into the optimal role of current and emerging prostacyclin therapies. Am J Cardiol 2013; 111:1A-16A; quiz 17A-19A. [PMID: 23414683 DOI: 10.1016/j.amjcard.2012.12.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Pulmonary arterial hypertension (PAH), which is a subset of pulmonary hypertension, is a group of diseases distinguished by vascular remodeling of the small pulmonary arteries with associated elevated pulmonary arterial pressure and right ventricular failure. This progressive and sometimes fatal disease occurs as an idiopathic disease or as a component of other disease states. Estimates of the incidence of PAH have varied from 5 to 52 cases/1 million population. Symptoms begin with shortness of breath with exertion and progress to dyspnea with normal activities and, finally, dyspnea at rest. Untreated patients with PAH have a 1-, 3-, and 5-year survival rate of 68%, 48%, and 34%, respectively. Treated, the survival rates improve to 91% to 97% after 1 year and 84% to 91% after 2 years. The current definition of PAH consists of 3 specific hemodynamic assessments confirmed by right heart catheterization findings. One of several important pathophysiologic mechanisms involved in PAH is pulmonary vascular remodeling, which is caused by endothelial and smooth muscle cell hyperproliferation. This is coincident with overexpression of the vasoconstrictor endothelin-1 and a reduction in the vasodilators nitric oxide and prostacyclin, which further impedes proper vasomotor tone, among other effects. Prostacyclin therapies augment the decreased prostacyclin levels in patients with PAH. The currently approved prostacyclins for the treatment of PAH include epoprostenol, iloprost, and treprostinil. Among the 3 medications, the delivery options include intravenous infusion, subcutaneous infusion, and inhaled formulations. Epoprostenol has been shown to have a positive effect on survival in patients with PAH. All prostacyclins have demonstrated improvements in functional class, exercise tolerance, and hemodynamics in patients with PAH. Intravenously and subcutaneously administered formulations of prostacyclins require continuous infusion pump administration, which presents clinical challenges for both the patient and the care provider. Dosing must be individualized and also presents a clinical challenge. Inhaled formulations seem efficacious in moderately symptomatic patients with PAH and might be appropriate when combined with an oral medication. Combination therapies are commonly used in clinical practice, with the decision to do so based on randomized controlled trial data and case study evidence. The present report provides an overview of PAH, the scientific rationale for treatment with prostacyclin therapy, and the benefits and risks of prostacyclin therapy, both as monotherapy and combined with other medications approved for the treatment of PAH.
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Jasińska-Stroschein M, Owczarek J, Łuczak A, Orszulak-Michalak D. The beneficial impact of fasudil and sildenafil on monocrotaline-induced pulmonary hypertension in rats: a hemodynamic and biochemical study. Pharmacology 2013; 91:178-84. [PMID: 23428587 DOI: 10.1159/000346921] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 01/08/2013] [Indexed: 11/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) still cannot be cured effectively, hence the search for novel treatments continues. The effects of sildenafil (25 mg/kg body weight) and fasudil (30 mg/kg body weight) given alone or in combination, on normalization of right ventricular pressure (RVP), right ventricle mass, as well as the levels of several biomarkers (HDL-C, BNP, VEGF-A), were assessed in a rat model of monocrotaline (MCT)-induced PAH. MCT (60 mg/kg body weight) induced clear PAH in male Wistar rats. After 21 days, a significant decrease in RVP accompanied by a reduction of right ventricular hypertrophy - a significant decrease in the right ventricle/left ventricle plus septum ratio - as a result of sildenafil or fasudil administration was assessed. The administration of fasudil and sildenafil alone or in combination caused a significant decrease in plasma BNP level as compared to MCT-treated rats. Fasudil alone or with sildenafil, but not sildenafil alone, significantly increased HDL-C level as compared to MCT-treated rats. Fasudil and sildenafil given alone or in combination caused a significant increase in plasma VEGF-A level as compared to rats exposed to MCT.
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Abstract
Pulmonary arterial hypertension (PAH) is a disorder of the small pulmonary arteries characterized by progressive fibrotic and proliferative changes that result in an increased pulmonary vascular resistance. It is a progressive and debilitating disease that leads to right ventricular dysfunction, impairment in activity tolerance and eventually right-sided heart failure, and premature death. The treatment goals for PAH include improvement in symptoms, improvement in functional class and exercise class, decreased morbidity, and preventing mortality. Combination therapy in the treatment of PAH is an emerging therapeutic option. Combining therapies with differing mechanisms of action will maximize therapeutic benefits such as symptom control and increased rate of survival. The updated 2007 American College of Chest Physicians evidence-based clinical practice guidelines recommend combination therapy in functional classes III and IV if there is no improvement with current therapy or if there is deterioration in class. PAH monotherapy has been shown to improve symptoms, but the patients’ hemodynamic parameters may not be normalized, leading to further pulmonary vascular remodeling. Combination therapy offers an additional option for those patients who are unable to stabilize on monotherapy.
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Launay D, Sitbon O, Hachulla E, Mouthon L, Gressin V, Rottat L, Clerson P, Cordier JF, Simonneau G, Humbert M. Survival in systemic sclerosis-associated pulmonary arterial hypertension in the modern management era. Ann Rheum Dis 2012. [PMID: 23178295 PMCID: PMC3841769 DOI: 10.1136/annrheumdis-2012-202489] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To assess the survival and prognostic factors in patients with newly diagnosed incident systemic sclerosis (SSc)–associated pulmonary arterial hypertension (PAH) in the modern management era. Methods Prospectively enrolled SSc patients in the French PAH Network between January 2006 and November 2009, with newly diagnosed PAH and no interstitial lung disease, were analysed (85 patients, mean age 64.9±12.2 years). Median follow-up after PAH diagnosis was 2.32 years. Results A majority of patients were in NYHA functional class III–IV (79%). Overall survival was 90% (95% CI 81% to 95%), 78% (95% CI 67% to 86%) and 56% (95% CI 42% to 68%) at 1, 2 and 3 years from PAH diagnosis, respectively. Age (HR: 1.05, 95% CI 1.01 to 1.09, p=0.012) and cardiac index (HR: 0.49, 95% CI 0.27 to 0.89, p=0.019) were significant predictors in the univariate analysis. We also observed strong trends for gender, SSc subtypes, New York Heart Association functional class, pulmonary vascular resistance and capacitance to be significant predictors in the univariate analysis. Conversely, six-min walk distance, mean pulmonary arterial and right atrial pressures were not significant predictors. In the multivariate model, gender was the only independent factor associated with survival (HR: 4.76, 95% CI 1.35 to 16.66, p=0.015 for male gender). Conclusions Incident SSc-associated PAH remains a devastating disease even in the modern management era. Age, male gender and cardiac index were the main prognosis factors in this cohort of patients. Early detection of less severe patients should be a priority.
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Affiliation(s)
- David Launay
- Service de Médecine Interne, Centre de référence de la sclérodermie systémique, Université Lille Nord de France, Hôpital Claude-Huriez, , Lille, France
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Abstract
Pulmonary arterial hypertension (PAH) may complicate diverse connective tissue diseases (CTDs). Approximately 10% of patients with systemic sclerosis develop PAH, the prevalence being much lower in other CTDs. However, PAH is an important contributor to morbidity and mortality in all forms of CTD. Despite similarities in presentation, hemodynamic perturbations, and pathogenesis, patients with CTD-associated PAH (CTD-PAH) usually have a poorer response to PAH-specific medications and poorer prognosis than patients with idiopathic PAH (IPAH). Select patients with CTD-PAH may be candidates for lung transplantation, but results are less favorable than for IPAH because of comorbidities and complications specifically associated with CTD.
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Affiliation(s)
- Stephen C Mathai
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, Baltimore, MD 21205, USA
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Cutolo M, Zampogna G, Vremis L, Smith V, Pizzorni C, Sulli A. Longterm effects of endothelin receptor antagonism on microvascular damage evaluated by nailfold capillaroscopic analysis in systemic sclerosis. J Rheumatol 2012; 40:40-5. [PMID: 23118114 DOI: 10.3899/jrheum.120416] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is characterized by microvascular injury, fibrosis, and hypoxia of involved tissues. The vasoactive peptide endothelin-1 (ET-1) seems to be implicated in these events. Using nailfold videocapillaroscopy (NVC), we evaluated longterm effects of ET-1 antagonist treatment on nailfold microvascular damage in patients with SSc, over a 3-year followup period. METHODS Thirty patients with SSc (mean age 64 ± 5 yrs, mean disease duration 8 ± 1 yrs) were recruited during their programmed standard treatment protocols. At baseline (T0), 15 patients with SSc (mean age 63 ± 15 yrs, mean disease duration 7 ± 3 yrs), already receiving cyclic intravenous infusion of iloprost (5 continuous days, average 80 μg/day, every 3 mo), continued the treatment for a further 3 years (ILO group). The remaining 15 patients with SSc (mean age 68 ± 13 yrs, mean disease duration 8 ± 4 yrs), although they continued the same cyclic intravenous iloprost treatment as the previous group, also received bosentan 125 mg twice a day for 3 years (ILO+BOS group). Qualitative analysis (scleroderma patterns) and semiquantitative scoring of the microvascular damage were performed by validated routine NVC methods. RESULTS During followup, a statistically significant increase of capillary number was observed in the ILO+BOS group (p < 0.02), with a significant and progressive increase of angiogenesis (p < 0.01). In contrast, the ILO group showed a statistically significant decrease of capillary number (p < 0.05). After 3 years the number of capillaries was significantly higher in the ILO+BOS group than in the ILO group (p < 0.05). The score for giant capillaries decreased significantly in both groups of patients with SSc (p < 0.05). CONCLUSION In this open study, longterm treatment with ET-1 receptor antagonist in combination with iloprost was found to interfere with progression of nailfold microvascular damage in patients with SSc, as assessed by NVC over a 3-year followup period.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy.
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Vera-Lastra O, Porres-Aguilar M. Pulmonary arterial hypertension associated with systemic sclerosis: Current diagnostic approach and therapeutic strategies. World J Rheumatol 2012; 2:12-20. [DOI: 10.5499/wjr.v2.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) represents a devastating vascular complication of systemic sclerosis (SSc) and is found in 10%-15% of cases carrying a severe prognosis. PAH has a dramatic impact on the clinical course and overall survival, being the single most common cause of death in patients with this entity. The clinical course and aggressive progression of PAH has led clinicians to perform annual screening for it, since early detection and diagnosis are the cornerstone of a prompt therapeutic intervention. The diagnosis of PAH can be challenging to clinicians, particularly in its early stages, since in the context of SSc, the multiple causes of dyspnea need to be assessed. Doppler echocardiography represents the best initial screening tool, however, right heart catheterization remains the gold standard and definitive diagnostic means. Remarkable advances have been achieved in elucidating the pathogenesis of PAH in the past two decades, leading to the development of disease-specific targeted therapies: prostacyclin analogues, endothelin receptor antagonists and inhibitors of five phosphodiesterase pathways. However, the clinical response to these therapies in SSc-associated PAH has not been as great as the one seen with idiopathic PAH. This review also focuses on the diagnosis and novel therapies that are currently available for PAH, as well as potential future therapeutic developments based on newly acquired knowledge of diverse pathogenic mechanisms.
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Ramani GV, Park MH. Pharmacotherapy for pulmonary arterial hypertension. Heart Fail Clin 2012; 8:385-402. [PMID: 22748901 DOI: 10.1016/j.hfc.2012.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a disabling, progressive disease. The past decade has seen an explosion in the available therapies for the management of PAH. Choosing appropriate pharmacotherapy can be a daunting task for the practitioner, as no head-to-head comparisons between drugs have been published. This article aims to assist the practitioner in developing an evidence-based, rational pharmacologic treatment algorithm for the management of patients with PAH. Currently approved pharmacotherapy and the pivotal trials that led to approval for the respective agents are reviewed. Common dilemmas in the treatment of PAH for which strong evidence is lacking are discussed.
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Affiliation(s)
- Gautam V Ramani
- University of Maryland School of Medicine, Baltimore VAMC, 110 South Paca Street, Baltimore, MD 21201-1559, USA.
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Salamonsen M, Keating D, Whitford H, Bailey M, Miller T, Manterfield C, Williams T. IVI epoprostenol as salvage therapy in pulmonary arterial hypertension: an Australian perspective. Intern Med J 2012; 41:245-51. [PMID: 20681957 DOI: 10.1111/j.1445-5994.2010.02333.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND IVI epoprostenol is the only therapy for pulmonary arterial hypertension (PAH) with a randomized controlled trial demonstrating improved survival, when used as first-line monotherapy. In Australia it is used as salvage therapy for those failing treatment with other targeted therapies or presenting in World Health Organization functional class (FC) IV. AIMS Report experience with IVI epoprostenol, administered as salvage therapy for the treatment of adults with PAH in a single Australian PAH centre. METHODS Retrospective case series of all patients commenced on IVI epoprostenol for PAH, between 2002 and 2010. Review of case notes with collection of data at baseline and after treatment, including FC, 6-min walk test (6MWT), right ventricular systolic pressure (RVSP) on echocardiogram, patient survival and treatment complications. Change in indices was assessed using the Wilcoxon Sign Rank Test and is expressed as median (inter-quartile range). RESULTS A total of 23 patients was included. Treatment was generally well tolerated with few major complications. At the end of the study period, nine patients were successfully bridged to transplant, five had a sustained response to IVI epoprostenol, six had an incomplete response but were clinically stabilized, two died awaiting transplant and one died who was not a candidate for transplantation. Overall, when measured at best level post initiation of IVI epoprostenol, there were significant improvements in FC -1 [0 to -1] (P < 0.0001), 6MWT (m) +117 [70-264] (P= 0.002) and RVSP (mmHg) -7.0 [4.0 to -45] (P= 0.03). CONCLUSION Findings support efficacy of epoprostenol as salvage therapy for patients with PAH.
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Affiliation(s)
- M Salamonsen
- Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital and Monash University Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.
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