1
|
Cruz Utrilla A, Gallego N, Cristo Ropero MJ, Perez Olivares-Delgado C, Tenorio Castano JA, Lapunzina P, Lopez Meseguer M, Martinez Menaca A, Arribas-Ynsaurriaga F, Escribano Subias P. BMPR2 variants in pulmonary arterial hypertension. Are they really worrisome? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1895] [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: 11/13/2022] Open
Abstract
Abstract
Background
Pulmonary arterial hypertension (PAH) is a rare and severe disease. The discovery of the gene encoding Bone Morphogenetic Protein Receptor Type 2 (BMPR2) in 2000 was the first evidence of an association between genetics and PAH. BMPR2 mutation carriers are younger and have higher haemodynamic severity, determining higher risk than sporadic cases. In the last few years, novel genetic variants have been identified. The risk of mortality of the currently known mutations is scarce.
Purpose
To describe the role of gene variants regarding long-term survival in a cohort of PAH patients.
Methods
We included patients diagnosed with PAH between January 2011-December 2020, following the ESC/ERC Guidelines recommendations. At least one genetic study was available in included individuals. Pulmonary venooclusive disease, PAH associated with congenital heart disease, or connective tissue disorders were excluded. Three groups were compared: no mutation, BMPR2 carriers and other genetic variants. Comparison of qualitative and quantitative variables was done by Chi-square test and ANOVA test, respectively. Crude and adjusted Log-rank test was performed for the evaluation of mortality.
Results
361 were finally included. The most frequent gene variant was BMPR2. Among the eight other gene variants, there were 2 cases of KCKN3, 2 of ACVRL1, and 1 case of KCNA5, TBX4, CPS1, and GDF2.
BMPR2 and the rest of mutation carriers were younger at diagnosis and had worse haemodynamic parameters than non-carriers. Nevertheless, these patients tended to perform higher distances in the 6-minute walk test. Interestingly, BMPR2 patients had higher DLCO values at diagnosis (table).
After 104.1±77.2 months of follow-up, there was a tendency for BMPR2 carriers toward lower crude free survival of mortality or lung transplantation. Nevertheless, this survival benefit disappears when adjusted by age (Table, figure).
Conclusions
The diagnostic yields of genetic analysis for pathogenic or likely pathogenic variants in idiopathic PAH are approximately 11%. BMPR2 is the most frequent causal gene. These patients are associated with marked haemodynamic impairment. Nevertheless, its younger age probably determines the better long-term results regarding mortality or lung transplantation observed when comparing these results with sporadic patients or those carrying other mutations.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Rio Hortega grant. Instituto de Salud Carlos III (ISCIII), Ministry of Science and Innovation, Spanish Government.
Collapse
Affiliation(s)
- A Cruz Utrilla
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| | - N Gallego
- Hospital La Paz, Instituto de Genética Médica y Molecular (INGEMM), Madrid, Spain
| | - M J Cristo Ropero
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| | - C Perez Olivares-Delgado
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| | - J A Tenorio Castano
- Hospital La Paz, Instituto de Genética Médica y Molecular (INGEMM), Madrid, Spain
| | - P Lapunzina
- Hospital La Paz, Instituto de Genética Médica y Molecular (INGEMM), Madrid, Spain
| | - M Lopez Meseguer
- University Hospital Vall d'Hebron, Pneumology Department, Barcelona, Spain
| | - A Martinez Menaca
- University Hospital Marques de Valdecilla, Pneumology Department, Santander, Spain
| | | | - P Escribano Subias
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| |
Collapse
|
2
|
Cruz Utrilla A, Gallego N, Torrent A, Garrido-Lestache E, Guillen I, Arias S, Moya A, Mendoza A, Espin J, Rodriguez Vazquez MM, Playan-Escribano J, Labrandero C, Tenorio Castano JA, Escribano Subias P, Del Cerro MJ. Genetic background in pediatric pulmonary arterial hypertension. Should we change the current recommendations for genetic testing? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1953] [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: 11/13/2022] Open
Abstract
Abstract
Background
Pulmonary arterial hypertension (PAH) is a rare and severe disease, genetically predisposed in a high proportion of patients. PAH is subclassified in different subtypes depending on the underlying condition. Gene variants are more frequent among heritable or idiopathic forms. Nevertheless, pathogenic variants have been described across the entire spectrum of this disease. Evidence regarding genetics in pediatric PAH is scarce [1].
Purpose
Our aim is to describe the prevalence of significant gene mutations among a pediatric PAH cohort and to define specific data in the different subtypes.
Methods
Samples for genetic studies were obtained from blood tests of patients included in the Spanish National Registry of Pediatric Pulmonary Hypertension (REHIPED). Guardians signed informed consent before the inclusion in the study. Qualitative variables were compared by Chi-square test. Quantitative variables were assessed by Kruskal-Wallis, considering the asymmetric distribution of variables. STATA 14.0 was used for analyses.
Results
Sixty four patients were included between 2011 and 2021. Median age of the entire sample was 7.1 years (2.0–12.6) and 42.2% of them were male. There were significant differences in the age at diagnosis and race between the different included groups (table). Pathogenic or likely pathogenic variants were more frequent in familial pulmonary venooclusive disease (PVOD) and familial PAH cases. A similar percentage of mutations were found in idiopathic cases and in PAH associated with congenital heart disease (Figure). Gene variants in the gene encoding the bone morphogenetic protein receptor type 2 (BMPR2) were the most frequent mutations in the PAH familial cohort and there was also the most frequent finding in congenital heart disease and sporadic PAH, in conjunction with the TBX4 gene. Homozygous or compound heterozygous EIF2AK4 (eukaryotic translation initiation factor 2 a kinase 4) mutations were found in all the patients diagnosed with PVOD. Heritable PAH and PVOD cases were diagnosed more frequently after family screening.
Conclusions
This study shows a comparable proportion of pathogenic-likely pathogenic gene mutations in patients diagnosed of pulmonary arterial hypertension associated with congenital heart disease and idiopathic cases, with similar distribution of specific genes. BMPR2 and TBX 4 were the most frequent gene variants in this pediatric PAH population. BMPR2 and EIF2AK4 are the most common mutations in familial PAH and PVOD subtypes, respectively.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ACU holds a Rio Hortega Grant from the Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation.JAT and NG hold grants from FEDER (Federaciόn Española de Enfermedades Raras) and from the FCHP. Table 1. Characteristics of PAH subtypesFigure 1. PAH and ACMG classification.
Collapse
Affiliation(s)
- A Cruz Utrilla
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| | - N Gallego
- Hospital La Paz, Instituto de Genética Médica y Molecular (INGEMM), Madrid, Spain
| | - A Torrent
- University Hospital Vall d'Hebron, Department of Pediatric Pulmonology, Barcelona, Spain
| | - E Garrido-Lestache
- University Hospital Ramon y Cajal de Madrid, Department of Pediatric Cardiology, Madrid, Spain
| | - I Guillen
- University Hospital Virgen del Rocio, Department of Pediatric Cardiology, Seville, Spain
| | - S Arias
- Hospital Universitario Infanta Cristina, Department of pediatric cardiology, Badajoz, Spain
| | - A Moya
- University Hospital La Fe, Department of pediatric Cardiology, Valencia, Spain
| | - A Mendoza
- University Hospital 12 de Octubre, Department of pediatric cardiology, Madrid, Spain
| | - J Espin
- Hospital Universitario Virgen Arrixaca, Department of pediatric cardiology, Murcia, Spain
| | - M M Rodriguez Vazquez
- University Hospital Virgen de las Nieves, Department of Pediatric cardiology, Granada, Spain
| | | | - C Labrandero
- University Hospital La Paz, Department of Pediatric Cardiology, Madrid, Spain
| | - J A Tenorio Castano
- Hospital La Paz, Instituto de Genética Médica y Molecular (INGEMM), Madrid, Spain
| | - P Escribano Subias
- University Hospital 12 de Octubre, Pulmonary Hypertension Unit. Cardiology Department, Madrid, Spain
| | - M J Del Cerro
- University Hospital Ramon y Cajal de Madrid, Department of Pediatric Cardiology, Madrid, Spain
| |
Collapse
|