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Forbes LM, Bull TM, Lahm T, Sisson T, O'Gean K, Lawley JS, Hunter K, Levine BD, Lovering A, Roach RC, Subudhi AW, Cornwell WK. Right ventricular performance during acute hypoxic exercise. J Physiol 2024. [PMID: 38409819 DOI: 10.1113/jp284943] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
Acute hypoxia increases pulmonary arterial (PA) pressures, though its effect on right ventricular (RV) function is controversial. The objective of this study was to characterize exertional RV performance during acute hypoxia. Ten healthy participants (34 ± 10 years, 7 males) completed three visits: visits 1 and 2 included non-invasive normoxic (fraction of inspired oxygen (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ) = 0.21) and isobaric hypoxic (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12) cardiopulmonary exercise testing (CPET) to determine normoxic/hypoxic maximal oxygen uptake (V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ ). Visit 3 involved invasive haemodynamic assessments where participants were randomized 1:1 to either Swan-Ganz or conductance catheterization to quantify RV performance via pressure-volume analysis. Arterial oxygen saturation was determined by blood gas analysis from radial arterial catheterization. During visit 3, participants completed invasive submaximal CPET testing at 50% normoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ and again at 50% hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12). Median (interquartile range) values for non-invasiveV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ values during normoxic and hypoxic testing were 2.98 (2.43, 3.66) l/min and 1.84 (1.62, 2.25) l/min, respectively (P < 0.0001). Mean PA pressure increased significantly when transitioning from rest to submaximal exercise during normoxic and hypoxic conditions (P = 0.0014). Metrics of RV contractility including preload recruitable stroke work, dP/dtmax , and end-systolic pressure increased significantly during the transition from rest to exercise under normoxic and hypoxic conditions. Ventricular-arterial coupling was maintained during normoxic exercise at 50%V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ . During submaximal exercise at 50% of hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ , ventricular-arterial coupling declined but remained within normal limits. In conclusion, resting and exertional RV functions are preserved in response to acute exposure to hypoxia at anF i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12 and the associated increase in PA pressures. KEY POINTS: The healthy right ventricle augments contractility, lusitropy and energetics during periods of increased metabolic demand (e.g. exercise) in acute hypoxic conditions. During submaximal exercise, ventricular-arterial coupling decreases but remains within normal limits, ensuring that cardiac output and systemic perfusion are maintained. These data describe right ventricular physiological responses during submaximal exercise under conditions of acute hypoxia, such as occurs during exposure to high altitude and/or acute hypoxic respiratory failure.
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Affiliation(s)
- Lindsay M Forbes
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, USA
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, USA
| | - Tim Lahm
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Tyler Sisson
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katie O'Gean
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Justin S Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin D Levine
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
| | - Andrew Lovering
- Department of Physiology, University of Oregon, Eugene, OR, USA
| | - Robert C Roach
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, USA
| | - Andrew W Subudhi
- Department of Physiology, University of Colorado, Colorado Springs, CO, USA
| | - William K Cornwell
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, USA
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2
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [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: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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3
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Forbes LM, Bull TM, Lahm T, Make BJ, Cornwell WK. Exercise Testing in the Risk Assessment of Pulmonary Hypertension. Chest 2023; 164:736-746. [PMID: 37061028 PMCID: PMC10504600 DOI: 10.1016/j.chest.2023.04.013] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023] Open
Abstract
TOPIC IMPORTANCE Right ventricular dysfunction in pulmonary hypertension (PH) contributes to reduced exercise capacity, morbidity, and mortality. Exercise can unmask right ventricular dysfunction not apparent at rest, with negative implications for prognosis. REVIEW FINDINGS Among patients with pulmonary vascular disease, right ventricular afterload may increase during exercise out of proportion to increases observed among healthy individuals. Right ventricular contractility must increase to match the demands of increased afterload to maintain ventricular-arterial coupling (the relationship between contractility and afterload) and ultimately cardiac output. Impaired right ventricular contractile reserve leads to ventricular-arterial uncoupling, preventing cardiac output from increasing during exercise and limiting exercise capacity. Abnormal pulmonary vascular response to exercise can signify early pulmonary vascular disease and is associated with increased mortality. Impaired right ventricular contractile reserve similarly predicts poor outcomes, including reduced exercise capacity and death. Exercise provocation can be used to assess pulmonary vascular response to exercise and right ventricular contractile reserve. Noninvasive techniques (including cardiopulmonary exercise testing, transthoracic echocardiography, and cardiac MRI) as well as invasive techniques (including right heart catheterization and pressure-volume analysis) may be applied selectively to the screening, diagnosis, and risk stratification of patients with suspected or established PH. Further research is required to determine the role of exercise stress testing in the management of pulmonary vascular disease. SUMMARY This review describes the current understanding of clinical applications of exercise testing in the risk assessment of patients with suspected or established PH.
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Affiliation(s)
- Lindsay M Forbes
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Bull
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barry J Make
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Forbes LM, Bull TM, Lahm T, Lawley JS, Hunter K, Levine BD, Lovering A, Roach RC, Subudhi AW, Cornwell WK. Right Ventricular Response to Acute Hypoxia among Healthy Humans. Am J Respir Crit Care Med 2023; 208:333-336. [PMID: 37311248 PMCID: PMC10395728 DOI: 10.1164/rccm.202303-0599le] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
| | - Todd M. Bull
- Division of Pulmonary Sciences and Critical Care Medicine
| | - Tim Lahm
- Division of Pulmonary Sciences and Critical Care Medicine
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Benjamin D. Levine
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Andrew Lovering
- Department of Physiology, University of Oregon, Eugene, Oregon; and
| | | | - Andrew W. Subudhi
- Department of Physiology, University of Colorado, Colorado Springs, Colorado
| | - William K. Cornwell
- Division of Cardiology
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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5
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Sonntag E, Akgün KM, Bag R, Rosensweig EB, Bernardo RJ, Burnetti C, Chybowski A, de Jesus Perez VA, Diwan J, Guthrie KM, Halscott T, Lahm T, Vaught J, Ventetuolo CE, Hemnes AR. Access to Medically Necessary Reproductive Care for Individuals with Pulmonary Hypertension. Am J Respir Crit Care Med 2023; 208:234-237. [PMID: 37311249 PMCID: PMC10395720 DOI: 10.1164/rccm.202302-0230vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/13/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
- Elizabeth Sonntag
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine – Pulmonary Disease, Virginia Commonwealth University, Richmond, Virginia
| | - Kathleen M. Akgün
- Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, and
- Veterans Affairs Connecticut Healthcare System, Yale University School of Medicine, New Haven, Connecticut
| | - Remzi Bag
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Erika B. Rosensweig
- Vagelos College of Physicians and Surgeons, New York Presbyterian/Irving Medical Center, Columbia University, New York, New York
| | - Roberto J. Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Amy Chybowski
- Division of Pulmonary and Critical Care Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, California
| | | | | | - Torre Halscott
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, University of Colorado, Aurora, Colorado
| | - Jason Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Corey E. Ventetuolo
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Alpert School of Medicine, Brown University, Providence, Rhode Island; and
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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6
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Chakraborty A, Nathan A, Orcholski M, Agarwal S, Shamskhou EA, Auer N, Mitra A, Guardado ES, Swaminathan G, Condon DF, Yu J, McCarra M, Juul NH, Mallory A, Guzman-Hernandez RA, Yuan K, Rojas V, Crossno JT, Yung LM, Yu PB, Spencer T, Winn RA, Frump A, Karoor V, Lahm T, Hedlin H, Fineman JR, Lafyatis R, Knutsen CNF, Alvira CM, Cornfield DN, de Jesus Perez VA. Wnt7a deficit is associated with dysfunctional angiogenesis in pulmonary arterial hypertension. Eur Respir J 2023; 61:2201625. [PMID: 37024132 PMCID: PMC10259331 DOI: 10.1183/13993003.01625-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is characterised by loss of microvessels. The Wnt pathways control pulmonary angiogenesis but their role in PAH is incompletely understood. We hypothesised that Wnt activation in pulmonary microvascular endothelial cells (PMVECs) is required for pulmonary angiogenesis, and its loss contributes to PAH. METHODS Lung tissue and PMVECs from healthy and PAH patients were screened for Wnt production. Global and endothelial-specific Wnt7a -/- mice were generated and exposed to chronic hypoxia and Sugen-hypoxia (SuHx). RESULTS Healthy PMVECs demonstrated >6-fold Wnt7a expression during angiogenesis that was absent in PAH PMVECs and lungs. Wnt7a expression correlated with the formation of tip cells, a migratory endothelial phenotype critical for angiogenesis. PAH PMVECs demonstrated reduced vascular endothelial growth factor (VEGF)-induced tip cell formation as evidenced by reduced filopodia formation and motility, which was partially rescued by recombinant Wnt7a. We discovered that Wnt7a promotes VEGF signalling by facilitating Y1175 tyrosine phosphorylation in vascular endothelial growth factor receptor 2 (VEGFR2) through receptor tyrosine kinase-like orphan receptor 2 (ROR2), a Wnt-specific receptor. We found that ROR2 knockdown mimics Wnt7a insufficiency and prevents recovery of tip cell formation with Wnt7a stimulation. While there was no difference between wild-type and endothelial-specific Wnt7a -/- mice under either chronic hypoxia or SuHx, global Wnt7a +/- mice in hypoxia demonstrated higher pulmonary pressures and severe right ventricular and lung vascular remodelling. Similar to PAH, Wnt7a +/- PMVECs exhibited an insufficient angiogenic response to VEGF-A that improved with Wnt7a. CONCLUSIONS Wnt7a promotes VEGF signalling in lung PMVECs and its loss is associated with an insufficient VEGF-A angiogenic response. We propose that Wnt7a deficiency contributes to progressive small vessel loss in PAH.
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Affiliation(s)
- Ananya Chakraborty
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
- These authors contributed equally
| | - Abinaya Nathan
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
- These authors contributed equally
| | - Mark Orcholski
- Department of Medicine, University of Laval, Quebec City, QC, Canada
| | - Stuti Agarwal
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | | | - Natasha Auer
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - Ankita Mitra
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | | | - Gowri Swaminathan
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - David F Condon
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - Joyce Yu
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - Matthew McCarra
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - Nicholas H Juul
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | | | | | - Ke Yuan
- Boston Children's Hospital, Boston, MA, USA
| | | | - Joseph T Crossno
- Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Paul B Yu
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Robert A Winn
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Tim Lahm
- National Jewish Center, Denver, CO, USA
| | - Haley Hedlin
- Division of Pulmonary and Critical Care, Stanford University, Palo Alto, CA, USA
| | - Jeffrey R Fineman
- Department of Pediatrics and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Robert Lafyatis
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carsten N F Knutsen
- Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA, USA
| | - Cristina M Alvira
- Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA, USA
| | - David N Cornfield
- Division of Pediatric Pulmonary and Critical Care Medicine, Stanford University, Palo Alto, CA, USA
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7
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Brown RD, Hunter KS, Li M, Frid MG, Harral J, Krafsur GM, Holt TN, Williams J, Zhang H, Riddle SR, Edwards MG, Kumar S, Hu CJ, Graham BB, Walker LA, Garry FB, Buttrick PM, Lahm T, Kheyfets VO, Hansen KC, Stenmark KR. Functional and molecular determinants of right ventricular response to severe pulmonary hypertension in a large animal model. Am J Physiol Heart Circ Physiol 2023; 324:H804-H820. [PMID: 36961489 PMCID: PMC10190846 DOI: 10.1152/ajpheart.00614.2022] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/01/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023]
Abstract
Right ventricular (RV) failure is the major determinant of outcome in pulmonary hypertension (PH). Calves exposed to 2-wk hypoxia develop severe PH and unlike rodents, hypoxia-induced PH in this species can lead to right heart failure. We, therefore, sought to examine the molecular and structural changes in the RV in calves with hypoxia-induced PH, hypothesizing that we could identify mechanisms underlying compensated physiological function in the face of developing severe PH. Calves were exposed to 14 days of environmental hypoxia (equivalent to 4,570 m/15,000 ft elevation, n = 29) or ambient normoxia (1,525 m/5,000 ft, n = 25). Cardiopulmonary function was evaluated by right heart catheterization and pressure volume loops. Molecular and cellular determinants of RV remodeling were analyzed by cDNA microarrays, RealTime PCR, proteomics, and immunochemistry. Hypoxic exposure induced robust PH, with increased RV contractile performance and preserved cardiac output, yet evidence of dysregulated RV-pulmonary artery mechanical coupling as seen in advanced disease. Analysis of gene expression revealed cellular processes associated with structural remodeling, cell signaling, and survival. We further identified specific clusters of gene expression associated with 1) hypertrophic gene expression and prosurvival mechanotransduction through YAP-TAZ signaling, 2) extracellular matrix (ECM) remodeling, 3) inflammatory cell activation, and 4) angiogenesis. A potential transcriptomic signature of cardiac fibroblasts in RV remodeling was detected, enriched in functions related to cell movement, tissue differentiation, and angiogenesis. Proteomic and immunohistochemical analysis confirmed RV myocyte hypertrophy, together with localization of ECM remodeling, inflammatory cell activation, and endothelial cell proliferation within the RV interstitium. In conclusion, hypoxia and hemodynamic load initiate coordinated processes of protective and compensatory RV remodeling to withstand the progression of PH.NEW & NOTEWORTHY Using a large animal model and employing a comprehensive approach integrating hemodynamic, transcriptomic, proteomic, and immunohistochemical analyses, we examined the early (2 wk) effects of severe PH on the RV. We observed that RV remodeling during PH progression represents a continuum of transcriptionally driven processes whereby cardiac myocytes, fibroblasts, endothelial cells, and proremodeling macrophages act to coordinately maintain physiological homeostasis and protect myocyte survival during chronic, severe, and progressive pressure overload.
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Affiliation(s)
- R Dale Brown
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Kendall S Hunter
- Department of Bioengineering, University of Coloradoo Denver, Denver, Colorado, United States
| | - Min Li
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Maria G Frid
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Julie Harral
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Greta M Krafsur
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Timothy N Holt
- Department of Clinical Sciences, College of Veterinary Medicine and Biological Sciences, Colorado State University, Fort Collins, Colorado, United States
| | - Jason Williams
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Denver, Colorado, United States
| | - Hui Zhang
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Suzette R Riddle
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | | | - Sushil Kumar
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Cheng-Jun Hu
- Department of Craniofacial Biology, School of Dental Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Brian B Graham
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, United States
| | - Lori A Walker
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Franklyn B Garry
- Department of Clinical Sciences, College of Veterinary Medicine and Biological Sciences, Colorado State University, Fort Collins, Colorado, United States
| | - Peter M Buttrick
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Tim Lahm
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, University of Colorado Denver, Denver, Colorado, United States
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Denver, Colorado, United States
| | - Vitaly O Kheyfets
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
- Department of Biomedical Informatics, University of Colorado Denver, Denver, Colorado, United States
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Denver, Colorado, United States
| | - Kurt R Stenmark
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, United States
- Department of Medicine, University of Colorado Denver, Denver, Colorado, United States
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8
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Sangam S, Sun X, Schwantes-An TH, Yegambaram M, Lu Q, Shi Y, Cook T, Fisher A, Frump AL, Coleman A, Sun Y, Liang S, Crawford H, Lutz KA, Maun AD, Pauciulo MW, Karnes JH, Chaudhary KR, Stewart DJ, Langlais PR, Jain M, Alotaibi M, Lahm T, Jin Y, Gu H, Tang H, Nichols WC, Black SM, Desai AA. SOX17 Deficiency Mediates Pulmonary Hypertension: At the Crossroads of Sex, Metabolism, and Genetics. Am J Respir Crit Care Med 2023; 207:1055-1069. [PMID: 36913491 PMCID: PMC10112457 DOI: 10.1164/rccm.202203-0450oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 03/14/2023] Open
Abstract
RATIONALE/OBJECTIVES Genetic studies suggest SOX17 deficiency increases pulmonary arterial hypertension (PAH) risk. Based on pathological roles of estrogen and hypoxia inducible factor 2α (HIF-2α) signaling in PA endothelial cells (PAECs), we hypothesized that SOX17 is a target of estrogen signaling that promotes mitochondrial function and attenuates PAH development via HIF-2α inhibition. METHODS We used metabolic (seahorse) and promoter lucifer assays in PAECs along with the chronic hypoxia murine model to test the hypothesis. MEASUREMENTS AND MAIN RESULTS Sox17 expression was reduced in PAH tissues (rodent models and from patients). Chronic hypoxic PH was exacerbated by mice with conditional Tie2-Sox17 (Sox17EC-/-) deletion and attenuated by transgenic Tie2-Sox17 over-expression (Sox17Tg). Based on untargeted proteomics, metabolism was the top pathway altered by SOX17 deficiency in PAECs. Mechanistically, we found HIF-2α levels were increased in the lungs of Sox17EC-/- and reduced in those from Sox17Tg mice. Increased SOX17 promoted oxidative phosphorylation and mitochondrial function in PAECs, which were partly attenuated by HIF-2α overexpression. Rat lungs in males displayed higher Sox17 expression versus females, suggesting repression by estrogen signaling. Supporting 16alpha-hydroxyestrone (16αOHE, a pathologic estrogen metabolite)-mediated repression of SOX17 promoter activity, Sox17Tg mice attenuated 16αOHE-mediated exacerbations of chronic hypoxic PH. Finally, in adjusted analyses in patients with PAH, we report novel associations between a SOX17 risk variant, rs10103692, with reduced plasma citrate levels (n=1326). CONCLUSIONS Cumulatively, SOX17 promotes mitochondrial bioenergetics and attenuates PAH, in part, via inhibition of HIF-2α. 16αOHE mediates PAH development via downregulation of SOX17, linking sexual dimorphism and SOX17 genetics in PAH. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Affiliation(s)
- Shreya Sangam
- Indiana University School of Medicine, 12250, Medicine, Indianapolis, Indiana, United States.,University of Arizona Medical Center - University Campus, 22165, Clinical and Translational Sciences, Tucson, Arizona, United States
| | - Xutong Sun
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Miami, Florida, United States
| | - Tae-Hwi Schwantes-An
- Indiana University, Medical and Molecular Genetics, Indianapolis, Indiana, United States
| | - Manivannan Yegambaram
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Miami, Florida, United States
| | - Qing Lu
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Miami, Florida, United States
| | - Yinan Shi
- Indiana University, Medicine, Indianapolis, Indiana, United States
| | - Todd Cook
- Indiana University School of Medicine, 12250, Medicine, Indianapolis, Indiana, United States
| | - Amanda Fisher
- Indiana University School of Medicine, 12250, Anesthesia, Indianapolis, Indiana, United States
| | - Andrea L Frump
- Indiana University School of Medicine, Division of Pulmonary, Allergy, Critical Care and Occupational Medicine, Indianapolis, Indiana, United States
| | - Anna Coleman
- Cincinnati Children's Hospital Medical Center, 2518, Division of Human Genetics, Cincinnati, Ohio, United States
| | - Yanan Sun
- First Affiliated Hospital of Guangzhou Medical University, 117969, State Key Laboratory of Respiratory Disease, Guangzhou, Guangdong, China.,Northwest A&F University, 12469, College of Veterinary Medicine, Yangling, Shaanxi, China
| | - Shuxin Liang
- First Affiliated Hospital of Guangzhou Medical University, 117969, State Key Laboratory of Respiratory Disease, Guangzhou, Guangdong, China
| | - Howard Crawford
- Henry Ford Health System, 2971, Henry Ford Pancreatic Cancer Center, Detroit, Michigan, United States
| | - Katie A Lutz
- Cincinnati Children's Hospital Medical Center, 2518, Cincinnati, Ohio, United States
| | - Avinash D Maun
- Indiana University School of Medicine, 12250, Medicine, Indianapolis, Indiana, United States
| | - Michael W Pauciulo
- Cincinnati Children's Hospital Medical Center, 2518, Cincinnati, Ohio, United States
| | - Jason H Karnes
- University of Arizona College of Pharmacy, 15498, Pharmacy Practice and Science, Tucson, Arizona, United States
| | - Ketul R Chaudhary
- Dalhousie University, 3688, Physiology and Biophysics, Halifax, Nova Scotia, Canada
| | - Duncan J Stewart
- Ottawa Hospital Research Institute, 10055, Regenerative Medicine, Ottawa, Ontario, Canada.,University of Ottawa, 6363, Cellular and Molecular Medicine, Ottawa, Ontario, Canada
| | | | - Mohit Jain
- University of California San Diego, 8784, Medicine, La Jolla, California, United States
| | - Mona Alotaibi
- University of California San Diego, 8784, Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, La Jolla, California, United States
| | - Tim Lahm
- Indiana University School of Medicine, 12250, Medicine, Indianapolis, Indiana, United States.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, United States
| | - Yan Jin
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Miami, Florida, United States
| | - Haiwei Gu
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Miami, Florida, United States
| | - Haiyang Tang
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou, China
| | - William C Nichols
- Cincinnati Children's Hospital Medical Center, Division of Human Genetics, Cincinnati, Ohio, United States
| | - Stephen M Black
- Florida International University, Center for Translational Science, Port Saint Lucie, Florida, United States.,Florida International University, 5450, Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Miami, Florida, United States.,Florida International University, 5450, Herbert Wertheim College of Medicine, Miami, Florida, United States
| | - Ankit A Desai
- Indiana University, Medicine, Indianapolis, Indiana, United States;
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9
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Frump AL, Yakubov B, Walts A, Fisher A, Cook T, Chesler NC, Lahm T. Estrogen Receptor-α Exerts Endothelium-Protective Effects and Attenuates Pulmonary Hypertension. Am J Respir Cell Mol Biol 2023; 68:341-344. [PMID: 36856412 PMCID: PMC9989477 DOI: 10.1165/rcmb.2022-0224le] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
| | | | | | - Amanda Fisher
- Indiana University School of MedicineIndianapolis, Indiana
| | - Todd Cook
- Indiana University School of MedicineIndianapolis, Indiana
| | | | - Tim Lahm
- National Jewish HealthDenver, Colorado
- University of ColoradoDenver, Colorado
- Rocky Mountain Regional Veterans Affairs Medical CenterAurora, Colorado
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10
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Bousseau S, Sobrano Fais R, Gu S, Frump A, Lahm T. Pathophysiology and new advances in pulmonary hypertension. BMJ Med 2023; 2:e000137. [PMID: 37051026 PMCID: PMC10083754 DOI: 10.1136/bmjmed-2022-000137] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.
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Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Rafael Sobrano Fais
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Sue Gu
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiovascular Pulmonary Research Lab, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrea Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
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11
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Bousseau S, Lahm T. Hungry for Chloride: Reprogramming Endothelial Cell Metabolism in Pulmonary Arterial Hypertension. Am J Respir Cell Mol Biol 2023; 68:11-12. [PMID: 36269721 PMCID: PMC9817906 DOI: 10.1165/rcmb.2022-0386ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine National Jewish Health Denver, Colorado
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine National Jewish Health Denver, Colorado
- Division of Pulmonary Sciences and Critical Care Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado
- Rocky Mountain Regional Veteran Affairs Medical Center Aurora, Colorado
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12
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DuPont M, Hunsicker J, Shirley S, Warriner W, Rowland A, Taylor R, DuPont M, Lagatuz M, Yilmaz T, Foderaro A, Lahm T, Ventetuolo CE, Grant MB. Comparison of Retinal Imaging Techniques in Individuals with Pulmonary Artery Hypertension Using Vessel Generation Analysis. Life (Basel) 2022; 12:1985. [PMID: 36556350 PMCID: PMC9781977 DOI: 10.3390/life12121985] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
(1) Background: Retinal vascular imaging plays an essential role in diagnosing and managing chronic diseases such as diabetic retinopathy, sickle cell retinopathy, and systemic hypertension. Previously, we have shown that individuals with pulmonary arterial hypertension (PAH), a rare disorder, exhibit unique retinal vascular changes as seen using fluorescein angiography (FA) and that these changes correlate with PAH severity. This study aimed to determine if color fundus (CF) imaging could garner identical retinal information as previously seen using FA images in individuals with PAH. (2) Methods: VESGEN, computer software which provides detailed vascular patterns, was used to compare manual segmentations of FA to CF imaging in PAH subjects (n = 9) followed by deep learning (DL) processing of CF imaging to increase the speed of analysis and facilitate a noninvasive clinical translation. (3) Results: When manual segmentation of FA and CF images were compared using VESGEN analysis, both showed identical tortuosity and vessel area density measures. This remained true even when separating images based on arterial trees only. However, this was not observed with microvessels. DL segmentation when compared to manual segmentation of CF images showed similarities in vascular structure as defined by fractal dimension. Similarities were lost for tortuosity and vessel area density when comparing manual CF imaging to DL imaging. (4) Conclusions: Noninvasive imaging such as CF can be used with VESGEN to provide an accurate and safe assessment of retinal vascular changes in individuals with PAH. In addition to providing insight into possible future clinical translational use.
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Affiliation(s)
- Mariana DuPont
- Department of Optometry and Vision Science, School of Optometry, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - John Hunsicker
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Simona Shirley
- Department of Political Science and Public Administration, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - William Warriner
- Research Computing, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Annabelle Rowland
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Reddhyia Taylor
- Department of Osteopathic Medicine, The Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19131, USA
| | - Michael DuPont
- Department of Optometry and Vision Science, School of Optometry, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mark Lagatuz
- Redline Performance Solutions, Ames Research Center, National Aeronautics and Space Administration, Moffett Field, Mountain View, CA 94043, USA
| | - Taygan Yilmaz
- Division of Ophthalmology, Department of Surgery, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Andrew Foderaro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO 80206, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO 80045, USA
- Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
| | - Corey E. Ventetuolo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI 02903, USA
| | - Maria B. Grant
- Department of Optometry and Vision Science, School of Optometry, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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13
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Long GM, Troutman AD, Gray DA, Fisher AJ, Lahm T, Coggan AR, Brown MB. Skeletal muscle blood flow during exercise is reduced in a rat model of pulmonary hypertension. Am J Physiol Regul Integr Comp Physiol 2022; 323:R561-R570. [PMID: 36036455 PMCID: PMC9602702 DOI: 10.1152/ajpregu.00327.2021] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by exercise intolerance. Muscle blood flow may be reduced during exercise in PAH; however, this has not been directly measured. Therefore, we investigated blood flow during exercise in a rat model of monocrotaline (MCT)-induced pulmonary hypertension (PH). Male Sprague-Dawley rats (∼200 g) were injected with 60 mg/kg MCT (MCT, n = 23) and vehicle control (saline; CON, n = 16). Maximal rate of oxygen consumption (V̇o2max) and voluntary running were measured before PH induction. Right ventricle (RV) morphology and function were assessed via echocardiography and invasive hemodynamic measures. Treadmill running at 50% V̇o2max was performed by a subgroup of rats (MCT, n = 8; CON, n = 7). Injection of fluorescent microspheres determined muscle blood flow via photo spectroscopy. MCT demonstrated a severe phenotype via RV hypertrophy (Fulton index, 0.61 vs. 0.31; P < 0.001), high RV systolic pressure (51.5 vs. 22.4 mmHg; P < 0.001), and lower V̇o2max (53.2 vs. 71.8 mL·min-1·kg-1; P < 0.0001) compared with CON. Two-way ANOVA revealed exercising skeletal muscle blood flow relative to power output was reduced in MCT compared with CON (P < 0.001), and plasma lactate was increased in MCT (10.8 vs. 4.5 mmol/L; P = 0.002). Significant relationships between skeletal blood flow and blood lactate during exercise were observed for individual muscles (r = -0.58 to -0.74; P < 0.05). No differences in capillarization were identified. Skeletal muscle blood flow is significantly reduced in experimental PH. Reduced blood flow during exercise may be, at least in part, consequent to reduced exercise intensity in PH. This adds further evidence of peripheral muscle dysfunction and exercise intolerance in PAH.
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Affiliation(s)
- Gary Marshall Long
- Department of Kinesiology, University of Indianapolis, Indianapolis, Indiana
| | - Ashley D Troutman
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Derrick A Gray
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Amanda J Fisher
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Tim Lahm
- Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush Veteran Affairs Medical Center, Indianapolis, Indiana
| | - Andrew R Coggan
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Mary Beth Brown
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
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14
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Volkmann ER, Siegfried J, Lahm T, Ventetuolo CE, Mathai SC, Steen V, Herzog EL, Shansky R, Anguera MC, Danoff SK, Giles JT, Lee YC, Drake W, Maier LA, Lachowicz-Scroggins M, Park H, Banerjee K, Fessel J, Reineck L, Vuga L, Crouser E, Feghali-Bostwick C. Impact of Sex and Gender on Autoimmune Lung Disease: Opportunities for Future Research: NHLBI Working Group Report. Am J Respir Crit Care Med 2022; 206:817-823. [PMID: 35549658 PMCID: PMC9799264 DOI: 10.1164/rccm.202112-2746pp] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 05/13/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Elizabeth R. Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Jill Siegfried
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Tim Lahm
- Pulmonary and Critical Care, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Corey E. Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Brown University, Providence, Rhode Island
| | - Stephen C. Mathai
- Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Virginia Steen
- Division of Rheumatology, Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Erica L. Herzog
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca Shansky
- Department of Psychology, Northeastern University College of Science, Boston, Massachusetts
| | - Montserrat C. Anguera
- Department of Biomedical Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sonye K. Danoff
- Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon T. Giles
- Division of Rheumatology, Department of Medicine, Columbia University, New York City, New York
| | - Yvonne C. Lee
- Division of Rheumatology, Department of Medicine, Northwestern University, Evanston, Illinois
| | - Wonder Drake
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Lisa A. Maier
- Division of Occupational Health and Environmental Health Sciences, National Jewish Health and the University of Colorado, Denver, Colorado
| | - Marrah Lachowicz-Scroggins
- Women’s Health Working Group, NIH Office of Research on Women's Health, National Institute of Health, Bethesda, Maryland
| | - Heiyoung Park
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | | | - Josh Fessel
- Division of Lung Diseases, NHLBI, Bethesda, Maryland
| | - Lora Reineck
- Division of Lung Diseases, NHLBI, Bethesda, Maryland
| | - Louis Vuga
- Division of Lung Diseases, NHLBI, Bethesda, Maryland
| | - Elliott Crouser
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, the Ohio State University, Columbus, Ohio; and
| | - Carol Feghali-Bostwick
- Division of Rheumatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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15
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Sobrano Fais R, Lahm T. Misbehaving Guests in the Right Ventricle: Macrophage NLRP3 Activation in Pulmonary Hypertension. Am J Respir Crit Care Med 2022; 206:532-534. [PMID: 35704289 DOI: 10.1164/rccm.202205-0977ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rafael Sobrano Fais
- National Jewish Health, 2930, Division of Pulmonary, Critical Care and Sleep Medicine, Denver, Colorado, United States
| | - Tim Lahm
- National Jewish Health, 2930, Division of Pulmonary, Critical Care and Sleep Medicine, Denver, Colorado, United States;
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16
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Cheng TC, Tabima DM, Caggiano LR, Frump AL, Hacker TA, Eickhoff JC, Lahm T, Chesler NC. Sex differences in right ventricular adaptation to pressure overload in a rat model. J Appl Physiol (1985) 2022; 132:888-901. [PMID: 35112927 PMCID: PMC8934674 DOI: 10.1152/japplphysiol.00175.2021] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
With severe right ventricular (RV) pressure overload, women demonstrate better clinical outcomes compared with men. The mechanoenergetic mechanisms underlying this protective effect, and their dependence on female endogenous sex hormones, remain unknown. To investigate these mechanisms and their impact on RV systolic and diastolic functional adaptation, we created comparable pressure overload via pulmonary artery banding (PAB) in intact male and female Wistar rats and ovariectomized (OVX) female rats. At 8 wk after surgery, right heart catheterization demonstrated increased RV energy input [indexed pressure-volume area (iPVA)] in all PAB groups, with the greatest increase in intact females. PAB also increased RV energy output [indexed stroke or external work (iEW)] in all groups, again with the greatest increase in intact females. In contrast, PAB only increased RV contractility-indexed end-systolic elastance (iEes)] in females. Despite these sex-dependent differences, no statistically significant effects were observed in the ratio of RV energy output to input (mechanical efficiency) or in mechanoenergetic cost to pump blood with pressure overload. These metrics were similarly unaffected by loss of endogenous sex hormones in females. Also, despite sex-dependent differences in collagen content and organization with pressure overload, decreases in RV compliance and relaxation time constant (tau Weiss) were not determined to be sex dependent. Overall, despite sex-dependent differences in RV contractile and fibrotic responses, RV mechanoenergetics for this degree and duration of pressure overload are comparable between sexes and suggest a homeostatic target.NEW & NOTEWORTHY Sex differences in right ventricular mechanical efficiency and energetic adaptation to increased right ventricular afterload were measured. Despite sex-dependent differences in contractile and fibrotic responses, right ventricular mechanoenergetic adaptation was comparable between the sexes, suggesting a homeostatic target.
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Affiliation(s)
- Tik-Chee Cheng
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Diana M. Tabima
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura R. Caggiano
- 2University of California, Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Irvine, California
| | - Andrea L. Frump
- 3Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy A. Hacker
- 4Cardiovascular Physiology Core Facility, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jens C. Eickhoff
- 5Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Tim Lahm
- 3Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana,6Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado,7Richard L. Roudebush Department of Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Naomi C. Chesler
- 1Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin,2University of California, Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Irvine, California,8Department of Biomedical Engineering, University of California, Irvine, California
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17
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DuPont M, Lambert S, Rodriguez‐Martin A, Hernandez O, Lagatuz M, Yilmaz T, Foderaro A, Baird GL, Parsons‐Wingerter P, Lahm T, Grant MB, Ventetuolo CE. Retinal vessel changes in pulmonary arterial hypertension. Pulm Circ 2022; 12:e12035. [PMID: 35506088 PMCID: PMC9052984 DOI: 10.1002/pul2.12035] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is classically considered an isolated small vessel vasculopathy of the lungs with peripheral pulmonary vascular obliteration. Systemic manifestations of PAH are increasingly acknowledged, but data remain limited. We hypothesized that retinal vascular changes occur in PAH. PAH subjects underwent retinal fluorescein angiography (FA) and routine disease severity measures were collected from the medical record. FA studies were analyzed using VESsel GENerational Analysis (VESGEN), a noninvasive, user‐interactive computer software that assigns branching generation to large and small vessels. FAs from controls (n = 8) and PAH subjects (n = 9) were compared. The tortuosity of retinal arteries was higher in PAH subjects compared to unmatched controls (1.17, 95% confidence interval: [1.14, 1.20] in PAH vs. 1.13, 95% CI: [1.12, 1.14] in controls, p = 0.01). Venous tortuosity was higher and more variable in PAH (1.17, 95% CI: [1.14, 1.20]) compared to controls (1.13, 95% CI: [1.12, 1.15]), p = 0.02. PAH subjects without connective tissue disease had the highest degree of retinal tortuosity relative to controls (arterial, p = 0.01; venous, p = 0.03). Younger PAH subjects had greater retinal arterial tortuosity, which attenuated with age and was not observed in controls. Retinal vascular parameters correlated with some clinical measures of disease in PAH subjects. In conclusion, PAH subjects exhibit higher retinal vascular tortuosity. Retinal vascular changes may track with pulmonary vascular disease progression. Use of FA and VESGEN may facilitate early, noninvasive detection of PAH.
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Affiliation(s)
- Mariana DuPont
- Department of Ophthalmology and Visual Sciences University of Alabama at Birmingham Birmingham Alabama USA
| | - Savanna Lambert
- School of Public Health University of Alabama Birmingham Birmingham Alabama USA
| | - Antonio Rodriguez‐Martin
- Department of Clinical & Diagnostic Sciences University of Alabama at Birmingham Birmingham Alabama USA
| | - Okaeri Hernandez
- Department of Biology University of Alabama at Birmingham Birmingham Alabama USA
| | - Mark Lagatuz
- Redline Performance Solutions, Ames Research Center National Aeronautics and Space Administration Moffett Field California USA
| | - Tayg Yilmaz
- Division of Ophthalmology and Department of Surgery Alpert Medical School of Brown University Providence Rhode Island USA
| | - Andrew Foderaro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Alpert Medical School of Brown University Providence Rhode Island USA
| | - Grayson L. Baird
- Department of Diagnostic Imaging, Alpert Medical School of Brown University Rhode Island Hospital Providence Rhode Island USA
| | - Patricia Parsons‐Wingerter
- Low Gravity Exploration Technology, Research, and Engineering Directorate, John Glenn Research Center National Aeronautics and Space Administration Cleveland Ohio USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Critical Care, Occupational and Sleep Medicine Indiana University Indianapolis Indiana USA
- Department of Anatomy, Cell Biology & Physiology Indiana University Indianapolis Indiana USA
- Richard L. Roudebush VA Medical Center Indianapolis Indiana USA
- Department of Health Services, Policy and Practice Brown University School of Public Health Providence Rhode Island USA
| | - Maria B. Grant
- Department of Ophthalmology and Visual Sciences University of Alabama at Birmingham Birmingham Alabama USA
| | - Corey E. Ventetuolo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Alpert Medical School of Brown University Providence Rhode Island USA
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Allen BJ, Ramanathan R, Frye H, Hacker TA, Lahm T, Chesler N. In-vivo and Ex-vivo Characterization of Estrogen Receptor α (ERα)-Mediated Effects on the Pulmonary Vasculature in PH. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Long GM, Troutman A, Gray D, Frump A, Fisher A, Lahm T, Coggan A, Brown MB. Diaphragmatic Blood Flow Is Increased In A Rat Model Of Pulmonary Arterial Hypertension. Med Sci Sports Exerc 2021. [DOI: 10.1249/01.mss.0000760184.62452.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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20
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Lahm T. Hormones, Hemodynamics, and Hepatic Function: Digesting the Intricacies of Sex Differences in Portopulmonary Hypertension. Chest 2021; 159:11-13. [PMID: 33422194 DOI: 10.1016/j.chest.2020.09.240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and the Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine; and the Richard L. Roudebush VA Medical Center, Indianapolis, IN.
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21
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Qin S, Predescu D, Carman B, Patel P, Chen J, Kim M, Lahm T, Geraci M, Predescu SA. Up-Regulation of the Long Noncoding RNA X-Inactive-Specific Transcript and the Sex Bias in Pulmonary Arterial Hypertension. Am J Pathol 2021; 191:1135-1150. [PMID: 33836164 PMCID: PMC8176134 DOI: 10.1016/j.ajpath.2021.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/15/2021] [Accepted: 03/16/2021] [Indexed: 12/20/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a sex-biased disease. Increased expression and activity of the long-noncoding RNA X-inactive-specific transcript (Xist), essential for X-chromosome inactivation and dosage compensation of X-linked genes, may explain the sex bias of PAH. The present studies used a murine model of plexiform PAH, the intersectin-1s (ITSN) heterozygous knockout (KOITSN+/-) mouse transduced with an ITSN fragment (EHITSN) possessing endothelial cell proliferative activity, in conjunction with molecular, cell biology, biochemical, morphologic, and functional approaches. The data demonstrate significant sex-centered differences with regard to EHITSN-induced alterations in pulmonary artery remodeling, lung hemodynamics, and p38/ETS domain containing protein/c-Fos signaling, altogether leading to a more severe female lung PAH phenotype. Moreover, the long-noncoding RNA-Xist is up-regulated in the lungs of female EHITSN-KOITSN+/- mice compared with that in female wild-type mice, leading to sex-specific modulation of the X-linked gene ETS domain containing protein and its target, two molecular events also characteristic to female human PAH lung. More importantly, cyclin A1 expression in the S and G2/M phases of the cell cycle of synchronized pulmonary artery endothelial cells of female PAH patients is greater versus controls, suggesting functional hyperproliferation. Thus, Xist up-regulation leading to female pulmonary artery endothelial cell sexual dimorphic behavior may provide a better understanding of the origin of sex bias in PAH. Notably, the EHITSN-KOITSN+/- mouse is a unique experimental animal model of PAH that recapitulates most of the sexually dimorphic characteristics of human disease.
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Affiliation(s)
- Shanshan Qin
- Center for Genetic Medicine, Quantitative Data Science Core, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dan Predescu
- Center for Genetic Medicine, Quantitative Data Science Core, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brandon Carman
- Center for Genetic Medicine, Quantitative Data Science Core, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Priyam Patel
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Rush University, Chicago, Illinois
| | - Jiwang Chen
- Pulmonary Critical Care Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Miran Kim
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Tim Lahm
- Health Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Geraci
- Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Rush University, Chicago, Illinois
| | - Sanda A Predescu
- Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Rush University, Chicago, Illinois.
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22
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Leopold JA, Kawut SM, Aldred MA, Archer SL, Benza RL, Bristow MR, Brittain EL, Chesler N, DeMan FS, Erzurum SC, Gladwin MT, Hassoun PM, Hemnes AR, Lahm T, Lima JA, Loscalzo J, Maron BA, Rosa LM, Newman JH, Redline S, Rich S, Rischard F, Sugeng L, Tang WHW, Tedford RJ, Tsai EJ, Ventetuolo CE, Zhou Y, Aggarwal NR, Xiao L. Diagnosis and Treatment of Right Heart Failure in Pulmonary Vascular Diseases: A National Heart, Lung, and Blood Institute Workshop. Circ Heart Fail 2021; 14:e007975. [PMID: 34422205 PMCID: PMC8375628 DOI: 10.1161/circheartfailure.120.007975] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Right ventricular dysfunction is a hallmark of advanced pulmonary vascular, lung parenchymal, and left heart disease, yet the underlying mechanisms that govern (mal)adaptation remain incompletely characterized. Owing to the knowledge gaps in our understanding of the right ventricle (RV) in health and disease, the National Heart, Lung, and Blood Institute (NHLBI) commissioned a working group to identify current challenges in the field. These included a need to define and standardize normal RV structure and function in populations; access to RV tissue for research purposes and the development of complex experimental platforms that recapitulate the in vivo environment; and the advancement of imaging and invasive methodologies to study the RV within basic, translational, and clinical research programs. Specific recommendations were provided, including a call to incorporate precision medicine and innovations in prognosis, diagnosis, and novel RV therapeutics for patients with pulmonary vascular disease.
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Affiliation(s)
- Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Micheala A. Aldred
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Department of Medicine, Indiana University, Indianapolis, IN
| | - Stephen L. Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ray L. Benza
- Department of Medicine, Allegheny General Hospital, Pittsburgh, PA
| | | | - Evan L. Brittain
- Division of Cardiovascular Medicine and Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, TN
| | - Naomi Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI
| | - Frances S. DeMan
- Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Mark T. Gladwin
- Department of Medicine, Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, UPMC and the University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M. Hassoun
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Anna R. Hemnes
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Department of Medicine, Indiana University, Indianapolis, IN
| | - Joao A.C. Lima
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School and Department of Cardiology, Boston VA Healthcare System, West Roxbury, MA
| | - Laura Mercer Rosa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John H. Newman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Susan Redline
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart Rich
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Franz Rischard
- Department of Medicine, University of Arizona- Tucson, Tucson, AZ
| | - Lissa Sugeng
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Emily J. Tsai
- Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Corey E. Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - YouYang Zhou
- Departments of Pediatrics (Division of Critical Care), Pharmacology, and Medicine, Northwestern University Feinberg School of Medicine. Chicago, Illinois
| | - Neil R. Aggarwal
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Lei Xiao
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
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23
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Frump AL, Albrecht M, Yakubov B, Breuils-Bonnet S, Nadeau V, Tremblay E, Potus F, Omura J, Cook T, Fisher A, Rodriguez B, Brown RD, Stenmark KR, Rubinstein CD, Krentz K, Tabima DM, Li R, Sun X, Chesler NC, Provencher S, Bonnet S, Lahm T. 17β-Estradiol and estrogen receptor α protect right ventricular function in pulmonary hypertension via BMPR2 and apelin. J Clin Invest 2021; 131:129433. [PMID: 33497359 DOI: 10.1172/jci129433] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 01/22/2021] [Indexed: 12/30/2022] Open
Abstract
Women with pulmonary arterial hypertension (PAH) exhibit better right ventricular (RV) function and survival than men; however, the underlying mechanisms are unknown. We hypothesized that 17β-estradiol (E2), through estrogen receptor α (ER-α), attenuates PAH-induced RV failure (RVF) by upregulating the procontractile and prosurvival peptide apelin via a BMPR2-dependent mechanism. We found that ER-α and apelin expression were decreased in RV homogenates from patients with RVF and from rats with maladaptive (but not adaptive) RV remodeling. RV cardiomyocyte apelin abundance increased in vivo or in vitro after treatment with E2 or ER-α agonist. Studies employing ER-α-null or ER-β-null mice, ER-α loss-of-function mutant rats, or siRNA demonstrated that ER-α is necessary for E2 to upregulate RV apelin. E2 and ER-α increased BMPR2 in pulmonary hypertension RVs and in isolated RV cardiomyocytes, associated with ER-α binding to the Bmpr2 promoter. BMPR2 is required for E2-mediated increases in apelin abundance, and both BMPR2 and apelin are necessary for E2 to exert RV-protective effects. E2 or ER-α agonist rescued monocrotaline pulmonary hypertension and restored RV apelin and BMPR2. We identified what we believe to be a novel cardioprotective E2/ER-α/BMPR2/apelin axis in the RV. Harnessing this axis may lead to novel RV-targeted therapies for PAH patients of either sex.
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Affiliation(s)
- Andrea L Frump
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marjorie Albrecht
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bakhtiyor Yakubov
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sandra Breuils-Bonnet
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Valérie Nadeau
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Eve Tremblay
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Francois Potus
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Junichi Omura
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Todd Cook
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amanda Fisher
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brooke Rodriguez
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - R Dale Brown
- Department of Pediatrics, University of Colorado-Denver, Aurora, Colorado, USA
| | - Kurt R Stenmark
- Department of Pediatrics, University of Colorado-Denver, Aurora, Colorado, USA
| | - C Dustin Rubinstein
- Genome Editing and Animal Models Core, University of Wisconsin Biotechnology Center
| | - Kathy Krentz
- Genome Editing and Animal Models Core, University of Wisconsin Biotechnology Center
| | | | - Rongbo Li
- Department of Genetics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Xin Sun
- Department of Genetics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Steeve Provencher
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Sebastien Bonnet
- Pulmonary Hypertension Research Group, Institute Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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24
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Hye T, Dwivedi P, Li W, Lahm T, Nozik-Grayck E, Stenmark KR, Ahsan F. Newer insights into the pathobiological and pharmacological basis of the sex disparity in patients with pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1025-L1037. [PMID: 33719549 DOI: 10.1152/ajplung.00559.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) affects more women than men, although affected females tend to survive longer than affected males. This sex disparity in PAH is postulated to stem from the diverse roles of sex hormones in disease etiology. In animal models, estrogens appear to be implicated not only in pathologic remodeling of pulmonary arteries, but also in protection against right ventricular (RV) hypertrophy. In contrast, the male sex hormone testosterone is associated with reduced survival in male animals, where it is associated with increased RV mass, volume, and fibrosis. However, it also has a vasodilatory effect on pulmonary arteries. Furthermore, patients of both sexes show varying degrees of response to current therapies for PAH. As such, there are many gaps and contradictions regarding PAH development, progression, and therapeutic interventions in male versus female patients. Many of these questions remain unanswered, which may be due in part to lack of effective experimental models that can consistently reproduce PAH pulmonary microenvironments in their sex-specific forms. This review article summarizes the roles of estrogens and related sex hormones, immunological and genetical differences, and the benefits and limitations of existing experimental tools to fill in gaps in our understanding of the sex-based variation in PAH development and progression. Finally, we highlight the potential of a new tissue chip-based model mimicking PAH-afflicted male and female pulmonary arteries to study the sex-based differences in PAH and to develop personalized therapies based on patient sex and responsiveness to existing and new drugs.
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Affiliation(s)
- Tanvirul Hye
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, Texas
| | - Pankaj Dwivedi
- Department of Pharmaceutical and Administrative Sciences, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Wei Li
- Department of Chemical Engineering, Texas Tech University, Lubbock, Texas
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Eva Nozik-Grayck
- Department of Pediatrics and Medicine, Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Kurt R Stenmark
- Department of Pediatrics and Medicine, Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Fakhrul Ahsan
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, Texas.,Department of Pharmaceutical and Biomedical Sciences, California Northstate University, Elk Grove, California
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25
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Tello K, Richter MJ, Yogeswaran A, Ghofrani HA, Naeije R, Vanderpool R, Gall H, Tedford RJ, Seeger W, Lahm T. Sex Differences in Right Ventricular-Pulmonary Arterial Coupling in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2020; 202:1042-1046. [PMID: 32501730 DOI: 10.1164/rccm.202003-0807le] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Khodr Tello
- Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | - Manuel J Richter
- Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | | | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center, Giessen, Germany.,Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Imperial College London, London, United Kingdom
| | | | | | - Henning Gall
- Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | - Ryan J Tedford
- Medical University of South Carolina, Charleston, South Carolina
| | - Werner Seeger
- Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | - Tim Lahm
- Indiana University School of Medicine, Indianapolis, Indiana and.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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26
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Glick M, Baxter C, Lopez D, Mufti K, Sawada S, Lahm T. Releasing the brakes: a case report of pulmonary arterial hypertension induced by immune checkpoint inhibitor therapy. Pulm Circ 2020; 10:2045894020960967. [PMID: 33240485 PMCID: PMC7675877 DOI: 10.1177/2045894020960967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 07/06/2020] [Accepted: 08/30/2020] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors successfully treat various malignancies by inducing an immune response to tumor cells. However, their use has been associated with a variety of autoimmune disorders, such as diabetes, hepatitis, and pneumonitis. Pulmonary arterial hypertension due to checkpoint inhibitor use has not yet been described. We present a novel case of pulmonary arterial hypertension associated with systemic lupus erythematosus and Sjogren's syndrome overlap that was induced by therapy with the checkpoint inhibitor durvalumab.
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Affiliation(s)
- Matthew Glick
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Chase Baxter
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - David Lopez
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Kashif Mufti
- Department of Medicine, Division of Rheumatology, Indiana University School of Medicine, Indianapolis, USA
| | - Stephen Sawada
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, USA.,Richard L. Roudebush VA Medical Center, Indianapolis, USA
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27
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Honigberg M, Lahm T, Wood M, Ho J, Kohli P, Natarajan P. Association of premature menopause with incident pulmonary hypertension. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3173] [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: 11/12/2022] Open
Abstract
Abstract
Background
Several forms of pulmonary hypertension (PH) disproportionately affect women. Prior animal and human studies suggest that oestradiol exerts mixed effects on the pulmonary vasculature. Whether premature menopause represents a risk factor for PH is currently unknown.
Purpose
To test the independent association of premature menopause with incident PH.
Methods
We included women in the UK Biobank who were 40–69 years old and postmenopausal at enrolment and underwent pulmonary function testing at the baseline study visit. Women with missing menopause data, prevalent PH, extreme pulmonary function test outliers (Z>5 or Z<−5), and those with congenital heart disease were excluded. Premature menopause was defined as occurring before age 40 years. Reproductive history, including age at menopause and use of menopausal hormone therapy (MHT), was ascertained by participant self-report at enrolment. PH risk factors and relevant co-morbidities were captured by participant self-report and by ICD code. Incident PH was ascertained by the appearance of a qualifying ICD code (ICD-9 4160; ICD-10 I27.0, I27.2). Follow-up began at study enrolment, with time to censoring determined by date of PH diagnosis or last encounter in the medical record. Multivariable Cox proportional hazard models tested the association between premature menopause and incident PH, with adjustment for age, race, ever-smoking, body-mass index, systolic blood pressure, antihypertensive medication use, non-high-density lipoprotein cholesterol, cholesterol-lowering medication use, C-reactive protein, prevalent type 2 diabetes, obstructive sleep apnoea, heart failure, venous thromboembolism, mitral regurgitation, aortic stenosis, forced vital capacity (FVC), the forced expiratory volume in 1 second (FEV1)/FVC ratio, and ever-use of MHT.
Results
Among 138,518 postmenopausal women (mean [SD] age at enrolment 60.0 [5.4] years), 5,440 women (3.9%) had a history of premature menopause. Incident PH was diagnosed in 253 women over a median 8.1 (interquartile range 7.4–8.8) years of follow-up. Mean age at menopause was 48.3 (6.4) years among women with incident PH vs. 49.7 (5.1) years among those without PH (P<0.001). Crude cumulative incidence of PH was 0.40% among women premature menopause vs. 0.17% among those without (Figure 1). After multivariable adjustment, premature menopause remained independently associated with PH (hazard ratio [HR] 1.91, 95% CI 1.15–3.16, P=0.01). Ever-use of MHT was not significantly associated with incident PH (HR 0.93, 95% CI 0.68–1.26, P=0.62). In sensitivity analysis excluding 4,461 women with prevalent heart failure, venous thromboembolism, mitral regurgitation, or aortic stenosis, the HR for PH associated with premature menopause was 2.19 (95% CI 1.28–3.74, P=0.004).
Conclusions
Premature menopause is an independent risk factor for PH in women.
Figure 1
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): U.S. National Heart, Lung, and Blood Institute
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Affiliation(s)
- M Honigberg
- Massachusetts General Hospital, Boston, United States of America
| | - T Lahm
- Indiana University School of Medicine, Indianapolis, United States of America
| | - M Wood
- Massachusetts General Hospital, Boston, United States of America
| | - J Ho
- Massachusetts General Hospital, Boston, United States of America
| | - P Kohli
- Massachusetts General Hospital, Boston, United States of America
| | - P Natarajan
- Massachusetts General Hospital, Boston, United States of America
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28
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Cheng TC, Philip JL, Tabima DM, Kumari S, Yakubov B, Frump AL, Hacker TA, Bellofiore A, Li R, Sun X, Goss KN, Lahm T, Chesler NC. Estrogen receptor-α prevents right ventricular diastolic dysfunction and fibrosis in female rats. Am J Physiol Heart Circ Physiol 2020; 319:H1459-H1473. [PMID: 33064565 DOI: 10.1152/ajpheart.00247.2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although women are more susceptible to pulmonary arterial hypertension (PAH) than men, their right ventricular (RV) function is better preserved. Estrogen receptor-α (ERα) has been identified as a likely mediator for estrogen protection in the RV. However, the role of ERα in preserving RV function and remodeling during pressure overload remains poorly understood. We hypothesized that loss of functional ERα removes female protection from adverse remodeling and is permissive for the development of a maladapted RV phenotype. Male and female rats with a loss-of-function mutation in ERα (ERαMut) and wild-type (WT) littermates underwent RV pressure overload by pulmonary artery banding (PAB). At 10 wk post-PAB, WT and ERαMut demonstrated RV hypertrophy. Analysis of RV pressure waveforms demonstrated RV-pulmonary vascular uncoupling and diastolic dysfunction in female, but not male, ERαMut PAB rats. Similarly, female, but not male, ERαMut exhibited increased RV fibrosis, comprised primarily of thick collagen fibers. There was an increased protein expression ratio of TIMP metallopeptidase inhibitor 1 (Timp1) to matrix metalloproteinase 9 (Mmp9) in female ERαMut compared with WT PAB rats, suggesting less collagen degradation. RNA-sequencing in female WT and ERαMut RV revealed kallikrein-related peptidase 10 (Klk10) and Jun Proto-Oncogene (Jun) as possible mediators of female RV protection during PAB. In summary, ERα in females is protective against RV-pulmonary vascular uncoupling, diastolic dysfunction, and fibrosis in response to pressure overload. ERα appears to be dispensable for RV adaptation in males. ERα may be a mediator of superior RV adaptation in female patients with PAH.NEW & NOTEWORTHY Using a novel loss-of-function mutation in estrogen receptor-α (ERα), we demonstrate that female, but not male, ERα mutant rats display right ventricular (RV)-vascular uncoupling, diastolic dysfunction, and fibrosis following pressure overload, indicating a sex-dependent role of ERα in protecting against adverse RV remodeling. TIMP metallopeptidase inhibitor 1 (Timp1), matrix metalloproteinase 9 (Mmp9), kallikrein-related peptidase 10 (Klk10), and Jun Proto-Oncogene (Jun) were identified as potential mediators in ERα-regulated pathways in RV pressure overload.
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Affiliation(s)
- Tik-Chee Cheng
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jennifer L Philip
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Santosh Kumari
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Bakhtiyor Yakubov
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy A Hacker
- Cardiovascular Research Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Alessandro Bellofiore
- Department of Biomedical, Chemical and Materials Engineering, San Jose State University, San Jose, California
| | - Rongbo Li
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Xin Sun
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Kara N Goss
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Cellular and Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Lahm T, Hess E, Barón AE, Maddox TM, Plomondon ME, Choudhary G, Maron BA, Zamanian RT, Leary PJ. Renin-Angiotensin-Aldosterone System Inhibitor Use and Mortality in Pulmonary Hypertension: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking Database. Chest 2020; 159:1586-1597. [PMID: 33031831 DOI: 10.1016/j.chest.2020.09.258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 06/09/2020] [Revised: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The renin-angiotensin-aldosterone system (RAAS) contributes to pulmonary hypertension (PH) pathogenesis. Although animal data suggest that RAAS inhibition attenuates PH, it is unknown if RAAS inhibition is beneficial in PH patients. RESEARCH QUESTION Is RAAS inhibitor use associated with lower mortality in a large cohort of patients with hemodynamically confirmed PH? STUDY DESIGN AND METHODS We used the Department of Veterans Affairs Clinical Assessment Reporting and Tracking Database to study retrospectively relationships between RAAS inhibitors (angiotensin converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], and aldosterone antagonists [AAs]) and mortality in 24,221 patients with hemodynamically confirmed PH. We evaluated relationships in the full and in propensity-matched cohorts. Analyses were adjusted for demographics, socioeconomic status, comorbidities, disease severity, and comedication use in staged models. RESULTS ACEI and ARB use was associated with improved survival in unadjusted Kaplan-Meier survival analyses in the full cohort and the propensity-matched cohort. This relationship was insensitive to adjustment, independent of pulmonary artery wedge pressure, and also was observed in a cohort restricted to individuals with precapillary PH. AA use was associated with worse survival in unadjusted Kaplan-Meier survival analyses in the full cohort; however, AA use was associated less robustly with mortality in the propensity-matched cohort and was not associated with worse survival after adjustment for disease severity, indicating that AAs in real-world practice are used preferentially in sicker patients and that the unadjusted association with increased mortality may be an artifice of confounding by indication of severity. INTERPRETATION ACEI and ARB use is associated with lower mortality in veterans with PH. AA use is a marker of disease severity in PH. ACEIs and ARBs may represent a novel treatment strategy for diverse PH phenotypes.
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Affiliation(s)
- Tim Lahm
- Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, IN.
| | - Edward Hess
- Veterans Affairs Eastern Colorado Health Care System, Denver, CO
| | - Anna E Barón
- Veterans Affairs Eastern Colorado Health Care System, Denver, CO; Colorado School of Public Health, Denver, CO
| | - Thomas M Maddox
- Washington University School of Medicine Division of Cardiology and Healthcare Innovation Lab, St. Louis, MO
| | - Mary E Plomondon
- Veterans Affairs Eastern Colorado Health Care System, Denver, CO
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center, Providence, RI; Alpert Medical School of Brown University, Providence, RI
| | - Bradley A Maron
- Veterans Affairs Boston Healthcare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Roham T Zamanian
- Stanford University Division of Pulmonary, Allergy, and Critical Care Medicine and Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA
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30
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Agrawal V, Lahm T, Hansmann G, Hemnes AR. Molecular mechanisms of right ventricular dysfunction in pulmonary arterial hypertension: focus on the coronary vasculature, sex hormones, and glucose/lipid metabolism. Cardiovasc Diagn Ther 2020; 10:1522-1540. [PMID: 33224772 PMCID: PMC7666935 DOI: 10.21037/cdt-20-404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare, life-threatening condition characterized by dysregulated metabolism, pulmonary vascular remodeling, and loss of pulmonary vascular cross-sectional area due to a variety of etiologies. Right ventricular (RV) dysfunction in PAH is a critical mediator of both long-term morbidity and mortality. While combinatory oral pharmacotherapy and/or intravenous prostacyclin aimed at decreasing pulmonary vascular resistance (PVR) have improved clinical outcomes, there are currently no treatments that directly address RV failure in PAH. This is, in part, due to the incomplete understanding of the pathogenesis of RV dysfunction in PAH. The purpose of this review is to discuss the current understanding of key molecular mechanisms that cause, contribute and/or sustain RV dysfunction, with a special focus on pathways that either have led to or have the potential to lead to clinical therapeutic intervention. Specifically, this review discusses the mechanisms by which vessel loss and dysfunctional angiogenesis, sex hormones, and metabolic derangements in PAH directly contribute to RV dysfunction. Finally, this review discusses limitations and future areas of investigation that may lead to novel understanding and therapeutic interventions for RV dysfunction in PAH.
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Affiliation(s)
- Vineet Agrawal
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tim Lahm
- Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Anna R. Hemnes
- Division of Allergy, Pulmonology and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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31
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Al-Hilal TA, Keshavarz A, Kadry H, Lahooti B, Al-Obaida A, Ding Z, Li W, Kamm R, McMurtry IF, Lahm T, Nozik-Grayck E, Stenmark KR, Ahsan F. Pulmonary-arterial-hypertension (PAH)-on-a-chip: fabrication, validation and application. Lab Chip 2020; 20:3334-3345. [PMID: 32749432 PMCID: PMC7592346 DOI: 10.1039/d0lc00605j] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Currently used animal and cellular models for pulmonary arterial hypertension (PAH) only partially recapitulate its pathophysiology in humans and are thus inadequate in reproducing the hallmarks of the disease, inconsistent in portraying the sex-disparity, and unyielding to combinatorial study designs. Here we sought to deploy the ingenuity of microengineering in developing and validating a tissue chip model for human PAH. We designed and fabricated a microfluidic device to emulate the luminal, intimal, medial, adventitial, and perivascular layers of a pulmonary artery. By growing three types of pulmonary arterial cells (PACs)-endothelial, smooth muscle, and adventitial cells, we recreated the PAH pathophysiology on the device. Diseased (PAH) PACs, when grown on the chips, moved of out their designated layers and created phenomena similar to the major pathologies of human PAH: intimal thickening, muscularization, and arterial remodeling and show an endothelial to mesenchymal transition. Flow-induced stress caused control cells, grown on the chips, to undergo morphological changes and elicit arterial remodeling. Our data also suggest that the newly developed chips can be used to elucidate the sex disparity in PAH and to study the therapeutic efficacy of existing and investigational anti-PAH drugs. We believe this miniaturized device can be deployed for testing various prevailing and new hypotheses regarding the pathobiology and drug therapy in human PAH.
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Affiliation(s)
- Taslim A Al-Hilal
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, 1300 Coulter Dr., Amarillo, 79119 Texas, USA.
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32
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Affiliation(s)
- Tim Lahm
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
- Richard L. Roudebush Department of Veterans Affairs Medical Center, Indianapolis, Indiana
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33
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Krishnan S, Stearman RS, Zeng L, Fisher A, Mickler EA, Rodriguez BH, Simpson ER, Cook T, Slaven JE, Ivan M, Geraci MW, Lahm T, Tepper RS. Transcriptomic modifications in developmental cardiopulmonary adaptations to chronic hypoxia using a murine model of simulated high-altitude exposure. Am J Physiol Lung Cell Mol Physiol 2020; 319:L456-L470. [PMID: 32639867 DOI: 10.1152/ajplung.00487.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/22/2022] Open
Abstract
Mechanisms driving adaptive developmental responses to chronic high-altitude (HA) exposure are incompletely known. We developed a novel rat model mimicking the human condition of cardiopulmonary adaptation to HA starting at conception and spanning the in utero and postnatal timeframe. We assessed lung growth and cardiopulmonary structure and function and performed transcriptome analyses to identify mechanisms facilitating developmental adaptations to chronic hypoxia. To generate the model, breeding pairs of Sprague-Dawley rats were exposed to hypobaric hypoxia (equivalent to 9,000 ft elevation). Mating, pregnancy, and delivery occurred in hypoxic conditions. Six weeks postpartum, structural and functional data were collected in the offspring. RNA-Seq was performed on right ventricle (RV) and lung tissue. Age-matched breeding pairs and offspring under room air (RA) conditions served as controls. Hypoxic rats exhibited significantly lower body weights and higher hematocrit levels, alveolar volumes, pulmonary diffusion capacities, RV mass, and RV systolic pressure, as well as increased pulmonary artery remodeling. RNA-Seq analyses revealed multiple differentially expressed genes in lungs and RVs from hypoxic rats. Although there was considerable similarity between hypoxic lungs and RVs compared with RA controls, several upstream regulators unique to lung or RV were identified. We noted a pattern of immune downregulation and regulation patterns of immune and hormonal mediators similar to the genome from patients with pulmonary arterial hypertension. In summary, we developed a novel murine model of chronic hypoxia exposure that demonstrates functional and structural phenotypes similar to human adaptation. We identified transcriptomic alterations that suggest potential mechanisms for adaptation to chronic HA.
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Affiliation(s)
- Sheila Krishnan
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robert S Stearman
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lily Zeng
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Amanda Fisher
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Elizabeth A Mickler
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brooke H Rodriguez
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Edward R Simpson
- Department of BioHealth Informatics, School of Informatics and Computing, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana.,Center for Computational Biology and Bioinformatics, Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Todd Cook
- Indiana Center for Vascular Biology and Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Medicine, Division of Hematology and Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mircea Ivan
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark W Geraci
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Robert S Tepper
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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Long GM, Frump A, Troutman A, Mailand M, Ellis KA, Fisher A, Avin K, Lahm T, Coggan AR, Brown MB. Dietary Nitrate Does Not Increase Exercising Muscle Blood Flow In Rat With Pulmonary Arterial Hypertension. Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000675992.64423.dc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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35
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Chelvanambi S, Hester JM, Sharma S, Lahm T, Frump AL. Slide-Seq for Spatially Mapping Gene Expression. Metabolic Syndrome Exacerbates Group 2 Pulmonary Hypertension, and NAD Metabolism Is Influenced by Tissue Origin. Am J Respir Cell Mol Biol 2020; 62:112-114. [PMID: 31633380 DOI: 10.1165/rcmb.2019-0333ro] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Sarvesh Chelvanambi
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and
| | - James M Hester
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and
| | - Samantha Sharma
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and.,Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, and
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36
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Frump AL, Lahm T. Tips for success in pulmonary hypertension treatment: progress in isolating endothelial cells from pulmonary artery catheters. Eur Respir J 2020; 55:55/3/2000122. [PMID: 32198271 DOI: 10.1183/13993003.00122-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Dept of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Dept of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Richard L. Roudebush VA Medical Center, Indiana University, Indianapolis, IN, USA
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37
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Frump AL, Lai YC, Lahm T. Assessing the cancer hypothesis of pulmonary arterial hypertension: the devil is in the detail. Am J Physiol Lung Cell Mol Physiol 2020; 318:L1140-L1141. [PMID: 32186392 DOI: 10.1152/ajplung.00084.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
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38
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Daniell H, Mangu V, Yakubov B, Park J, Habibi P, Shi Y, Gonnella PA, Fisher A, Cook T, Zeng L, Kawut SM, Lahm T. Investigational new drug enabling angiotensin oral-delivery studies to attenuate pulmonary hypertension. Biomaterials 2020; 233:119750. [PMID: 31931441 PMCID: PMC7045910 DOI: 10.1016/j.biomaterials.2019.119750] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/16/2019] [Accepted: 12/28/2019] [Indexed: 01/21/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a deadly and uncurable disease characterized by remodeling of the pulmonary vasculature and increased pulmonary artery pressure. Angiotensin Converting Enzyme 2 (ACE2) and its product, angiotensin-(1-7) [ANG-(1-7)] were expressed in lettuce chloroplasts to facilitate affordable oral drug delivery. Lyophilized lettuce cells were stable up to 28 months at ambient temperature with proper folding, assembly of CTB-ACE2/ANG-(1-7) and functionality. When the antibiotic resistance gene was removed, Ang1-7 expression was stable in subsequent generations in marker-free transplastomic lines. Oral gavage of monocrotaline-induced PAH rats resulted in dose-dependent delivery of ANG-(1-7) and ACE2 in plasma/tissues and PAH development was attenuated with decreases in right ventricular (RV) hypertrophy, RV systolic pressure, total pulmonary resistance and pulmonary artery remodeling. Such attenuation correlated well with alterations in the transcription of Ang-(1-7) receptor MAS and angiotensin II receptor AGTRI as well as IL-1β and TGF-β1. Toxicology studies showed that both male and female rats tolerated ~10-fold ACE2/ANG-(1-7) higher than efficacy dose. Plant cell wall degrading enzymes enhanced plasma levels of orally delivered protein drug bioencapsulated within plant cells. Efficient attenuation of PAH with no toxicity augurs well for clinical advancement of the first oral protein therapy to prevent/treat underlying pathology for this disease.
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Affiliation(s)
- Henry Daniell
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Venkata Mangu
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bakhtiyor Yakubov
- Department of Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, Indianapolis, IN, USA
| | - Jiyoung Park
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peyman Habibi
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yao Shi
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia A Gonnella
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda Fisher
- Department of Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, Indianapolis, IN, USA
| | - Todd Cook
- Department of Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, Indianapolis, IN, USA
| | - Lily Zeng
- Department of Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, Indianapolis, IN, USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, Indianapolis, IN, USA; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN, USA; Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
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39
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Philip JL, Tabima DM, Wolf GD, Frump AL, Cheng TC, Schreier DA, Hacker TA, Lahm T, Chesler NC. Exogenous Estrogen Preserves Distal Pulmonary Arterial Mechanics and Prevents Pulmonary Hypertension in Rats. Am J Respir Crit Care Med 2020; 201:371-374. [PMID: 31661294 PMCID: PMC6999110 DOI: 10.1164/rccm.201906-1217le] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jennifer L. Philip
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
- University of Wisconsin–Madison
School of Medicine and Public HealthMadison, Wisconsin
| | - Diana M. Tabima
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
| | - Gregory D. Wolf
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
| | - Andrea L. Frump
- Indiana University School of
MedicineIndianapolis, Indianaand
| | - Tik-Chee Cheng
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
| | - David A. Schreier
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
| | - Timothy A. Hacker
- University of Wisconsin–Madison
School of Medicine and Public HealthMadison, Wisconsin
| | - Tim Lahm
- Indiana University School of
MedicineIndianapolis, Indianaand
- Richard L. Roudebush VA Medical
CenterIndianapolis, Indiana
| | - Naomi C. Chesler
- University of Wisconsin–Madison
College of EngineeringMadison, Wisconsin
- University of Wisconsin–Madison
School of Medicine and Public HealthMadison, Wisconsin
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Abstract
Pulmonary hypertension (PH) encompasses a syndrome of diseases that are characterized by elevated pulmonary artery pressure and pulmonary vascular remodeling and that frequently lead to right ventricular (RV) failure and death. Several types of PH exhibit sexually dimorphic features in disease penetrance, presentation, and progression. Most sexually dimorphic features in PH have been described in pulmonary arterial hypertension (PAH), a devastating and progressive pulmonary vasculopathy with a 3-year survival rate <60%. While patient registries show that women are more susceptible to development of PAH, female PAH patients display better RV function and increased survival compared to their male counterparts, a phenomenon referred to as the "estrogen paradox" or "estrogen puzzle" of PAH. Recent advances in the field have demonstrated that multiple sex hormones, receptors, and metabolites play a role in the estrogen puzzle and that the effects of hormone signaling may be time and compartment specific. While the underlying physiological mechanisms are complex, unraveling the estrogen puzzle may reveal novel therapeutic strategies to treat and reverse the effects of PAH/PH. In this article, we (i) review PH classification and pathophysiology; (ii) discuss sex/gender differences observed in patients and animal models; (iii) review sex hormone synthesis and metabolism; (iv) review in detail the scientific literature of sex hormone signaling in PAH/PH, particularly estrogen-, testosterone-, progesterone-, and dehydroepiandrosterone (DHEA)-mediated effects in the pulmonary vasculature and RV; (v) discuss hormone-independent variables contributing to sexually dimorphic disease presentation; and (vi) identify knowledge gaps and pathways forward. © 2020 American Physiological Society. Compr Physiol 10:125-170, 2020.
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Affiliation(s)
- James Hester
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Corey Ventetuolo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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41
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Han MK, Arteaga-Solis E, Blenis J, Bourjeily G, Clegg DJ, DeMeo D, Duffy J, Gaston B, Heller NM, Hemnes A, Henske EP, Jain R, Lahm T, Lancaster LH, Lee J, Legato MJ, McKee S, Mehra R, Morris A, Prakash YS, Stampfli MR, Gopal-Srivastava R, Laposky AD, Punturieri A, Reineck L, Tigno X, Clayton J. Female Sex and Gender in Lung/Sleep Health and Disease. Increased Understanding of Basic Biological, Pathophysiological, and Behavioral Mechanisms Leading to Better Health for Female Patients with Lung Disease. Am J Respir Crit Care Med 2019; 198:850-858. [PMID: 29746147 DOI: 10.1164/rccm.201801-0168ws] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Female sex/gender is an undercharacterized variable in studies related to lung development and disease. Notwithstanding, many aspects of lung and sleep biology and pathobiology are impacted by female sex and female reproductive transitions. These may manifest as differential gene expression or peculiar organ development. Some conditions are more prevalent in women, such as asthma and insomnia, or, in the case of lymphangioleiomyomatosis, are seen almost exclusively in women. In other diseases, presentation differs, such as the higher frequency of exacerbations experienced by women with chronic obstructive pulmonary disease or greater cardiac morbidity among women with sleep-disordered breathing. Recent advances in -omics and behavioral science provide an opportunity to specifically address sex-based differences and explore research needs and opportunities that will elucidate biochemical pathways, thus enabling more targeted/personalized therapies. To explore the status of and opportunities for research in this area, the NHLBI, in partnership with the NIH Office of Research on Women's Health and the Office of Rare Diseases Research, convened a workshop of investigators in Bethesda, Maryland on September 18 and 19, 2017. At the workshop, the participants reviewed the current understanding of the biological, behavioral, and clinical implications of female sex and gender on lung and sleep health and disease, and formulated recommendations that address research gaps, with a view to achieving better health outcomes through more precise management of female patients with nonneoplastic lung disease. This report summarizes those discussions.
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Affiliation(s)
- MeiLan K Han
- 1 Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Emilio Arteaga-Solis
- 2 Division of Pediatric Pulmonology, Columbia University Medical Center, New York, New York
| | - John Blenis
- 3 Pharmacology Ph.D. Program, Sandra and Edward Meyer Cancer Center, New York, New York
| | - Ghada Bourjeily
- 4 Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah J Clegg
- 5 Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Dawn DeMeo
- 6 Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeanne Duffy
- 7 Department of Medicine and.,8 Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ben Gaston
- 9 Pediatric Pulmonology, Case Western Reserve University, Cleveland, Ohio
| | - Nicola M Heller
- 10 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna Hemnes
- 11 Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth Petri Henske
- 12 Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raksha Jain
- 13 Division of Pulmonary and Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tim Lahm
- 14 Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lisa H Lancaster
- 15 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joyce Lee
- 16 Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, Colorado
| | | | - Sherry McKee
- 18 Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Reena Mehra
- 19 Neurologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alison Morris
- 20 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Y S Prakash
- 21 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Martin R Stampfli
- 22 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rashmi Gopal-Srivastava
- 23 Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland
| | - Aaron D Laposky
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | | | - Lora Reineck
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | - Xenia Tigno
- 24 Division of Lung Diseases, NHLBI/NIH, Bethesda, Maryland; and
| | - Janine Clayton
- 25 Office of Research on Women's Health, NIH-Office of the Director, Bethesda, Maryland
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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Affiliation(s)
- Andrea L Frump
- 1 Department of Medicine Indiana University School of Medicine Indianapolis, Indiana
| | - Tim Lahm
- 1 Department of Medicine Indiana University School of Medicine Indianapolis, Indiana.,2 Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis, Indiana and.,3 Richard L. Roudebush VA Medical Center Indianapolis, Indiana
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Leary PJ, Hess E, Barón AE, Branch KR, Choudhary G, Hough CL, Maron BA, Ralph DD, Ryan JJ, Tedford RJ, Weiss NS, Zamanian RT, Lahm T. H2 Receptor Antagonist Use and Mortality in Pulmonary Hypertension: Insight from the VA-CART Program. Am J Respir Crit Care Med 2019; 197:1638-1641. [PMID: 29437490 DOI: 10.1164/rccm.201801-0048le] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Edward Hess
- 2 Veterans Affairs Eastern Colorado Health Care System Denver, Colorado
| | - Anna E Barón
- 2 Veterans Affairs Eastern Colorado Health Care System Denver, Colorado.,3 Colorado School of Public Health Denver, Colorado
| | | | - Gaurav Choudhary
- 4 Providence Veterans Affairs Medical Center Providence, Rhode Island.,5 Alpert Medical School of Brown University Providence, Rhode Island
| | | | - Bradley A Maron
- 6 Veterans Affairs Boston Healthcare System Boston, Massachusetts.,7 Brigham and Women's Hospital Boston, Massachusetts.,8 Harvard Medical School Boston, Massachusetts
| | | | | | - Ryan J Tedford
- 10 Medical University of South Carolina Charleston, South Carolina
| | | | | | - Tim Lahm
- 12 Richard L. Roudebush Veterans Affairs Medical Center Indianapolis, Indiana and.,13 Indiana University School of Medicine Indianapolis, Indiana
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45
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Long GM, Frump A, Troutman A, Mailand M, Ellis KA, Fisher A, Avin K, Coggan AR, Lahm T, Brown MB. Exercising Skeletal Muscle Blood Flow is Diminished in a Rat Model of Pulmonary Arterial Hypertension. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000562337.85607.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The role of perinatal insults in the development of adult onset pulmonary
hypertension (PH) is unclear. We surveyed patients with and without PH for a
history of early life risk factors, and identified prematurity, oxygen use, and
respiratory illness each as risk predictors for development of adult PH.
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Affiliation(s)
- Kara N Goss
- 1 Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Eric D Austin
- 2 Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Therese J Battiola
- 1 Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert S Tepper
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- 4 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,5 Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
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Frump AL, Selej M, Wood JA, Albrecht M, Yakubov B, Petrache I, Lahm T. Hypoxia Upregulates Estrogen Receptor β in Pulmonary Artery Endothelial Cells in a HIF-1α-Dependent Manner. Am J Respir Cell Mol Biol 2019; 59:114-126. [PMID: 29394091 DOI: 10.1165/rcmb.2017-0167oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
17β-Estradiol (E2) attenuates hypoxia-induced pulmonary hypertension (HPH) through estrogen receptor (ER)-dependent effects, including inhibition of hypoxia-induced endothelial cell proliferation; however, the mechanisms responsible for this remain unknown. We hypothesized that the protective effects of E2 in HPH are mediated through hypoxia-inducible factor 1α (HIF-1α)-dependent increases in ERβ expression. Sprague-Dawley rats and ERα or ERβ knockout mice were exposed to hypobaric hypoxia for 2-3 weeks. The effects of hypoxia were also studied in primary rat or human pulmonary artery endothelial cells (PAECs). Hypoxia increased expression of ERβ, but not ERα, in lungs from HPH rats as well as in rat and human PAECs. ERβ mRNA time dependently increased in PAECs exposed to hypoxia. Normoxic HIF-1α/HIF-2α stabilization increased PAEC ERβ, whereas HIF-1α knockdown decreased ERβ abundance in hypoxic PAECs. In turn, ERβ knockdown in hypoxic PAECs increased HIF-2α expression, suggesting a hypoxia-sensitive feedback mechanism. ERβ knockdown in hypoxic PAECs also decreased expression of the HIF inhibitor prolyl hydroxylase 2 (PHD2), whereas ERβ activation increased PHD2 and decreased both HIF-1α and HIF-2α, suggesting that ERβ regulates the PHD2/HIF-1α/HIF-2α axis during hypoxia. Whereas hypoxic wild-type or ERα knockout mice treated with E2 demonstrated less pulmonary vascular remodeling and decreased HIF-1α after hypoxia compared with untreated hypoxic mice, ERβ knockout mice exhibited increased HIF-2α and an attenuated response to E2 during hypoxia. Taken together, our results demonstrate a novel and potentially therapeutically targetable mechanism whereby hypoxia, via HIF-1α, increases ERβ expression and the E2-ERβ axis targets PHD2, HIF-1α, and HIF-2α to attenuate HPH development.
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Affiliation(s)
- Andrea L Frump
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Mona Selej
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Jordan A Wood
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Marjorie Albrecht
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Bakhtiyor Yakubov
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine
| | - Irina Petrache
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine.,2 Richard L. Roudebush VA Medical Center, and
| | - Tim Lahm
- 1 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine.,2 Richard L. Roudebush VA Medical Center, and.,3 Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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48
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Philip JL, Murphy TM, Schreier DA, Stevens S, Tabima DM, Albrecht M, Frump AL, Hacker TA, Lahm T, Chesler NC. Pulmonary vascular mechanical consequences of ischemic heart failure and implications for right ventricular function. Am J Physiol Heart Circ Physiol 2019; 316:H1167-H1177. [PMID: 30767670 DOI: 10.1152/ajpheart.00319.2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Left heart failure (LHF) is the most common cause of pulmonary hypertension, which confers an increase in morbidity and mortality in this context. Pulmonary vascular resistance has prognostic value in LHF, but otherwise the mechanical consequences of LHF for the pulmonary vasculature and right ventricle (RV) remain unknown. We sought to investigate mechanical mechanisms of pulmonary vascular and RV dysfunction in a rodent model of LHF to address the knowledge gaps in understanding disease pathophysiology. LHF was created using a left anterior descending artery ligation to cause myocardial infarction (MI) in mice. Sham animals underwent thoracotomy alone. Echocardiography demonstrated increased left ventricle (LV) volumes and decreased ejection fraction at 4 wk post-MI that did not normalize by 12 wk post-MI. Elevation of LV diastolic pressure and RV systolic pressure at 12 wk post-MI demonstrated pulmonary hypertension (PH) due to LHF. There was increased pulmonary arterial elastance and pulmonary vascular resistance associated with perivascular fibrosis without other remodeling. There was also RV contractile dysfunction with a 35% decrease in RV end-systolic elastance and 66% decrease in ventricular-vascular coupling. In this model of PH due to LHF with reduced ejection fraction, pulmonary fibrosis contributes to increased RV afterload, and loss of RV contractility contributes to RV dysfunction. These are key pathologic features of human PH secondary to LHF. In the future, novel therapeutic strategies aimed at preventing pulmonary vascular mechanical changes and RV dysfunction in the context of LHF can be tested using this model. NEW & NOTEWORTHY In this study, we investigate the mechanical consequences of left heart failure with reduced ejection fraction for the pulmonary vasculature and right ventricle. Using comprehensive functional analyses of the cardiopulmonary system in vivo and ex vivo, we demonstrate that pulmonary fibrosis contributes to increased RV afterload and loss of RV contractility contributes to RV dysfunction. Thus this model recapitulates key pathologic features of human pulmonary hypertension-left heart failure and offers a robust platform for future investigations.
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Affiliation(s)
- Jennifer L Philip
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering , Madison, Wisconsin.,Department of Surgery, University of Wisconsin-Madison , Madison, Wisconsin
| | - Thomas M Murphy
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering , Madison, Wisconsin
| | - David A Schreier
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering , Madison, Wisconsin
| | - Sydney Stevens
- Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering , Madison, Wisconsin
| | - Margie Albrecht
- Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Andrea L Frump
- Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Timothy A Hacker
- Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
| | - Tim Lahm
- Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center , Indianapolis, Indiana
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering , Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
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49
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Krishnan S, Lahm T. A case report of hepatopulmonary syndrome in hereditary hemorrhagic telangiectasia (HHT): Not all right-to-left shunting in HHT is due to pulmonary arteriovenous malformations. Medicine (Baltimore) 2018; 97:e11513. [PMID: 30095617 PMCID: PMC6133419 DOI: 10.1097/md.0000000000011513] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by abnormal vessel growth that results in telangiectasias and arteriovenous malformations (AVMs) in the skin, mucosa, and viscera. Up to 30% of patients with HHT exhibit pulmonary AVMs (PAVMs), clinically manifesting as right-to-left shunting and hypoxemia. PATIENT CONCERNS We report an unusual and novel case of a patient with HHT who lacked clinical sequelae of portal hypertension but presented to clinic with hypoxemia without dyspnea. DIAGNOSES Diagnostic workup revealed noncardiac right-to-left shunting due to hepatopulmonary syndrome (HPS) from HHT-induced portal hypertension rather than PAVMs. The diagnosis was confirmed by the absence of PAVMs on chest computed tomography and evidence of elevated portal pressures as noted by the presence of small esophageal varices on upper endoscopy and histologic findings on liver biopsy. INTERVENTION Due to the patient's mild symptoms, no further intervention was required. He was closely followed up in the outpatient setting for changes in symptoms and underwent annual screening for development of PAVMs. OUTCOMES The patient continues to do well clinically. He has not experienced worsening hypoxemia or dyspnea and has not developed PAVMs. LESSONS Given that management of hypoxemia in HPS drastically differs from that of hypoxemia due to PAVMs, this case demonstrates the importance of evaluating HHT patients for HPS if they exhibit impaired oxygenation and noncardiac right-to-leftshunting in the setting of hepatic arteriovenous shunting.
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Affiliation(s)
- Sheila Krishnan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Richard L. Roudebush VA Medical Center; Indianapolis, IN
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50
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Elinoff JM, Agarwal R, Barnett CF, Benza RL, Cuttica MJ, Gharib AM, Gray MP, Hassoun PM, Hemnes AR, Humbert M, Kolb TM, Lahm T, Leopold JA, Mathai SC, McLaughlin VV, Preston IR, Rosenzweig EB, Shlobin OA, Steen VD, Zamanian RT, Solomon MA. Challenges in Pulmonary Hypertension: Controversies in Treating the Tip of the Iceberg. A Joint National Institutes of Health Clinical Center and Pulmonary Hypertension Association Symposium Report. Am J Respir Crit Care Med 2018; 198:166-174. [PMID: 29425462 PMCID: PMC6058980 DOI: 10.1164/rccm.201710-2093pp] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Richa Agarwal
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Raymond L. Benza
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael J. Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ahmed M. Gharib
- National Institute of Diabetes, Digestive, and Kidney Diseases, and
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre (Assistance Publique–Hôpitaux de Paris), Institut National de la Santé et de la Recherche Médicale U999, University Paris–Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ioana R. Preston
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Oksana A. Shlobin
- Pulmonary Vascular Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Virginia D. Steen
- Rheumatology Division, Department of Medicine, Georgetown University, Washington, DC; and
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